
Protrusive Dental Podcast
The Forward Thinking Dental Podcast
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Jul 3, 2025 • 1h 10min
Digital Articulators Explained with Seth Atkins – PDP230
We use articulators to help ‘mimic’ our patient’s jaw movements, to ultimately do less adjustments/revisions in the future.
But are digital articulators there yet? Or is analog king?
Or is digital dentistry just flashy tech with no real-world benefits?
Can a virtual articulator truly match the movements of your patient’s jaw?
Is a CBCT really better than a facebow—and WHEN should you use which?
In this cutting-edge episode with Dr. Seth Atkins, we dive into the world of digital articulation—exploring how tools like virtual articulators, CBCT alignment, and 3D-printed provisionals are transforming clinical workflows.
You’ll learn how to combine analog wisdom with digital precision, improve lab communication, and make full-mouth rehabs more predictable and efficient than ever.
From mounting accuracy to motion capture, this episode is your ultimate guide to articulating smarter in the digital age.
https://www.youtube.com/watch?v=fT31Ecf_kDo
Watch PDP230 on YouTube
Protrusive Dental Pearl: Always send your lab the color version of your digital scan — the PLY file — not just the STL. STL shows shape, but PLY shows color — like markings and tissue detail. Ask your lab: “Are you seeing color, or do you need the PLY?”
Better scans = better results
Need to Read it? Check out the Full Episode Transcript below!
Key Takeaways:
Digital methods can enhance accuracy and patient outcomes → but only when used intentionally.
Understanding both analog and digital techniques is crucial → they complement each other, not compete.
Mentorship plays a significant role in advancing dental education → experience accelerates clinical confidence.
Digital workflows can significantly reduce chair time → and improve patient comfort in the process.
The integration of CBCT with digital workflows enhances diagnostics → giving clearer insight into static and functional relationships.
Digital provisionals offer a cost-effective and efficient solution → saving time, money, and frustration for both dentist and patient.
Axiography is essential for capturing patient motion accurately → because real movement matters more than assumptions.
Highlights of the Episode:
00:00 Introduction
04:00 Protrusive Dental Pearl
05:32 Interview with Dr. Seth Atkins and his Journey into Digital Dentistry
08:06 The Evolution of Digital Articulation
13:38 Digital Workflow and Mentorship
20:01 Accuracy and Efficiency in Digital Dentistry
22:32 Static and Dynamic Relations in Digital Dentistry
31:01 Interjection 1
36:05 Practical Guidelines on Integrating CBCT
37:15 Interjection 2
40:59 Clinical Observations in Dental Rehabilitation
42:29 Interjection 3
45:21 Introduction to Axiography
46:40 Advancements in Digital Dentistry
49:33 3D Printing in Dental Practice
53:31 Motion Tracking on Digital Articulators
57:30 Cost Efficiency of Digital Tools
01:01:10 Alternatives to CBCT
01:05:52 Involvement with AES and Future Plans
Check out the study mentioned: “Comparison of the accuracy of a cone beam computed tomography-based virtual mounting technique with that of the conventional mounting technique using facebow”
🎓 Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES).
🗓️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician”
📍 February 18–19, 2026 · Chicago, Illinois Don’t miss Dr. Jaz Gulati and Dr. Mahmoud Ibrahim as featured speakers, presenting on “Occlusion Basics and Beyond.”
If you loved this episode, be sure to watch Basics of 3D Printing, Milling and Digital Dentistry – PDP224
#PDPMainEpisodes #OcclusionTMDandSplints
This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.
This episode meets GDC Outcome C – Maintenance and development of knowledge and skill within clinical practice.
AGD Subject Code: 610 – Fixed Prosthodontics – Emerging techniques and technology
Aim: To provide a comprehensive understanding of how digital articulators can enhance clinical workflows, improve occlusal precision, and minimize restorative complications through accurate static and dynamic articulation.
Dentists will be able to:
Differentiate between analog and digital articulation methods, including their benefits and limitations.
Apply digital workflows to provisional restorations, improving efficiency, patient experience, and predictability.
Recognize cost-saving and diagnostic advantages of digital design in restorative and full-arch treatment planning.
Click below for full episode transcript:
Teaser: I got into some of the digital things initially, more for selfish reasons. The key there is not necessarily digital for the sake of digital. It's how well can we do analog?
Teaser:Do you think the new grad, the new generation coming through, all they’ll ever know is digital, is that a bad thing or is that a good thing?
Yes, and the reason I say that is I think it’s the correct answer for both. Yes, bad and good.
Are you at any point picking up your analog facebow and then working on analog articulators to wax up, or have you got to a point now whereby the trust and the faith you have in your digital workflow means that you can do it fully digitally?
The biggest thing that a lot of people don’t understand is-
Jaz’s Introduction:Analog versus Digital. Are we there yet? How on earth does a digital articulator work and what’s the point? And are there any real advantages to the digital workflow other than it looking cool and pretty on the screen? Can it help you be more efficient, more accurate, more predictable?
We’re gonna cover all those things with our guest today, Dr. Seth Atkins. I tell you, this guy is a wiz. He’s part of the organizing committee of the AES, that’s American Equilibration Society, and this is part of the AES takeover. We are promoting the AES 2026 conference, which has got some of the biggest names in occlusion, comprehensive dentistry and TMD over two days in Chicago.
The date is 18th and 19th of February, 2026, and it’s called the Evolution of the Oral Physician. The lineup, I tell you, is absolutely phenomenal, and also it’s a privilege to be one of the speakers alongside Mahmoud Ibrahim. We have the 8:00 AM slot on Thursday 19th of February, so it’d be great to see as many of you there as possible.
Hello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Let’s talk about digital articulators. Now, let’s go back to basics for our students and younger colleagues. The whole point of an articulator is that we can mimic the patient on the table because we can’t take the patient home with us and design the restoration in the mouth.
And then fit it the next day. We have always needed a way to mimic the patient, mimic their head, mimic their movements, mimic their bite so that we can work on the benchtop. So the analog way was to use a face bow and then feed that face bow into something like a semi adjustable articulator. Now what you see on the articulator, this analog articulate in front of you, we’re hoping is somewhat representative of your actual real patient, so that when you design the cuspal inclines of the molar, let’s say that you are restoring that when you put it in the mouth.
And the patient then moves left and right, it happens, so in the same way as it did on the articulator. The ultimate benefit of that is less adjustments, more accuracy, and ensuring that the design that you intended actually works in the patient’s mouth. Now, when you talk about comprehensive dentistry and doing more units, doing full mouth cases, you can appreciate how important it is to replicate the patient.
And let me tell you, this episode is all about digital. We are moving away from analog facebow and analog articulators. Now you’ll see how Seth explains why we can never probably be fully a hundred percent digital in these big cases because the final stages still need to be analog because our patient, when we fit the crown in the mouth. That’s an analog process, so we still need some analog knowledge, but how can we harness the power of digital articulators?
It’s a very exciting, very geeky episode, and I put a few interjections in there to help make it as tangible as possible so that our younger colleagues, our students, can also follow along. That’s always the mission of this podcast.
I asked Seth how we are now transferring the patient to the digital articulator. So like I said, in the analog world, we use a face bow and we talk about the role of face bow, but then how do we actually now use a digital face bow, if you like, and then how do we ensure that the movements are as close as possible on the digital articulator?
Dental PearlThe Protrusive Dental Pearl is one that was given to me by Dr. John Cranham. As you know, I attended his lecture recently in Copenhagen, all about occlusion, cosmetics and digital. And what he’s doing with digital is amazing. Just like Seth, the top tip that can help your lab technician is as well as when you send over the STL files to your lab, what they don’t get is the color.
Very often the lab software, all they get is like the digital stone models. They don’t get to see the color models, they don’t get to see if there’s any ink on the teeth, i.e. articulating paper marks. And sometimes when it’s clear when you’re looking at a color scan. What’s gingiva and what’s tooth?
Sometimes when you’re looking at it on stone, it’s difficult to tell. So the tip is to also ensure that they can see the color version of the model many times. This is with a .ply file. That’s a .ply file. So our scans are STL files. The color overlaying is a PLY file. So ask your lab, hey, are you seeing what I’m seeing?
Are you seeing color? Or do I need to send you the PLY file? If anything, if it’s one thing that this tip allows you to do or encourage you to do is to have that conversation with your technician. Anytime we can have more of a conversation with our lab techs about our workflows, we are benefiting. We are growing because we depend so much on our lab techs.
So my friends, get in touch with your lab. Ask about the PLY file. Do they have it already or do they need it? Because it can help them, it can give them additional data. Make sure you check out the link below to learn more from Dr. John Cranham and of course, how you can come to AES 2026. I’ll put all the links there. Let’s now join the main episode and I’ll catch you in the outro.
Main Episode:Dr. Seth Atkins, welcome to the Protrusive Dental Podcast. Thanks for being up at this time in the US, whereabouts, since you’re in Texas, right?
[Seth]Yes, sir. That’s correct.
[Jaz]Well, it’s great to have you, my friend. I saw you, two years ago now at the AES. A wonderful presentation. You are a real whiz. You are a, I’m sure you get called all the time. You’re a real whiz with the whole digital stuff. And we’re excited to learn from you today. But Seth, I wanna start with more about you, my friend. Tell us about you as a dentist, a family man, a practice owner, your digital enthusiasm.
[Seth]Absolutely. Yeah. I mean, honestly I got into some of the digital things initially more for selfish reasons. I practiced South of Dallas, Texas, about 30 minutes, and when I took over the practice, I guess 2013 or so, my kids were six and four. And we were blessed in the sense that the practice got busy.
Things took off quickly, which was good. But the last thing I wanted to be doing was working up patients after hours. And during the day, you’re seeing patients, it’s hard to have time to do it. And yeah, I’d bring my wax at home, wax at the house. My wife would get mad so I’d make a mess. All these things.
And it was tough to do, after the kids went to bed. And so originally I started looking at things really more just, how could I do this more efficiently? What can I do to streamline some of these things to make it easier to be more present with my family, hang out with the kids, and do all the things you wanna do as a father and a parent in those scenarios on it.
And it kind of occurred to me that it’s a lot easier to do a lot of this on the computer. I can have a laptop at home, I can wax up on the screen, I can combine the photography, do all the things that we want to do digitally, and it’s a lot easier. You don’t have to carry the stuff back and forth, it expedites that quite a bit.
And you kind of quickly learn, you gain a lot in efficiency in doing it. Not only cost-wise, but time-wise. And for me, that was huge, initially. Was lucky in the sense that I started scanning back in ’07, ’08, like as soon as I got out of dental school. And so I’ve had a long time learning the scans and the pitfalls and pros and cons, but it took me a good seven, eight years before I realized we’re not really doing anything with the scans.
And we’ve reached this tipping point where I think the majority of clinicians are now scanning finally. But you really don’t get the return on the technology and the leverage you’ve got digitally until you start to do something with that data. And that was where-
[Jaz]More than just printing the models. The next step, the next level like you did, but you did it so early. I mean, back then, were you a little bit like worried like, am am I doing the right thing? Am I sacrificing accuracy? Were you a little bit concerned at that point?
[Seth]Well, yeah, for sure. I mean, that’s always a concern, right? Even all the literature early on it was, digital is not as good. Analog has been the standard and over the last 10 to 15 years, we’ve seen that change dramatically. We’ve got a number of systematic reviews now showing digital is at least as accurate in some cases, especially on the articulation side, some other things.
It’s the best representation of the patient by far. And that’s kind of been, I think the paradigm shift for many people is depending upon where you get your training, when you were trained, all those things. We’ve got some, maybe, I don’t wanna use the word bias, but legacy concepts that permeate.
And we’ve always gotta be critical in reevaluating what is the current state, where are we at? And because the point of digital is not just to go digital. ‘Cause at the end of the day, everything digital ends up analog, right? ‘Cause we’ve gotta go back to the patient’s mouth. So the key there is not necessarily digital for the sake of digital, it’s how well can we do analog?
And what’s kind of ironic with that is we’re reaching the point that digital, at least in certain arenas, does analog better than analog. And that’s kind of spot where your mind kinda goes, wait a minute, what’s going on? Like, where are we at with this? And I think that’s really the take home on all of it is, some of the things we looked at with the articulation, things were meant more to bridge the gap because you had this fear, right?
If I went digital, how can I go back home? Am I stuck? How do I get out of the pool if I jump in the deep end? And the reality is, I think we’ve got the capability now to seamlessly go back and forth between analog and digital. And that gets rid of a lot of the hurdles for people.
Because if you can go back home to what you’re used to at any point in the process, it makes it easier to try something. The nice thing with digital in a lot of ways is that once you’ve got the technology, it really doesn’t cost you much to try something. It’s kinda like a video game, right? I grew up as a kid playing games and if you’re gonna go fight the Bosch, you save the game right before you go fight them.
So if you screw it up, you just turn it off, turn it back on, you’re right back where you were. And that’s the same thing with digital. If you wanna print something or design something and you’re at a spot where you’re kind of sketchy, if this is gonna work, save it and you try it. If it doesn’t work, you reevaluate. Go back and, you know, go back to the other methodologies on it.
[Jaz]So Seth, I was at a lecture by John Cranham in Copenhagen just last week, and it was about the cosmetic occlusion workflow and then how much of what he’s doing is digital like you, and he made an interesting point, which is very relevant to what you are saying about, okay, you can still go back to analog.
But an interesting observation that John made is that nowadays with the new grads coming through, because they never got to or they don’t get to go and wax things up and mount an articulator. He was worried that when they go straight to digital, that they be missing out a huge chunk in education. They may be missing out in terms of the why or the foundations of it.
But actually, he concluded that it’s not really a disadvantage at all because they get the concepts through digitally and for them they kind of bypass the whole analog and that’s not necessarily a weakness. What do you think about that? Do you think the new grad, the new generation coming through, all they’ll ever know is digital, is that a bad thing or is that a good thing?
[Seth]Yes, and the reason I say that is I think it’s the correct answer for both. Yes. Bad and good. For a couple reasons with it. I think understanding where we came from is important because it lets us, from a chronology perspective see how things evolved. It also gives us the capability to evaluate is something new really better or is it just new?
And I think if we don’t have that lens of being able to go back and reference that, that can be a problem. And then the other half of that I would answer is right now, except for a very, very small percentage of people, analog is how we do articulation. And if you don’t understand how we do things, the analog with the facebow, the articulator programming and it’s relative strengths and weaknesses, it doesn’t allow you to manage the miss and handle that instrument appropriately.
And when I say that, ’cause we’ve always used the analog articulation and it was the best that we had, but it’s not a exact representation of the patient. And so if we don’t have the capability to be absolutely accurate, we need to understand and try to control our misses. And that was basically the strategy with how we program the articulator, how check bites work, even just all of those things with the analog instrument.
And to understand that basis and where that came from, I think you’ve gotta have a little bit of the analog side of things. Now, fast forward 20 years when the technology is different, and we may have digital axiography and all these things being more ubiquitous, it may be a different ballgame because I think that’s the big debate that we look at now, is instead of resigning ourselves to a certain level of inaccuracy, can we shrink that error and make it where we’re really shooting to hit the bullseye as opposed to just being on one side of the dartboard or the other.
And I think that’s really the next evolution and where things are going, but that’s also where things are developing currently. Maybe the state of the art is how do we handle that? How do we think differently? How do we design differently? How do we really try to build that in to be more efficient chairside doing it.
[Jaz]Well, you mentioned axiography and so from my younger colleagues. I’m gonna just get you to define that in a moment. But just one part of your journey, which I’d just love to know is two part actually. The role of mentors in you uptaking digital and really going for it.
And also your source of education and comprehensive, because not every dentist is gonna think about going home and waxing up, right? It’s really you enter the stage of comprehensive dentistry. So tell us about your background in becoming a more comprehensive dentist and the role of mentorship that you may or may not have had when you were moving digital.
[Seth]Absolutely. I mean, failure is a great motivator, right? And you get out and you see something and it doesn’t work, and you try to figure out why. And initially my goal for going more comprehensive was I didn’t like redoing things, and you don’t like disappointing patients, and you wanna try to give people the best that you can.
And then, we realize when you graduate, the education’s kinda lacking in a sense. I don’t mean that to be despairing, but just they don’t have enough time in three or four years to cram in just even the basics, let alone trying to figure out bigger, comprehensive things.
So I started going down the road initially of figuring out, there’s a lot I don’t know, and where do I start? So I went down, ideally a comprehensive pathway. I started with Spear kind of going through that continuum on it. In looking at it, going back, just the basic training, that’s where you started looking at the bigger picture.
How do I need to understand joints? And I don’t know how the education is over there on the UK, but we spend maybe two hours talking about joints in dental school. It’s abysmal. And they just basically tell you if you suspect intracapsular issue refer, and when you start looking at patients, especially the ones that need restoration, the chances of having some issues at the joint level go up tremendously.
Because in my experience, people with healthy joints structurally intact, joints, good anatomy, barring a couple of exceptions, really don’t thrash their teeth. And so we’ve got stability on the back end of the system, more on the posterior determinants that nobody talks about. And so, starting to understand failure, you look at, a Monday morning situation, you go to the office and patients fracture the distal lingual cusp of a lower second molar.
You see the big wear facet, you see the cupping, your brain’s looking occlusally. Like, we have some issues here. We may not have vertical at the joint. Like we want all these things. And that’s the one that’s the frustration coming out, right? Your new grad clinician, you prepped the tooth, get everything ready.
A team member comes back, I’ve got no room, I can’t make a temporary. And you know you did the reduction, you checked everything out, it’s like, what the heck? And you go back and reduce some more and you’re still outta room. You do some more and you’re still outta room. And now you’re thinking, do I need to talk to this patient about endo?
What are we looking at? Because we’re running outta space to reduce. And these are all conversations that I would much rather have on the front end of the system or the front end than an excuse on the back. And so it was just the school of hard knocks a lot of ways trying to figure out, okay, why did I not catch this earlier?
What can I do to try to make that better? And that’s what kind of got me started on it. And then the digital side was more initially from the scanning, just the practice builder. Just nobody likes impressions from the patient perspective. And so it was initially kind of a builder to say, all right, we can get you in and we can do the diagnostics and we can take the mold or whatever we need to do and not have to have that analog experience in doing it.
And with that, that was probably my initial motivation to try to figure it out is if more patients are able to say, yes, we can help more people do more things, grow the office, all the good parts that come around that. But early on, scanning was tough. I mean, it really wasn’t accurate. At times, depending on when you did it, we didn’t understand the limitations of what the machines can and can’t do.
And sometimes we’re trying to fit a round peg in a square hole in the sense that, that’s not the right modality to fix the problem that we’re going after. And I think even today, that’s where a lot of people run into issues, is we listen to the reps and who’s selling the scanners and oh yeah, you can do everything with it.
There’s no limitations. And then you quickly find out it doesn’t always work like you want. And there wasn’t really a support system to help people troubleshoot that. You know, when I started doing a lot of the digital stuff, there was no manual in any of it. So we try something, I would go to lab groups and look at their forums and ask questions.
And sometimes in Dentaltown may have it or just honestly Googling it, trying it, trying to figure out something that did it. And my background in college, I was initially electrical engineering and computer science. So I like technology, I like all these things.
[Jaz]It all makes sense now. Every podcast with a guest, I have a a click moment where they mention something in their journey and it’s just like, oh, that’s why he’s into this. That was your click moment for me.
[Seth]Okay. Yeah. And I got to third, fourth year university and I really liked interacting with people. I didn’t wanna write code behind a computer all day. And my younger brother who’s an oral surgeon, we were, nobody in our family was in healthcare. And my dad was like, well, what do you think you wanna do? He kind of thought dentistry or medicine, and he’s all right, well go volunteer in a bunch of offices during the summers, just sweep floors, pick up trash, just watch and see what you think you wanna gravitate to.
So we went to all the different kinds of offices we could find, and dentistry kind of clicked for both of us. Just different specialties in doing it. But when you look at it, you see how things work and you see the workflows and you see the inefficiencies. And that’s when it kind of started putting together, at least in my head.
Okay, some of these digital things offer an opportunity and if we can implement them correctly and kind of put together a framework that allows us to do that predictably, I think that’s when it really takes off. And I think that’s what you started to really see the last five to 10 years is a lot of the wrinkles that get worked out.
People have beat their head against the wall, figuring out the initial hurdles, and then that makes life easier for everybody else. If you’re willing to share and say, here’s how we did it, this is what I would avoid. How do we move forward with something in a framework that’s much easier to implement on it?
And that’s really kind of what got me into it, is I was willing to play with things and check it out initially, and that allowed me to have the experience to share it with other people. Okay. If I was starting today, here’s how we do this. Where would I implement, what would I pick, what order, kind of all those things to make that a much less of a headache, putting it in and actually a benefit for the practice.
[Jaz]Well, as we evolve this discussion now, I think the first thing I wanna know from you is, are you fully digital now? Let’s say you have a wear case. Are you at any point picking up your analog facebow and then working on analog articulators to wax up? Or have you got to a point now whereby the trust and the faith you have in your digital workflow, it means that you can do it fully digitally?
[Seth]Fully digitally for I’d say 99% of it. Now, we’ve got some capabilities now where we bring the mounted models based off the CBCT positioning on an analog instrument, but that’s mainly for the lab to finish the final restorations. And you know, because like I said, the whole point of digital is to go analog.
So we’ve gotta go back at some point. And that was one of the main hiccups is you’ve got these unmounted models and you could check contacts and things, but when they wanna do the final finishing, if they stain and glaze and all the little hand touches that they put on, we really didn’t have a good way to evaluate all that.
And that’s where, we came up with the jigs and the ability to basically add attachments to the printed models that precisely replicate the position on the analog instrument that we had on the digital instrument. And that gives us a number of options we didn’t have in the past.
So now predominantly for the lab to check, but early on before we had the trust, it was more to give us the capability to go back and forth when we need to. And the biggest thing that a lot of people don’t understand is whether you’re taking an analog impression or sending a digital scan at a lab, you’re probably digital either way. And the reason I say that is what is the lab doing? They’re scanning your model, the models that they make, virtually designing and waxing everything and then bringing that to you at the end of the day.
And so, that was kind of initially the knock on digital was, it’s not accurate, all these things. And then people didn’t realize you’re digital regardless. You just don’t know it yet because it’s such a small percentage of labs now that are hand waxing, hand investing, doing all those things. And they realize the efficiencies that we gain doing it a long time ago, and they’re doing it at scale because they’ve got more restorations, more clients, they see more things that we’re gonna see as individual clinicians on a daily basis.
And then the next reason that we did that predominantly was, if you send your scan to the lab or you’re just sending impressions in a facebow with no check bites, ask the lab how they’re programming your articulator. And if you don’t know the answer to that question, I think it’s a worthwhile.
Path to go down. Because the reality is we’re giving the labs many times, part of what they need. We can give them some information to help with the static relation. But when you do an articulation, there’s two types. So you have your static, which is your relation, the maxilla to the hinge axis, but you also have your dynamic relation.
That’s your programming on it. And before we had the digital axiography, the patient motion, the mod jaws, that kind of thing, we didn’t really have any good ways to derive the programming values for the dynamic side with a digital scan. They had some programs.
[Jaz]So, to clarify, talking about the condylar guidance on the articulator and-
[Seth]Correct. Because you think with analog instrument, you take check bites, right? Take your protrusive bites or your lateral check bites. When we had our mounted model, you would put those check bytes on and that’s how you program the po, the back end of the articulator doing it digitally. And my argument is the most compelling reason to go digital, quite frankly, is the virtual articulator because it’s got many more or much more capability to replicate patient anatomy than the analog.
But what was simultaneously, I think is potentially its biggest strength was also initially the biggest weakness. And that the virtual articulator was great, but you had no way to program it. And because of that, it wasn’t really useful. And for a long time, even with the design softwares, ExoCAD three shape, those kind of things, labs weren’t even buying the articulation module. They would just have it purely as a clap clap type scenario because they didn’t have a way to program.
And the reality with that is, and when I started looking at the softwares kind of playing with all this stuff, I quickly realized we need to know what the inputs are and what it’s capable of as clinicians, because it’s really more designed for us in the lab. Once you realize that, and I said, oh, if I give you X, Y, and Z to my technician, they can execute at a much higher level because we’re giving them better input.
And that was really what kind of started me thinking, okay, how do we drive these values? How do we give the lab what they need to execute at the highest level possible? And once that happens, you start to collaborate more. You realize some of the synergies and the software, your collaboration on design goes up to another level.
Because we’re no longer like taking snapshots and emailing pictures. They can send me the entire scene file, I can go through the software, change the wax up, manipulate it, do all these things in real time, and it’s much more efficient and it gives me the capability to visualize the case much more efficiently on it.
You know, because really with digital, the advantage lies in twofolds. Computers are very good at aligning things and they’re also give us the capability to combine different records that aren’t able to do that we can’t do in the analog world. So that’s why you can stitch like your CT to your intraoral scans, to your face scans, your photography, and it gives us the capability to layer the patient from a diagnostic perspective.
And that’s something that analog, you can’t take a pano, combine it with your CT or your articulator. They’re all different media and because of that, we lack the ability to cross over.
[Jaz]That’s what excites me the most, Seth, I mean, just that stack is just phenomenal. I’m not there yet, but in my journey, that’s what excites me the most. The fact that the capability to layer, just like you said is phenomenal. What I wanna draw now is some, some ideas for those most dentists who may be listening right now are probably analog, right? For this part. They may be scanning, but when they have a comprehensive case and they wanna do kind of a wax up, they’ll then be getting their face bow out.
And the ultimate goal is to try and get the movements that you see on the screen to be somewhat identical is a strong word, but similar to the real movements that you have in the mouth. We all know the TMJ is the best articulator, but when the mandible, the digital mandible moves to the left, it moves in the same way that the patient’s mandible moves.
So now that you’re using a digital workflow, please explain, instead of using a analog facebow or an ear bow, what are we using to capture the relationship of the maxilla to the condyle? How are we doing that digitally so that we can actually, get represented cans and whatnot on the digital articulator?
[Seth]Sure. Well, and there’s a couple different ways to accomplish that. When we talk about, you know, ’cause you’re asking about static relation there, which is gonna be the first part of the articulation, the mounting side. And when we talk about static relation, it comes in two flavors. We’ve got an anatomic relation, which is purely relating condyles to the hinge axis.
Then many times we’ve got an aesthetic relation, which is relating things to the horizon, and those are both important because they allow us to do different things. The patient, if you’re trying to get the instrument to mimic the patient anatomy as best you can, you ideally want an anatomical relation, right?
Because we want to get things as close as possible to the anatomy. But with their technicians, many times we send ’em a scan and that’s all they see. They don’t really know where the horizon is, they don’t know where the cant is. We’ve gotta give them more information to capture that and that’s where the aesthetic relation comes in.
You know, Dr. Kois did a lot of work with the Kois boat and it’s not necessarily, it’s an average value relation anatomically, but what it does to do is correct the cants so that you can wax in a way that gives us aesthetic results that are coherent with facial anatomy and what we’re looking at from that perspective.
Interjection:Hello again guys. Another interjection for this episode, Kois Bow. What is Kois Bow? It’s named after the legend, John Kois. And I try to like find some visuals or clips for those who are watching. Obviously for those who are listening, I’ll make sure you can follow along. But I have to tell you that the video I found is like it needs an update.
Maybe I didn’t look properly, but the video is from John Kois and it’s like from a long time ago, and we know it was uploaded 12 years ago, but it looks like it’s from a lot longer. And it literally looks like someone is doing like a facebow transfer or a facebow recording on what someone who looks like John Travolta basically.
And that’s what I’m seeing at the moment. And so essentially, you know that fox’s guide plane we used to use for like dentures, right? Complete dentures. You get that fox’s guide plane, make sure the cant is good. You look from the front and then you check the occlusal plane from the side.
Well, it kind of is what a Kois Bow is like. It’s actually properly called the Kois’ Dento-Facial Analyzer. And you don’t need like a traditional face bow if you’re using this. But the real advantage of this is that how it prioritizes the aesthetics, because you’re looking from the front, you’re making sure it’s all level with the eyes and you’re looking from the back and you can use an aesthetic plane.
So you truly are using the aesthetic relation rather than the anatomic relation. And now in combination with the Kois reference classes, the Kois group are really taking this to the next level. So this led the ideal of using the aesthetic reference back to the episode.
[Seth]We did that with the ear bow for a long time. And we’ve got a lot of literature with the regular face bow that on a good day it’s gonna get us within five millimeters of the true hinge axis, which sounds like, okay, we’re pretty close in doing it. But now that we’ve got this digital data and more things at our disposal, many times now we’re using a CT initially to do that hinge access relation and it makes sense.
‘Cause you know, the facebow, the whole point’s to capture the maxilla relative to the condyles. If you have a CT of adequate volume, you’ve got the condyles, you’ve got the maxilla. If you take that scan in a seated position, all the anatomy is there that you need for the relation. So how I’m doing that today in the digital side, if we’re not doing axiography, and I’ll kind of get off on the nuance of that in a second.
You’re aligning an intraoral scan to your CBCT, and then once you do that in the software, you can move them as one cohesive unit. So then I’m overlaying that on the virtual articulator and you just position the condyles of the patient over the articulator condyles, rotate it till you- intraoral planes parallel to the upper member. You’ve got all the information you need done with it related now that’s gonna give you.
[Jaz]That’s the ultimate then. Using the CBCT to use, essentially got the skull of the patient, the maxilla, and you are manipulating the articulator relative to that. And you can see the condyles. There’s no guesswork. That’s amazing. And so that is, would you say the most accurate, is that what the evidence is saying as well?
[Seth]So we’ve got literature now. There’s a paper that was just released that was interesting. They were comparing clinicians and they were given a multiple trials, I think it was 15 times for each clinician and they, versus an analog facebow positioning it.
On a reference model and then translating that to the analog instrument and then doing the same thing with the CT and aligning the scans and transitioning. Once they did it, they scanned the final mountings on both and overlaid all of them to get an idea of how repeatable is each one, and also how close to the hinge axis of the analog of the reference instrument.
The final results were. And what they found is they confirmed with the ear bow still five millimeters, it was like 5.2 millimeters plus or minus two. What was interesting is that you had better repeatability and closer to the actual anatomy doing it with the ct. So they found that the rare, there was only two and a half millimeters plus or tip minus a little.
So they cut the variance from the hinge axis in half doing it on the digital side already. And I’ve got that article. I can’t remember if it’s pre-press or it was just published in JPD, but it’s interesting ’cause we’ve already cut our error in half. Just going through that method with it.
It’s also something that’s easier to store because you don’t have to worry about, if you take your facebow records, some people don’t wanna mount it in office, they wanna send it to the lab. It gets beat up, distorted in the process, the wax melts. I mean, any of the things that go into potential sources of air and doing it.
And that’s one of the other nice parts on the digital side is record storage becomes much easier. That record on the CT, if we align, it’s gonna be equally as accurate 10 years from now as it is right now. And not that you would need it that far down the road, but it gives us the capability to keep things on hand, replicate things with a higher level of accuracy.
And it makes that aspect from the maintenance side much easier to do. And so CT, if I’m on that respect, I think already is cutting the air in half. Now I know sometimes you can’t get the CT and then there’s concerns on your radiographic exposure, things like that. And many times if I have a reason to get it, that’s where I’m using that as well as kind of an ancillary benefit. But the other part we talked about was the patient motion, and you’ve got ways that you can do the articulation now that don’t require-
[Jaz]Before we get to the articulation, ’cause I’m really enjoying this bit on the static relationship. You raise an interesting point there about the radiation, right? So I think where I’m getting from you is that if the sole reason for the CBCT is to help you align it on the digital articulator, then that’s probably unjustifiable or justifiable. But if you’re also applying some implants, you might as well just get a bigger field of, you get the condyles in and for that sake, a little bit more radiation. You’re getting a better programming. Can you just give us some clear guidelines on what you are practicing?
[Seth]Sure. Well, let me maybe backtrack just a little for reference. So, we talked about allowing the CT, the intraoral scan in overlaying that on the virtual instrument. And the virtual instrument is a carbon copy of the analog.
Everything is identical. Same programming inputs, same dimensions. They move the same if you have models in the same positions with the same programming. So in a sense, interchangeable in that regard. And when I started overlaying scans of patients on the instruments, you very quickly realize they don’t match very well.
And that was kind of a light bulb moment for me. If you look at the semi adjustable instrument, at most, every intercondylar distance is set at 110 millimeters and you start to unpack where did that number even come from?
Interjection:Hey guys, it’s Jaz with interjection number two. semi-adjustable articulators, okay. Briefly, right, that 110 millimeter value is from like one condyle on the articulator to the other, condyle on the articulator. And this is where some inaccuracy comes from. ‘Cause you know, if you look at the average person, fine, they might be close enough. But we have a huge variation, lots big heads, small heads.
And so this is a source of error and just getting very primitive for the function of a semi adjustable articulator is that its purpose is to replicate the mouth. So when you’re doing a wax up on the articulator and they transfer it to the mouth, we hope that because you use an articulator to create the jaw movements, that it will be similar in the mouth, therefore, least adjustments as possible.
But we all know the best articulator is the TMJ. And now obviously this episode’s all about digital articulators, which will eventually fully replace these physical articulators. But when you understand things like this fixed distance of 110 millimeters, or the fact that in a semi adjustment articulator you can change the condylar guidance angle to help improve your accuracy, these are some things that we should know about analog articulators. Back to the episode.
[Seth]It was kind of an artifact originally on the Lee panographs that were courting elements on those back when they were doing the old school fully adjustables were at 110 millimeters. So when they moved it over to try to make the analog instrument match the patient tracings, they put the condylar heads at the same width so that they could make sure the movements were one-to-one in doing it.
What’s interesting is you start looking at actual patient anatomy. Nobody’s at 110, and I’m talking even at the lateral poles. Generally, if I’m doing my virtual articulations for splints and things, I’ll measure from the midpoint of each condyle ’cause I think that’s kind of probably the middle of the road.
If you take in a heat map of activity with lateral and rotational movements, it’s probably somewhere in the middle. But even then, on a lot of patients that need restoration, the articulator at 110, they’re at 75, 80, 82. And you start thinking, okay, you got 30 millimeters of shift. When you start to model that digitally, it’s interesting.
So you can take a model on an articulator. Have the 1/1oth intercondylar distance and if you’re measuring the distance from each condyle to like midpoint between the maxillary centrals, changing the intercondylar distance to correct it to let’s just say from 110 to 80 will shift that link to the central seven or eight millimeters on each side.
And so what initially got me looking a lot of this is, yeah, I’ve got a practice that we’ve got a fairly heavy joint based diagnostic component to it. And so I see a lot of patients with compromised joint anatomy and invariably we make these patients appliances at times to see if we can change the load at the joint level to facilitate adaptation and healing as best as we can before ruling out surgical intervention, those kind of things.
And I would go through the same process in every patient, take your ear bow, facebow, get everything done, have a splint made. And sometimes the splints were 20, 30 minutes easy for like a flat plane group function appliance. Other times it was an hour and a half and I’m like, what’s the difference why are some of these so much faster than others and you start trying to investigate that.
‘Cause initially you think, okay, the lab screwed it up. I’m gonna do it all myself. Started making ’em myself. Same thing, same variability. It wasn’t until I started overlaying these scans on the articulator and comparing the patient anatomy to our instrument that I realized some match better than others.
Some are more average than others. And the patients that were a better match to the analog instrument, the adjustment times were lower. The ones that varied more, we were working with poor data on the input, which is makes perfect sense while the output doesn’t match. And we see the same thing clinically.
There’s times, you’re doing a rehab and you insert it and you’ve got minimal adjustments, and then you’ve got the other, where it looks great on the analog instrument or the articulator, but you go to the mouth and the guidance isn’t right and you’ve gotta go in and grind a bunch of things. And we’re getting a more compelling body of literature that there’s not a single restorative material on the planet that benefits from adjustment.
[Jaz]That’s very true.
[Seth]And with zirconia especially, if you sue on them, had some date, literature out that the minute you touch it with a bur, if we don’t refire it, we’re losing 50% of the strength. Then they probably, if we’re not firing it to heal ’em and maybe 1% of people are re firing everything after adjustment.
It just doesn’t make sense from a practicality perspective. So all these benefits that we’re seeing with zirconia being the strongest material and all these things, you take half the strength away, we’re below Emax immediately. And you start wondering, okay, maybe that’s why we’re seeing some failures in certain places we didn’t expect.
And there’s a number of factors that play into that. But the take home there was many patients don’t match our instrument. And especially the ones that I see that need more comprehensive restoration, when the joints aren’t structurally intact, the growth gets to be altered and you lack projection.
They end up being class two. It’s the same difference in orthodontic practice. 80% of ortho patients are class two. And the reason is the back end’s not growing like it should, which leads to compromises on the tooth position, on the front end of the system.
Interjection:Hello, Protruserati. Jaz here with some injections, right? So this episode, because it’s about occlusion, because it’s about our articulators, we need some interjections just to make sure everything’s really tangible. So the point Seth is making here is that many class two patients, class two, meaning, large overjet classically in a class two div one.
But if you think about the causes of a skeletal class two, well, it’s either that the maxilla is too big or it’s the mandible that’s too small. That will create you a class two skeletal pattern. And so what Seth is saying, and he is totally right, is that the main cause of class two is that the mandible is too small.
Not necessarily that the maxim is too big, but the mandible is too small, it’s too set back. It is retrognathic in nature. It’s smaller and set back in nature. And, and the final distinction here is he said poor posterior growth. And what he is referring to is the condylar growth and the health of the TMJs.
So someone who does a really good job of talking about this is Dr. Jim McKee. Jim’s a previous guest on the podcast, Jim McKee, came on the podcast before, talked about piper classification, but he’s brilliant at talking about this stuff. And essentially if you have a destruction in your TMJ, in your growth years, during childhood, during teenage years, then that condyle and that posterior mandible will not develop normally.
If that doesn’t develop normally, then that will contribute to a class two because it’ll make your mandible deficient. So just making that important distinction. Once again, if you’re enjoying these and these are helpful, please comment, let me know. The last few times I’ve done this, everyone’s been saying good things generally, and so we’re kind of keeping it in the podcast, but there’s still time to say, no Jaz, this is not good, so you gotta let me know. Back to the ep.
[Seth]My wheel spinning on that was, okay, how do we make things better match the patient? Because at the end of the day, that’s the goal. Legacy concepts, if you look at how we did things, it was more about making our patient fit an analog instrument. It’s a fine point, but instead of making the instrument fit the patient, we are making the patient fit the instrument and trying to control where the screw up was.
And I think that’s where I was kind of alluding earlier that I think is the biggest difference we’re going to see is we’re switching the order now. We’re actually truly trying to make what we’re doing digitally truly match the patient as opposed to forcing them into a box that they may or may not conform to.
[Jaz]So with the digital articulator, then that intercondylar distance, can you just simply just plus, plus, plus minus, minus, minus, and change that seamlessly?
[Seth]So on some, yes. Some programs, yes. Some you can. Others you gotta be a little more adventurous and maybe go into the code and tweak it. Like ExoCAD does it let you do it off the rack. But there are ways to go about it, but the digital axiography side overcomes that limitation as well.
[Jaz]So tell us, what is axiography tell us the definition. What is axiography?
[Seth]Sure. Yeah. So initially in the analog world, it came from the fully adjustable articulators where they would go in and they had an apparatus that went on the face that attached to the lower jaw.
And as it moved, it made physical tracings on paper, on recording elements. And that’s how they use that to program the analog instrument. They would use that to find a hinge axis and you could actually change all the parameters on the D5A Denar and some of the old, fully adjustable articulators.
And it was a great way to match the patient as best we could, but it was cumbersome. It took a lot of time and it a lot of effort. And what they found was most people weren’t gonna do it. So we started going then to semi adjustable where you only have a few things to input, but you try to manage the miss so that the analog instrument is designed to, as a general rule, be flatter than the patient’s anatomy.
And that’s a benefit, right? Because if the instrument’s flatter as we grind everything in the accessory, cus pipes are shorter. So when you go to the mouth, you have a steeper disclusion, you don’t have interferences. And that works great if we’re trying to execute canine guidance where you only need to have one plane steeper than the others and things come apart.
But when we start having to do these progressive group functions and other things where patients may need more support at a joint level, it gets a lot harder to accomplish. So what we started looking at on the digital side is we’ve got ways now to capture all that data much more seamlessly. And these would be like Zebris or Mod Jaw or the different, you know, digital axiography or sometimes term patient motion that you see.
And what it really is, honestly, it’s a high speed camera that sits in front of the patient. There’s reflectors that are fiducials that get attached to the lower arch. And as the patient moves, the camera’s just purely articulating and capturing those movements at very high resolution relative to a tiara they wear that gives you the reflectors for that upper arch.
And once you have this data, it can be brought in seamlessly into your design software, like ExoCAD or 3Shape, and it comes in fully mounted. The articulator gives you programming, so you’ve got all your programming already done. And where it overcomes the analog, the virtual limitations is you actually have the movement on the screen.
So I can take you through protrusive closest speaking space, left and right, para function. You can even have the patient chew and eat and masticate. And what you start to see is, articulators mainly on the bench work inside out. You start it static and you go into discursive this way. Where the form really meets function is when patients chew.
They’re not starting in and going out. They’re coming out on return stroke in, and there’s a lot more variability and a different dynamic to that than we’re used to thinking about. And because of that, that’s just data we weren’t able to capture ’cause you can’t replicate on analog instrument, any of that.
Where we now, when we start to see it digitally, one of my preferred workflows now in any case is we virtually wax the case up ahead of time. We go to prep. And when we’re doing our provisionals, I’m not relining provisionals or doing shells or doing full arches anymore, we’re virtually combining our definitive prep scans with the virtual wax up and 3D printing.
The provisional is fully contoured. So everything is two year definitive margins. There’s no reline. It allows us to do like full arches of single units now, which is huge for hygiene staging. It makes life so much easier ’cause now you know, if you’ve got a full arch maxillary restoration or provisional.
The worst call you get is Ms. Jones calls one of ’em chipped. Okay? Which, where? Where did it break? What do we gotta do? There’s nothing more inefficient to try to patch or take off a full arch provisional. Doing it as individual units is massive because now which one chipped number five. I can have number five reprinted before the patient gets the office.
The characterization is done. We verify that the scan was accurate initially when we did it. So I mean, I hardly even have to see the patient. We can go in. Assistant can see the provisional, make sure everything’s good. I’ll come in, double check the bite, figure out what went wrong. And it’s just a huge time savings doing it.
[Jaz]And these 3D printed provisionals are like a temp bond, placed in. Is that how you’re doing it, like temporary cement and then you are giving some time for adaptation and checking whether you are happy that the patient’s TMJ is articulating as you planned for everything in the design stage?
[Seth]Yeah. Generally, I like Duralon for the 3D printed provisionals just because I think I’ve had better success with that, but just from a long-term maintenance perspective on it. But exactly that. And it gives you the capability to one, verify everything, right? Especially on the aesthetic side.
Do we like the tooth form? Do we like the shape, do we, is function what we want it to be? And even though you can plan everything digitally, I feel very to very high level. The patient articulator is always the final judge. And because of that, I still always want to give them some time to evaluate and check and make sure we’re on a path that we like.
I also like it from a phasing perspective because, I mean, that’s the biggest issue that we see a lot of times is, if a patient is of more modest means, affording a full arch at once can be very tough. And so it gives us the capability to phase cases differently. So as opposed to, let’s just say they’re in an insurance environment, they can do two crowns a year.
We can initially get the case stable with the 3D printed provisionals, get everything where we wanted as individual units. Well you’ve already got a fully designed crown, you’ve already got your master scan, your margins are done, everything’s done. I don’t need to bring that patient back in to prep and press two crowns a year.
I can send those to the lab, have them turn it to our definitive material, bring the patient in, pop those two off, put the provisional, their definitives on a ceramic. They’re not having to come back to the office to repress, they’re not having to do any of those things. So now my chairside efficiency goes dramatically in doing it.
I also like it because it’s easier to maintain those patients ’cause if you wanted to maintain a phase a case over two or three years. If you’re doing it splinted, you worry about hygiene, you worry about can they get in there to clean all the different things. As well as, two years is a long time to trust any provision without something going wrong.
And going in and remaking a full arch provisional could be three, four hours by the time you get it off, clean it up, have everything redone. Now it’s literal 20 minute visits ’cause you know, individual, which unit broke you can accommodate for all that. And the next objection or question that sometimes gets asked is, well what if they wear change over time?
Well if that happens, you just bring the patient in and re-scan for the occlusal changes. The lab can combine that seamlessly without having to redo all the other parts. And you can adapt very quickly to anything that happens when you do it. And that’s probably, honestly my best part of doing this digital now is I really don’t, it’s taken a lot of the stress off full arch provisionals, bigger case temporization, and even the stress on my body doing it.
‘Cause now a lot of times we’ll do in demand design with my lab technician. So if I’m gonna prep the maxillary arch at eight, I may tell them to definitive scan by 10:30 or 11. I send the scan off, the wax ups done. I can go have a coffee, hang out, take a break. My designer will virtually combine the two 30, 40 minutes later, all the files go to my inbox, drop ’em on the printer.
It’s a 15 minute print, 20 minutes to characterize, which I can have my team do that in the back and I’ll come back 30, 40 minutes later to see all of ’em when we do it. And so, huge difference. And you could go see another patient if you wanted to. I prefer to sit and take a break and I don’t, prepping is tough.
And it, and to me, if you want an argument on why to go digital doing it, that’s it. I mean, it’s huge and not that you yet necessarily have to start at the full arch level. Take the scenario where a patient comes in, they chomp down number 19 and shattered existing crown. So you’ve got no crown, new patient, no matrix.
And that’s always a time consuming deal, right? Because you’ve gotta figure out, okay, did I put a stainless steel crown on and take a matrix? How do I get something to make a provisional crown for this patient? Well do it digitally. Get everything prepped, get everything where you want it. Pack your core, take your definitive scan.
You can virtually wax the tooth up in two minutes, put it on the printer like the Midas now from SprintRay, you know, seven minute print and then five minutes post-processing and you’re ready to go. I mean huge efficiency perspective.
[Jaz]I mean this concept of putting your cord in and scanning for the definitive has so many advantages. Like you said, I mean, I guess there was a phase where people might have been doing the rough prep, then putting temps on it and then going back and refining it. I mean, what a service to our patients, not only just time, but comfort. This whole digital workload you described really is fantastic. But one thing we touched on was yes, getting the static right, and then we touched on axiography, and you mentioned about motion collection.
But in terms of actually the articulation, what are you currently using? You described all these, I mean, are you using a module at the moment? How can we make sure that when you put it on the digital articulator, yes, you’ve got your CBCT and the condyle and you’ve lined that all up to give you sort the best idea.
You’ve got the cancel correct, but now the actual motion, what metrics are you using or what can we be recording chair side to make sure that the kind of checks that we have so that when you move the mandible on the screen, it’s like the patient moves.
[Seth]So two ways of looking at it, one is we try to match the patient precisely, and that’s where I think you’ve gotta have the digital ay side of it, just because there’s no way to capture those movements, mod jaw, debris, any of those that allow you to capture.
The other is we get the better static relation using the CT. So we’ve got a better initial starting position, but we still have to use analog check bites. That’s the only other way to derive those values. And the way that we would do that is we’ve gotta get the model in the identical position on the analog and the virtual instrument.
So if I’m not using Mod Jaw on these scenarios, what I would do is take my CT, align that to the analog instrument and my project, a few years ago I was working with AD two, which is an articulator company. It actually came out of AES. it was maybe four or five years ago at AES and I was taking a break walking through the vendors and Dave who owns AD 2, was at the booth.
I saw he had a jig in the back. It was kind of, one of the jigs for putting a printed model on an analog instrument. It was kind of more akin to what Dr. Kois and them were doing with their analog jig, with their average value jigs that they had. And we started talking shop a little bit and I said, if you figured out how to position the jig coordinates, where it loads relative to the virtual instrument as opposed to the model.
And that was what I was working with ’cause initially I like ExoCAD for doing a lot of this, but ExoCAD has a different global coordinate positioning system than 3Shape does. Where 3Shape positions, everything relative to your scan. ExoCAD has a global positioning relative just to that reference.
And that sounds like we’re off in the weeds, but the significance of that is I was able to encode the positioning of a virtual attachment in ExoCAD. Not relative to the scan, but relative to the articulator. So when you add this virtual attachment, it loads in the same position relative to the virtual instrument, not the model.
So the benefit of that is when you use the CT to position the model, the attachment loads relative to the articulator. So as long as they intersect, when we print those as one unit, it puts it in the identical position on the analog instrument with the same jig.
[Jaz]So you don’t need to get the mounting stone and that kind of stuff, right?
[Seth]No, never that. Exactly. And what that allows you to do is, we talked earlier, we have the same programming, same dimensions, same instruments. If the models are the same in both, I can now take my check bites on the analog instrument. So take your protrusive bites, take your lateral bites program, the analog, and I can plug those values directly back into the digital.
So now we’ve got the dynamic movement programmed without having to guess. The downside to that is we’re still resigned to the same miss, right? Because the analog instrument can’t precisely replicate the movements. So we’re gonna have accurate programming on the analog to give us the flatter movements, the things we’re desiring, but it’s not going to be the highest level of replication of the patient.
And so, depending on where you’re at in the process and the adoption, and to be clear, yeah, if somebody was asking me today, what order do I get these things in? The motion side is the absolute last thing you need. You need to be scanning, you need to be comfortable with the software, you need to be 3D printing all those things.
Because if you don’t have those tools in your tool belt. You can’t really take advantage of what the motion offers in that scenario audit. So from that perspective, that would be where I would tell you to start is if you’ve got a scanner, you’ve got one of the more expensive pieces of the puzzle, but you need to get comfortable with software because the software is what’s going to allow you to manipulate the data and actually do something with it that’s productive, both from an efficiency and an ROI perspective.
Because when you send to the lab, you really don’t gain much. But when you’ve got the software in-house, if you wanna 3D print the provisional, that’s where you gain the time on. And the other deal I didn’t even talk about is 3D printing than the provisionals is less expensive than using bisacryl.
[Jaz]Oh wow. I didn’t know that.
[Seth]Which is huge. Yeah. The average bisacryl in the US is about a 1.50, a provisional. I can print them, if you’re using, depending on the resin, it’s usually 60 to 75 cents per. So you’re already cutting your cost by more than half.
[Jaz]Something that’s stronger and better fit and all those advantages for something that’s way less that, I didn’t know that. That’s amazing.
[Seth]And that’s where you start to actually pay for the digital stuff, right? ‘Cause when you buy a scanner, the rep’s always saying you’re gonna save $20,000 of poly vinyl. Well, yes, but over five years. And they don’t tell you the monthly fee on the scanners and the maintenance.
And what if things break when you’re just scanning, you’re really neutral at best in terms of the financial side of things. But when you start doing provisionals, okay, now we’re saving 75 cents to a dollar every time we print one. You do a splint, a digital splint from a labs 150 to $200.
It costs you $7 to print a model is $4 to print, which sounds okay. It’s cheaper on its own than doing mounting stone and all the others. But now when you’re doing a wax up. A wax up in the US is 50 to $75 a unit virtually, it costs me $4 just to print the model for the stent. And so a 10 unit wax up, 700 versus four.
It doesn’t take you long to actually start to pay for all the technology you wanna bring into practice. And that’s something that many times isn’t talked about because as clinicians we’re always looking at what’s best for the patient. But the reality is we have to run a business because if we can’t be profitable, we can’t pay our team and pay our staff and do what we need to do to learn the things we need to learn to handle our and take care of patients.
And that’s something that isn’t touched on very often. Or I guess it’s, I would say it’s more rare that usually when you bring in something new, you’re doing it at an expense for a clinical benefit, right? So I’m gonna be more accurate doing this, but it’s hard to make it truly cash flow and make a good business decision.
And I think that’s where digital really has the potential to differentiate itself, is you can bring in all these technologies and all these synergies come in and you actually have a way to make it a good business decision. In addition to enhancing your clinical outcomes, and that’s where I think it’s special in that regard.
[Jaz]And for many of us, Seth, think of how much fun you can have, right? Think it’s the intersection of technology and dentistry. I mean, you could stand, you can see from how you speak about it and your presentation at AES man, like. For, many people, right? This may not be their cup of tea ’cause they just hate it.
They very much love the analog world. They hate anything digital, I get it. But for most of us, we actually embrace this. We went to scanning because of the problems it solves and patients love it. They love when they can move their models around. And then when you’re able to give them that level of service that you’re describing, and then the amount of fun you can have with it as well, it makes our job so much more satisfying, so much more rewarding.
So I think that alone has a huge benefit and always, always gotta keep learning, right? If you keep it fresh, keep your mind stimulated, then that’s another wonderful reason to look into digital. Last question before we just talk about how we can learn more about the AES and the exciting things coming up with AES 2026 is for those of us who don’t, I mean, we’ve got a CBCT at our practice, but many clinicians around the world don’t have access to CBCT.
I’ve seen whereby a good way to perhaps replicate the static detail, the cants and whatnot is aligning the digital articulator with the patient’s photos. So using that as a tool for the lab, can you describe that workflow, whether you think that is the second best or is there anything else that is perhaps inexpensive and something that we can use to get digitize the patient without using face scanning? Without using CBCT?
[Seth]I mean, photos give an opportunity right now, the problem with the photo side is it’s two dimensional. And so if you’re using a straight on and a side photo to try to do it, you can get some idea of it. But there’s some wobble in the system on it. In those scenarios I would tell you go with the analog facebow and used the traditional method to do it ’cause that’s inexpensive, easy to do.
And we can then digitize that and work off that framework very easily doing it. And so that’s the other way to look at doing it is, you can take measurements off the analogs and plug those into the digital and use that for your positioning and you’re going to be probably as good as the photos, if not better doing it for sure.
[Jaz]So essentially just so I’ve got the workflow right, it’s as an alternative to the photos, it’s doing everything as we usually do, face bow mounted and articulator at your desired bite. And then how are we getting the articulated models? Is it by scanning the positions or just taking like ruler measurements and then plugging those into the software?
[Seth]You can do both. So, if your lab has a lab scanner, you can send that mount to model to the lab. They can easily digitize the articulator and that allows for the alignment of it. The other way to do it would be, and that’s actually how like one of my favorite splint programs is a program called D3 Tool or D3 Splint. It was written by a dentist who also was a coder, or he also did commercial software design. And I like it from that scenario because he understands what we’re doing as clinicians, but it’s also very intuitive and it’s dirt cheap.
I think it’s 600 US one time fee and you own it. But in that program, there’s arrows that you can drag and draw, and it basically has three measurements ’cause to position something in space, you need an X, Y, and a Z coordinate. And it’s a measurement from each condyle to the central point between the centrals and an angular measurement from the infraorbital through the condyle down.
So you’ve got right condyle to central point, left condyle to central point and an angle. Well, that gives you your three coordinates. So all I would do if I wanted to do that virtual articulation, you can use a ruler. So measure, just put that face bow record on the analog instrument. You don’t have to pour a model, you don’t have to do any of that.
And just take a linear measurement condyle to there, condyle to there, and use a protractor. Between those that you can put in the digital splint program and immediately go in and do your virtually articulated splint. Now you have a little wobble for the can and there’s some finer points that you can do to tweak that, but you’re gonna be much closer than you otherwise would’ve been arbitrarily throwing that in.
And so that’s kind of the very easy, low cost MacGyver way to get there doing it. But there’s other methods that you can do that obviously increase complexity going down, but that would give you a starting point. For sure. And I would tell you that’s a great place to learn to trust it is make two splints, have one done, starting it with better values at on the input and have one, do it done as average and start to see where’s the difference in doing it.
And that was really kind of one of the nice things digitally is when it only costs me six or seven bucks to make a splint, I can do multiple proposals. Same thing with wax-ups. Usually having three or four aesthetic proposals is cost prohibitive ’cause it costs you too much to the lab. Well doing it now with virtual libraries and only costing $4 to print the difference, you can actually have so much more flexibility and it lets us see, have the patient see these proposals ahead of time. There’s less guesswork. More likely they’re gonna be happy with the initials which is less time remaking, less time starting over, just everything gets more efficient in that scenario.
[Jaz]I think the thing to emphasize here for those listening is what Seth has done is because of the fact that it doesn’t cost much more to change a few variables and print it, you’ve been able to test and test and test, what if you change this?
What if you change that? And really your workflows now a representation of all those near misses and failures, which were inexpensive failures because you were able to make that adjustment, spend 10 minutes to print it again and get it corrected. And what a service to your patients. So that again, is a huge advantage of digital there.
Tell us about your involvement with AES, Seth. How did you get involved with AES? You’re on the squad of AES in terms of organization. What role do you have with AES and how did you come into that and what have we got in store for AES 2026?
[Seth]Awesome. Yeah. I had a couple cocktails one evening and started talking up in one of the suites after the meeting. And the next thing I knew, I woke up the next morning and was gonna be involved in planning the 26 program, which sounds funny, but that’s kind of how thing it goes down occasionally. And it’s been a great opportunity. Jim McKee was the one who originally got me involved with the organization on it and had never planned a program before.
So first time coming in as a program chair doing all that. Yeah, I would’ve been blessed. The fantastic co-chair Liz Turner, who is awesome. And she and I were kind of charged with executing the vision for the current president’s meeting, which is Bobby Supple. And Bobby is very much an occlusion nerd.
He’s very much tech scan digital guy. So he was trying to put together a meeting that would bring a lot of these concepts together. And one of the nicest things about AES for those who aren’t familiar is they make it a point of trying to bring different vantage points into the same room and letting ’em talk it out.
Which this panel discussions and things where the point is to let everybody see what’s out there and then try to figure out what you believe is the best truth going forward on. And so for 26, we’re looking at a lot of different things. There’s a very heavy digital component, but we have a lot of sympathetics and airway and all the different things coming together that are problems for us clinically today.
So we have, example Jeff Rouse is coming in and looking at the etiology of wear patterns and maybe he is gonna look at, is it more of a global thing as opposed to a toothpaste level deal. We’ve got Tracey Nguyen, talking about airway on it as well. We’ve got Mark Piper, Nick Yiannios talking about the roles of Sympathetics, how they play a role, ’cause the sympathetic nervous system I’m finding in my practice is something that makes a huge difference in a lot of cases, but it’s something we were never taught to look at.
Alter alterations and sympathetic tone. How do you diagnose it? How do you figure out if that is part of the problem? And I’ll use an example. We have these patients that maybe have an asymmetric response to procedure pain wise. So you go in, you think, man, the tooth popped right out. It shouldn’t be a problem, and I’m hurting the next day.
And three days later, they’re hurting, and a week later they’re hurting. And then they don’t look like they have a dry socket. You can’t figure out what is going on. Well, you start looking at these patients and the apnea patients and the airway patients and people who have systemic inflammatory diseases, their sympathetics are cranked up all the time.
And we start looking at substance P and pain response. And they’re just, they respond differently. And I had a patient where I was curious that they had increased sympathetic tone and we were taking out two teeth, 18 and lower second molars bilaterally. And there’s diagnostic nerve blocks you can do to kind of turn off the sympathetics to see if they play a role.
We do that a lot for the joints. But so outta curiosity, I told the patient what we were doing and I was gonna do this block on one side and not do the block on the other. Taking out both teeth, same teeth, symmetric, same side, the two, the side where we block the sympathetics, uneventful, healing, no problem at all.
The side that we didn’t had that asymmetric pain response, it hurts dry socket, I can’t get it to go away. All the things. And at that point, my mind was like, there’s a piece to the puzzle we’re missing here. And I think that’s what Mark and Nick are gonna really focus on is maybe a different way of seeing the same patient and using that to factor in our diagnostics, our discussion, our treatment planning, setting expectations for where we’re gonna go. We’ve got Lukasz Lassman coming in who I think was on the podcast last week?
[Jaz]Just yeah, just yesterday was published.
[Seth]Insanely smart guy. And he’s looking at vertical dimension and how we alter it. Maybe some of the conceptions and misconceptions we may have on the literature and what that supports. He’s even gonna look at the role of the sympathetics and how does that play in? There’s a lot of things that tie in. I think at the end of the day, it’s going to be a very interesting meeting and it’s a fantastic time to come check out the whole dental world in terms of the States is in Chicago at that time.
There’s eight or nine other meetings going, you have lab day, all the things. It’s a cool way to come spend a few days when it’s cold in the middle of February. Not much else to do.
[Jaz]You know what, it wasn’t so bad that when I came two years ago, the weather was actually really good, but I know it can be very variable. But what a beautiful city. What a beautiful city. Chicago and honestly like, what you guys are, are bringing together all these top level clinicians is phenomenal. So I’m just wanna champion the event you guys are running. And so it’s been a great pleasure to host yourself, Jeff Rouse, Liz, Lukasz in terms, and Dania Tamimi. We recently published our episodes-
[Seth]Oh, I forgot Danny. Yeah.
[Jaz]And so, so many superstars and so many learning points. So I really encourage you all, if you’re able to come Feb 2026, make it the conference that you attend. Seth, thanks so much. Your hard work and organization so far. But the best is yet to come.
The hard work is yet to come still. But for now, we want to just spread the good word and honestly keep up the amazing work you’re doing in the digital side. Like, my mind is blown in terms of the possibilities. And may you continue to be, this super nerd in a nice way possible.
Like honestly, you are. You’re very clear, you’re very passionate and really intelligent. So, thanks so much for the good work you do. And I appreciate your time today on the podcast.
[Seth]Absolutely. I enjoyed the visit. 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. Hope you enjoyed the injections, but my goodness, Seth is some sort of wizard. I appreciate him very much for allowing us to use his slides during this presentation. But don’t worry for the audio listeners on Spotify and Apple, you didn’t miss out because the whole conversation happened without any visuals.
It was just to enhance what we’re doing. Now if you’d like to get CE, this episode is very much eligible. There was plenty of juice in this one. Protrusive Education is indeed a PACE approved education provider. The episode is eligible for one hour of CPD or one CE credit. Head over to our app Protrusive Guidance.
It’s also home to the nicest and geekiest community of dentists in the world. Click on this episode in the all episodes and CPD section, answer the quiz. And if you get 80% Mari from Team Protrusive, our CPD Queen will send you your certificate. You’ve done all the hard work, you’ve listened. You might as well get that certificate.
We’ve crossed the threshold recently so that now if you tally up all the CPD and CE available and Protrusive Guidance, it’s less than a dollar. So imagine getting a CE certificate for this episode for less than a dollar. There is so much good stuff on there, and just the network and the community that’s on Protrusive is absolutely amazing.
We’ve somehow attracted the nicest and geekiest people in the world. Head over to protrusive.co.uk/ultimate. That’s protrusive.co.uk/ultimate to get a free trial to make sure that you are happy with the education that’s on there. As always, thank you to Team Protrusive for their hard work in putting this together for the visuals of premium notes and to ensure that the mission of making dentistry tangible is totally accomplished.
Thanks again, my dear friends, I’ll catch you same time, same place next week. Bye for now.

Jun 26, 2025 • 1h 5min
Airway Dentistry with Jeff Rouse – PDP229
Are you considering the airway in your treatment planning?
Could centric relation (CR) be compromising your patient’s breathing?
When you open the vertical dimension, are you making the airway better—or worse?
Welcome to another AES 2026 series episode, this time with LEGEND Dr. Jeff Rouse as he joins Jaz in this eye-opening episode to explore how airway, aesthetics, and function are deeply interconnected—especially in prosthodontics.
They discuss key clinical scenarios like vertical dimension changes, examining how your choices may impact the airway—sometimes in ways you didn’t expect. With practical insights and examples, this episode will help you make smarter, airway-conscious decisions that elevate both your functional and aesthetic outcomes.
https://youtu.be/-Ut-qme7Vcg
Watch PDP229 on Youtube
Protrusive Dental Pearl: Plan your breaks 12 months in advance to avoid burnout and ensure quality time with your loved ones. Prioritize rest and connection before reaching exhaustion—your body, mind, and heart will thank you.
Need to Read it? Check out the Full Episode Transcript below!
Key Takeaways
Airway health is crucial in dentistry, impacting aesthetics and function.
Understanding airway issues can lead to better treatment outcomes for patients.
Breastfeeding plays a significant role in childhood development and airway health.
Interdisciplinary approaches are essential for effective adult treatment.
Aesthetics and function are key factors in airway prosthodontics.
Most patients are unaware of their airway issues until they are addressed.
Early intervention in childhood can prevent future airway problems.
Combining orthodontics and prosthodontics can enhance patient care.
Airway management is crucial for overall patient health.
A great bite is not just about teeth alignment.
Pathway wear can indicate deeper dental issues.
Vertical dimension changes can negatively impact airway.
Understanding joint positions is essential in treatment planning.
Continuous education is vital for modern dental practices.
Highlights of this patient:
02:22 Protrusive Dental Pearl
04:34 Interview with Dr. Jeff Rouse Begins
09:05 Understanding Airway Prosthodontics
15:58 The Role of Cone Beam CT Scans
17:58 Treating Children and Early Interventions
24:50 Addressing Adult Airway Issues
29:43 Multidisciplinary Approach in Dentistry
31:46 Patient Transformations and Airway Focus
34:42 Understanding Pathway Wear
41:32 Impact of Vertical Dimension on Airway
48:55 Exploring Different Occlusion Philosophies
51:34 A Sneak Peek at AES 2026: Dental Wear Patterns Of The Airway Patient
55:25 Upcoming Events and Resources
Explore the world of sleep disordered breathing with Prof. Ama Johal in PDP033: “Airway – Dentistry’s Elephant in the Room.”
🎓 Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES).
🗓️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician”📍 February 18–19, 2026 · Chicago, IllinoisDon’t miss Dr. Jeff Rouse as featured speaker, presenting on “Dental Wear Patterns Of The Airway Patient”
🎓 Learn more with Dr. Jeff Rouse on The Spear Education Online
#PDPMainEpisodes #CareerDevelopment #BreadandButterDentistry
This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.
This episode meets GDC Outcomes A, B and C.
AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Sleep medicine)
Aim: To deepen clinicians’ understanding of airway prosthodontics and empower them to recognize airway-related dental issues across all age groups.
Dentists will be able to –
Differentiate between anatomical airway dysfunction and sleep-disordered breathing, and understand the unique role of dentistry in addressing each.
2. Explain the principles of Airway Prosthodontics, including the significance of tooth position in facial space and its impact on breathing.
3. Recognize signs of airway compromise in both pediatric and adult patients, including atypical wear patterns, bruxism, reflux, and chronic fatigue.
Click below for full episode transcript:
Teaser: They don't want us playing in that world either. They don't. Their world is completely different than ours. And you as a dentist, you don't want to be in that world. It's an ugly, ugly world and most physicians would love to be dentists nowadays, 'cause we have so much more freedom to change and to act and to care for our patients than they do. Most people don't know what they don't know. They just call it normal.
Teaser:A woman I was visiting with earlier today had had orthognathic surgery and she said, I didn’t really realize that I never was able to breathe and I never slept until I had the surgery done. People that are constricted in their bites like this, their maxillas are constricted.
And if their maxillas are constricted and their nasal cavities constricted, they can’t breathe well through their nose. And so if you go from giving a small piece of cheese or beef jerky or a peanut to chew, they can manage their airway, have ’em bite into a sandwich with a bunch of bread and a bunch of stuff in it. They can’t, so their chewing cycle will move forward and they’ll hit their front.
For me, airway is just established the aesthetic position of the teeth first and the functional position of the teeth. If you get those things normalized, then we help the patient normalize what they do, which is close the mouth and breathe through their nose.
That’s dentistry and the success of that treatment is does the patient have a beautiful smile and a great bite? That’s success. Not did I reduce the apnea level? We’re treating 26 month old as the youngest I’ve ever heard, done Invisalign first to expand, start expansion early, but at four you can start to see if you’re leaving them in a constricted pediatric arch that the permanent teeth are gonna erupt outside of the housing of the bone. So the orthodontist never moved the teeth outta the bone. They were never in the bone to begin with.
Jaz’s Introduction:How does the airway relate to aesthetics and function? Interesting concept ’cause we think about aesthetics, we think about function, but are we necessarily thinking about the airway when it comes to our treatment planning?
Related to this is a scenario like, let’s think of complete dentures. When we deliver complete dentures, the joint position that we usually select is centric relation or seated condyle position. Now the question is, is this position adversely affecting their airway? i.e. by moving their condyles in into centric relation, which usually means they’re moving their jaw a little bit further back. Is that necessarily worsening their airway?
Well, we answered that in this episode. And how about when we’re opening someone’s bite? Well, in prosthodontics, when we open someone’s bite, there are some scenarios where you are at risk of making the airway worse and other scenarios where you’re probably not gonna make the airway worse.
And you’ll learn this episode exactly what those two distinctions are. I’m joined today by the Dr. Jeff Rouse absolute giant in our profession. What a lovely guy he is. Author of one of the best dentistry textbooks there are Global Diagnosis. He’s also a very prominent educator with spear education and the impact this man has made in airway and dentistry and prosthodontics is just absolutely amazing.
So it’s real privilege to host him today as part of our AES takeover. See, Jeff Rouse is one of the speakers at the AES Conference, 2026 in February, and that will be held in Chicago. And we’re trying to shine a light on this conference because it’s based on occlusion, right? It’s related to occlusion, but it’s so much more than occlusion.
In fact, the theme of the AES conference next year is the Evolution of the Oral Physician. Let me say that again. The Evolution of the Oral Physician. So it really looks more than just the occlusion. When I attended a few years back, they really are a comprehensive, holistic group that brings together all the occlusion camps and me and Mahmoud Ibrahim, have the privilege of being able to speak there.
But we are a small piece of it. You know, some of these giants, like Dania Tamimi that we had on previously, Lukasz Lassman, Jeff Rouse, who you’ll hear from today, is gonna make a really great conference. We’re shining a light, so check out aes-tmj.org, that’s aes-tmj.org to learn more about this conference in Feb 2026.
Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl, and quite often the pearl I give depends on my mood and my context and what I’ve been doing that day or the few days beforehand. And whilst this episode’s being published, probably six to eight weeks later, it’s actually Easter Monday today.
And so Spank Hall in England, I’m just reflecting on this Easter break that I’ve had. And honestly, it was just very, very special. For those of you who’ve been listening to every single episode, you may remember I had pneumothorax, a spontaneous pneumothorax. My lung collapsed in February. It canceled our family holiday, like a first world problem.
Yes, it was not nice. It was devastating actually. But there’s a reason for that. For me and my wife holidays are very, very special. It’s really quality time with our kids. It’s a time where I switch off and so we couldn’t go away in February. And so I was really nervous about flying in April and thank goodness, I survived and everything’s fine.
And honestly, it had just the loveliest 10 days away in the sun with my wife and two kids, and I’m feeling really great. And I guess the pearl is, please make time to rest. If you have a young family. And if they’re at school age, then yes, school holidays are expensive time to go away. But even if you don’t get away, just having that time to reset and connect with your family and making time for that is so special in my opinion.
And the reason I’m having to mention this is too many times I’m having conversations with dentists and they’re burnt out. And I always ask ’em, when was your last holiday? And they keep saying to me, ah, you know what? I’ve been meaning to book something, but I never get round to it. And I get to a point where I feel like I need a holiday right now, but I can’t actually book anything because of practice commitments, blah, blah.
So something I’ve said over and over again on the podcast, and I make no apologies, do you plan your breaks 12 months in advance? So I do. It’s why I’m able to be so organized in my diary. I know exactly when I’m taking a break from teeth, paying attention to family or things that are important to you.
And the next thing is really quite celebratory. Like for the first time in probably 20 years, I managed to get eight hour sleep for about 12 days straight. That was absolutely transformational for me. So Protruserati, please make time for your loved ones. Plan those breaks well in advance so you don’t have to wait until you’re burnt out to book a holiday.
You always have something to look forward to. So I’ve said it before, I’ll say it again. Look after your body, look after your mind, and by spending more time with loved ones, look after your heart. Let’s join the main episode now and I’ll catch you in the outro.
THE Dr. Jeff Rouse. Absolute pleasure to have you on the Protrusive Dental Podcast. How are you, sir?
[Jeff]I’m wonderful. Thank you. Thanks for having me here.
[Jaz]I’m so stoked. I told you this before we hit the record button. Your reputation, what you’ve done, your contribution and dentistry already just been phenomenal and I’m so excited that you’ll be speaking. You are such an established educator, your work with spirit education, your own stuff you do and you’ll be speaking AES as well.
It’s gonna be amazing. And as part of the buildup and excitement of that, it’s so great to talk about some key themes today. But for those younger colleagues who perhaps haven’t heard about you, tell us about you, your journey and what inspired you to take the route that you did take?
[Jeff]It’s strange you asked me that question, Jaz ’cause and by the way, thank you for having me on. I know the Protrusive podcast is worldwide and so it’s such a treat to actually get a chance to talk to you. It’s strange you asked me that question ’cause I was, today, I was sitting around thinking like, what a weird route I’ve taken to get to where I am.
How some of the things that happened to me, if I had made a different decision, there’s no way I’d be in the position I’m in right now. So for all those people out there that were horrible and undergraduate and dental school, there’s hope you can actually make it to a podcast one day ’cause I was terrible in school.
I had no passion for it. I didn’t really understand what dentistry was all about. I went into dentistry because a friend of mine wanted to be an orthodontist and I lost my desire to go to medicine. And I say lost desire. I would’ve probably never gotten into medical school. But I didn’t want to get into medical school, but I didn’t know what else to be.
And so a buddy of mine said, you want to go to dental school? And I said, yeah, whatever. And I must have done well on the exam ’cause I got into dental school somehow ’cause my grades were horrible. Got to dental school, the guy there said, C equals DDS. And so I just said, well, that’s easy enough. I can make Cs.
And so I did. And the last year in school I met a professor, Bill Robbins, who I later ended up working with and writing a textbook with. But I met him and he showed me the dentistry could be more than what my local dentist was doing. And that there was science to it and there was an art to it, and that allowed me to go to a residency.
And so I did a two year GPR came back and went to general practice, practice as a general dentist for 14 years. And once again, Bill and I were working together. We were writing textbooks together, we were lecturing all over the world. And I knew there was something different or something more that still I was passionate about.
And so I had an opportunity where I could work my practice and go to prosthodontic residency at the same time. So it took me four years to do it, but I did, and I became a prosthodontist. And after that, then I had opportunities that would’ve never happened had I not taken that, which is I got to work with Greg Kenzer and Frank Spear up in Seattle.
And from there ended up teaching at Spear. So a handful of decisions of just saying yes to hard work and saying yes to the fear that was accompanying it and it paying off. So I think we get comfortable and I’ve always gotten anxious when I’m comfortable. And so for those of you that think there’s more, there is, you just have to be willing.
Like I tell my kids, you have to be willing to take a deep breath and take that leap, even though it’s scary. And in many ways I got lucky, but in a lot of ways, it was just being able to say the word yes, I’m gonna do that. So that’s how I ended up getting here.
[Jaz]Wonderful way to start the podcast. Richard Branson says, if an opportunity comes along that just really, really good, say yes and then figure out how you’re gonna do it later. And so this is the same Bill Robbins that I think spoke at AES two years ago on global diagnosis.
[Jeff]Yeah. That’s what we wrote here.
[Jaz]And I met- and that was all work together. And what a charismatic chap he is. What a lovely human being. And just his charisma. It’s just oozing, it’s just pleasure to see him.
[Jeff]There are very few people in the world that you’re better, you as a person are better off having been around him. And he’s one of those people that just being around him and being in his presence creates such a benefit to you. Like the energy coming from him just feeds you. And yeah, I was lucky enough to work with him for four years and he’s my best friend in dentistry for, I don’t know, 30 years now. So it’s awesome.
[Jaz]What a story. And yeah, that was definitely palpable when I met him a few years ago. Today’s topics we’re gonna take lots of little detours and stuff because to do a topic like this justice, you have to kind of like build the context into it. And I want to help dentists understand a few key things related to airway based prosthodontist.
Some people may be thinking that’s a new term for others who maybe done your classes and stuff, they may be more familiar. But what I was thinking was when we do our restorative dentistry, let’s say. We can do something that may affect the phonetics, and we think about that. We think about the tooth length and thinking, oh, that might affect the phonetics.
We plan our restoration. So we think about the cleansability. You know, we often opt for certain designs, so there’ll be cleansability, but sometimes perhaps we may be guilty in dentistry of not thinking about how our dentistry, obviously more and more with your good work, people are becoming more aware of this, but how might our dentistry affect the airway?
So I guess I’m gonna let you really lead the direction on that. But when it comes to the decision making and the kind of dentistry that we deliver, what kind of situations where may we be impacting the airway without perhaps realizing?
[Jeff]Yeah, good question. Let me back up a step so that everyone is clear. The biggest confusion that I run into when I’m speaking today is when you used the word airway and you used it properly, in my opinion. The issue that I run into is people, at first when you would go to lectures would say, my patient has sleep apnea, or My patient has a sleep problem. And then myself and other people kind of following the same course started utilizing the word airway to differentiate it.
And now if you go to a lecture, you’re gonna hear people say, my patient has an airway problem. But the next thing out of their mouth is they went in for a sleep study and their apnea level is 24. So they’re using the term incorrectly. Airway, the way that you were using it was about anatomy or changes to anatomy that could affect your ability to breathe.
Tooth position, vertical dimension are some of the things that you were outlining. And that’s where we start. So back in the day, I came up with the term airway prosthodontics, just to differentiate it from sleep dentistry. So we were clear, but it still hasn’t become clear. So let me see if I can create some more clarity to it.
[Jaz]Because what I’m thinking immediately is will not, the first part, will not, the airway based prosthodontics that will also impact our sleep. And so they are connected in a big way, right?
[Jeff]They are, but I would go to an easier step because if you connect it to sleep and say sleep apnea, let’s say, the moment you connect it to a medical problem, your markers for success change dramatically. The minute you say my patient has sleep apnea, in order for you to be successful, you have to make that go away. Right? It either has to, success is reducing the apnea level by half and being under 20, cure is under five and the apnea hypopnea index, right?
So the minute you establish the standard for care or your metric for care as apnea, you’re playing in the medical world. I don’t wanna play in the medical world. I don’t want anything to do with that. And to be honest with you, I had a physician in my office, an ENT in my office for five years, and they don’t want us playing in that world either.
They don’t. Their world is completely different than ours and you as a dentist, you don’t want to be in that world. It’s an ugly, ugly world. And most physicians would love to be dentists nowadays because we have so much more freedom to change and to act and to care for our patients than they do. So with that in mind, that was my original goal, was how can I use this to integrate medicine and dentistry for the first time, let’s work together as a team.
And the more I did it, the more I figured out we don’t wanna do that because they’re gonna take over. And if we are treating to the apnea level, it’s medicine. And medicine then wins and every decision. And I don’t want to be there. So came up with the term airway prosthodontics, which actually could impact the apnea, but doesn’t focus on the apnea.
That’s not our central theme. Our central theme is doing the two things that we’ve taught at either in global diagnosis or facially generated treatment planning in the spear world, which are where do the teeth belong in the face and how do you get ’em to function correctly? Those are one and two of every system that’s ever been developed that you’re using for treatment planning.
So when we look at aesthetics, there are three main areas of aesthetic tooth positioning that happen on a wax rim before you ever set a tooth, which is you’re gonna get the transverse dimension correct. You’re gonna get the AP dimension correct. You’re gonna get the vertical dimension correct. So you get all those three things established, and then you start setting the teeth into ideal position.
The vertical, the transverse, and the sagittal dimension and position of the upper arch are all key airway factors. And so if any of those anatomic factors are irregular, you will have more difficulty breathing during the day and at night when you go to sleep. So aesthetics in the maxilla is number one, not only the way we’ve always thought about treatment planning, but it’s number one for airway because it’s connected to the nasal cavity and changes in those dimensions.
Orthodontically, orthopedically, orthognathically will make you breathe better. How much better? We don’t know. No one will ever be able to tell you in advance, but we know it makes you breathe better. The second is function. By the way, function used to lead back in the day when I learned it, function was the leader.
It was all occlusion. It was a lower arch dictated treatment. And even in ortho, lower arch dictated treatment. Tweed orthodontics take teeth out, put the lower interiors over the ridge, move everything to it. Lower arch gnathology, Pankey-Mann-Skyler, everybody was lower arch. The upper arch just sort of sat there and you worked around it.
Today, if we established a maxilla first, the aesthetics first, and then do the lower arch the same way we would do a denture when we get the lower arch in the proper location to inter interdigitate, the airway is also better at that point. So are there other factors beyond that?
Yeah, sure there are. There are soft tissue issues or tongue ties, large tongues. Adenoids, tonsils, deviated septum, which actually come from constricted maxillas. There are lots of things that could be added onto that. But the two main factors that make you breathe better during the day and at night are aesthetics and function.
They’re exactly what we need to do in treatment planning. So for me, airway is just establish the aesthetic position of the teeth first and the functional position of the teeth. If you get those things normalized, then we help the patient normalize what they do, which is close them mouth and breathe through their nose.
That’s dentistry, and the success of that treatment is does the patient have a beautiful smile and a great bite? That’s success. Not did I reduce the apnea level. So that’s the big difference between the two.
[Jaz]When you’re assessing that in a patient in the medicine world, they use the, yes, apnea hypopnea index as a marker. You said that aesthetics and function, are you also using cone beam CT scans and they look at the volume of the airway? Is that a metric that you use as well in terms of, okay, by doing our prosthodontic intervention, we’ve improved the airway by volumetric percentage?
[Jeff]Yes, but I don’t treat to a number that way. Do I look at it? Yes. You know the interesting thing about cone beams, the thing I look at most often is we now know that if you do a cone beam and do slices at the first premolars, so we’re doing AP slices first, premolars, then go back to the first molars and do the same thing. Measure from bone to bone on the palate.
We know the widths that you need to be healthy so I can take a CT of you or any of your patients. And I can cut it and go, you’re too narrow. You’re gonna be sick. And you look at me and go, well, I don’t snore, I don’t have this, I don’t have that. I go give it 10 years or 10 pounds. And you’re gonna, so why would you wanna wait around the way medicine does until you’re sick?
Why don’t you treat it in advance ’cause we know you’re gonna be sick. And the closer you are to that number, the more risk you’re gonna have. We also know, if we look from the side, sagitally, we know that distance. We know that from porion, which your ear hole, if you drew a vertical line off it, an a point which is up under your nose, if you drew a line measuring between those two points, 97 millimeters is a number, you have to be greater than if it’s not greater than 97 millimeters, your odds go up dramatically with or without obesity.
Your odds go up because cranial facial is more important than weight. And we also know that vertical, people that grow vertically, VME patients. Those are airway patients. They’ve always been airway patients. We’ve called them adenoid faces forever. We called them that for a reason. So we know if your anatomy is off, you’re gonna be off.
So yes, I do use cone beam and I use it that way. I like cone beam even in children because I can see the nasal cavity, I can see any deviations, any issues in the nose. I can see the adenoids. I can see the tonsils in 3D. So we get a nice view of those structures also. So if I can get even really, really little kids, they have those quick cone beams, the four second versions, if you can get one of those, then even like four year olds, it’s awesome ’cause you can see anatomy you wouldn’t otherwise be able to see.
And in fact, we now know another, there are many reasons why you wanna treat kids very, very young. We’re treating 26 month old as the youngest I’ve ever heard, done Invisalign first to expand, start expansion early. But at four you can start to see if you’re leaving them in a constricted pediatric arch that the permanent teeth are gonna erupt outside of the housing of the bone. So, the orthodontist never moved the teeth outta the bone. They were never in the bone to begin with. So.
[Jaz]Well, that was actually gonna be my question. My next question is that, okay, based on what you’re describing, what percentage of your dentistry is for children, and then what percentage is for adults, let’s say someone in their forties who seems to have minimal dental issues, but you’ve made these diagnoses and you know these metrics and they’re gonna run trouble. At that point for an adult, it’s very much, I’m guessing, gonna be surgical orthodontic or a combination of both would be the mainstay of treatment, would you say?
[Jeff]All right. Let me answer the first part, which is children. Children are absolutely the key. I ran a family practice before I went back to pros. I don’t enjoy treating children anymore. I did ortho on kids. I did all that. It just wasn’t something that I enjoyed, and so I stopped. If I had to do it over again, I would continue. It was, the reason I stopped is I had one case that the patient went away for six months and the wire was active and I didn’t know how to recover from it. And so in my mind, I was like, I don’t know how to deal with that, so I don’t wanna do anymore.
And so I gave it up. I just gave it all the orthodontists. In hindsight, I should have just said, I don’t know enough. I need to learn some more. And instead of thinking, I knew it all, you know, right up front, and if I did, I would still be treating kids and I would have a bigger impact on my community because I would be treating young.
That’s where the problem needs to be dealt with. The problem needs to be dealt with in newborns. Newborns that are tongue tied. And having difficulty breastfeeding if you can’t breastfeed as a child, if growth discrepancies are huge. So breastfeeding is absolutely the best thing you can start. And if the mother doesn’t want to do it, that’s fine.
But what I find and just hate to see is when the parents come in and I look at the kid a little older and their tongue tied and lip tied, and I ask ’em about breastfeeding, they go, yeah, they weren’t good. They didn’t latch well or it hurt, or whatever it happened to be, well, they wanted to do it, but there was this anatomic restriction, which now we’re having to play ketchup because they didn’t get to grow normally as a kid.
So breastfeeding, what they eat, how they eat, lots of things that we can do to make kids grow and we start intervening way earlier. We getting ENTs involved to look at tonsils and adenoids in an earlier level. We don’t require apnea before those things are removed. We require symptoms, attention deficit, grinding their teeth, reflux, wetting the bed, thumb sucking beyond early years, moving around in the bed, sleep, talking, sleepwalk, any of those things.
Start promoting the idea of getting tonsils and adenoids out, and then also expanding arches. And so, yes.
[Jaz]This is very relevant to me, Jeff. So I’m sorry to intervene, but just to let you know that my son’s gonna be two tomorrow. He’s gonna be age two tomorrow. But since he’s never been a good sleeper, since he was born and I knew something wasn’t right ’cause I hear snorting and sometimes he would stop breathing and I knew something wasn’t right. And we have so many healthcare challenges around the world and getting diagnoses and stuff in the UK in particular. So I managed to see the right person that got this sleep test and lo and behold, he was diagnosed with moderate sleep apnea at age 18 months.
And he’s on the list for eventual when he’s like healthy enough for adenoidectomy, which actually my elder had as well. So I’ve seen firsthand why my interest grew in this ’cause I wanted to help my own son and he was breastfed. And he was breastfed fine. In fact, my wife made it to one year. And interesting stat is that in the UK, and I dunno what the US or rest of world stats are, but in the UK only 1% of mothers are breastfeeding at month six, only 1%. So my follow up question will be, do you think this has been a huge player in terms of the why we are seeing so many more of these issues?
[Jeff]Yes, there was a perfect storm of problems that happened in the late fifties, early sixties. Antibiotics started being used instead of surgery for tonsils and adenoids. Part of it was, it used to be if, like, if your brother got his out, you got yours out, which is wrong. So they were overdoing the surgeries.
Then they went completely the other way. Women went back into the workforce at really high numbers. And so breastfeeding went way down. Gerber introduced soft foods and mushy baby foods instead of the natural course was six months minimum breastfeeding, and then introduction of solid foods after that.
Gnawing on solid foods grows your face. There’s crap in the air, crap in the water. I mean, there’s all kinds of different stuff in our food, right? Everything plays a little bit of a role in what we call epigenetics. And so it’s environmental factors that are altering natural growth and development.
In addition, and this is totally a guess, there is some science to this, but not enough to be causative at all, but somewhat correlational, folic acid in prenatal vitamins, decreases neural tube defects, but the tongue ties are neural tube issues, so they close earlier than they should have. And so we get a lot more tongue ties than we used to in the past.
So yeah, it was a perfect storm of bad things that happen. Interestingly, I think it will be interesting to watch that percentage because at least in the states, people are starting to take an approach of what can I do to be healthier? Can I have clean foods? Can I do supplements? And in the space of taking care of children, there’s a refocus on breastfeeding I think. So we’ll see if that number grows, but that would be a good thing if it does.
[Jaz]Absolutely. I mean, it’s much high in some of the Scandinavian countries, like 33% and whatnot. But yeah. Interesting. Six months. It was 1% in the UK so well done to my wife. But yeah, sometimes not possible and stuff, so I wanna make this about, make anyone feel guilty and whatnot.
But no, I think as a fact we know that if you can, you are able to breastfeed your child. Yeah, it’s the best thing. I mean, a stat I had at the time was something like 20 times less likely to have some sort of orthodontic issue properly to do with your palate dimension, I imagine.
[Jeff]Absolutely decreases sleep disturbed breathing issues and it reduces malocclusions prematurely born children are absolutely gonna have sleep disturbed breathing issues ’cause they’re so far behind in growth and development and breastfeeding is the best way to catch them up.
‘Cause you can almost get them caught up to normal kids growth and development through breastfeeding. The nice part for, to sort of file away for people is whatever time you do it is good. If you breastfed for a month, the numbers are significantly better at eight years for your kid. So whatever you do is good. Your question then was about getting the older patient, the 40-year-old-
[Jaz]So that scenario described where you take a CBCT and then you notice that the dimension from first molar to first molar and the palatal bone and it’s not meeting a minimum number. And they say to you they don’t have any issues because they’re now an adult, they’re fully grown. What kind of treatment interventions are available to these patients?
[Jeff]Part of your question that’s interesting is they say, I don’t have issues. But most people don’t know what they don’t know. They just call it normal. Woman I was visiting with earlier today had had orthognathic surgery. And she said, I didn’t really realize that I never was able to breathe and I never slept until I had the surgery done.
And she said, you told me that about all this stuff, but I did it ’cause I didn’t like my profile and so aesthetically I thought it was gonna be a nice change. And she said, I just didn’t realize it. And now like it’s a different world. So part of our job as dentist is to, well, airway, like I said, airway’s just putting the teeth where they’re supposed to be is for aesthetics and function.
So if a person says, I don’t have a problem, I don’t necessarily have to argue with them about it. If we can come to some agreement, your teeth are in the wrong place and your bite is off, and that’s all I’m doing, then I know I’m gonna make your airway better and I don’t have to focus on it ’cause in the end, what success you have a pretty smile and you have a good bite, so, I don’t need you to believe you’ve got an airway problem.
The time it becomes important to get you to believe you have an airway problem is if you have ugly teeth and a bad bite and you’re not really wanting to do a whole lot about it, but you know that there’s an airway problem and a bad smile and a bad bite, the airway problem is the one that you can have a conversation about easier than any of the other ones.
I find it extremely difficult to have a conversation with people to say, oh my God, you’re ugly. Right? I mean. You don’t walk into a room and go, oh man, look at that. That’s hard. Even when it is like they got a crown on a central and you go, wow. Like, whoa, we can make those look like teeth nowadays.
I don’t know if you knew that. So you see that, or you look at their bite and it’s just totally messed up and they’re chipping teeth, breaking teeth. Oh no, I do fine. I eat right. Those two things for me are really hard to talk about, but if I can talk about health and link all of those things together, now I give them something they’re interested in, which is being healthier for a lifetime than they are right now, or would be in the future without any care.
But I get, what I get from it is I get to do all the cool dentistry I always wanna do, which is put the teeth where they’re supposed to be, rather than camouflage it with ceramics and stuff, put ’em where they’re supposed to be and then make ’em beautiful. And then, you know, put the bite together. And a lot of times I do less dentistry.
I mean, huge advantages from a dental perspective, great smiles, great bites, maybe less dentistry. Maybe if I have to do the same amount of dentistry. At least it’s the right shapes of teeth. I mean, they’re anatomically correct rather than warping teeth around and stuff. So what do you have to do?
And you’re right, typically orthodontics plays a big role in this, but it doesn’t necessarily have to jump all the way to to orthognatic. There’s a middle piece nowadays that is surgical based orthodontic therapy. And the surgical base, orthodontic therapy is not orthognatic in nature. The two main ones are, well, I’m gonna lump into surgery for a second, but it’s really not surgical.
The two main ways of expanding arches are surgically facilitated orthodontic therapy where we make corticotomy and cuts in the bone and add bone. That’s like adding base plate wax, so you get a little change in the anatomy, right? The other one is MARPE, so, so mini implant assisted rapid palatal expansion.
Now, I said you have to do a surgical intervention. That’s a non-surgical intervention, but it is an intervention, right? You have to put Tads in the palate and expand off the tads. Today, I’ve kind of gone the whole route on this. The original MARPE that we used was MSE, so four Tads, small, little tiny screws and such.
Today we’re using custom MARPE, so we’re using 6, 8, 10 long Tads, big solid MARPEs. And so we can split anyone open up to the age of 70. So you walk in my office and you need expansion and some AP, we can do all that non-
Interjection:Hey guys, it’s Jaz with an interjection. So we’ve got two interjections for this episode. Let’s talk about dual bite. Okay, so dual bite is basically a scenario whereby you have a patient who when they bite together, their teeth fit together well. Right. So they have their dental home, their maximum intercuspal position. The relationship between the teeth. Now this patient, right when you seat their condyles, their jaw drops right back like distalises, and they also have a bite in that position.
So this patient is said to have a dual bite, okay? They have a bite where they have like a dental home, and then they have the bite where they have a skeletal home, i.e. the condyles are in the Fosse, or I like say the balls are in the cups and in this position, their teeth also have a bite. So they have a bite that’s further forward and a bite that’s further back.
And this is a dual bite patient. If you routinely start to check your patients for where their centric relation contact point is, or where their stable condylar position is, whether you deprogram your patient or use a leaf gauge or whatever, then you’ll start to identify these dual bite patients who have this very large slide. So that’s what we mean by a dual bite patient.
[Jeff]Surgically, and then orthognathic comes into play only in my office when non-surgical expansion with MARPE and SFOT on the lower ’cause the lower dictates how wide I can make the upper go. That doesn’t resolve whatever the problem is. My smile doesn’t look good, my bite doesn’t look good.
But the main one is I’m still don’t feel good. I’m still grinding my teeth. I still have reflux, I still have TMD issues, I still whatever. And in that case, we’ve gotta move forward and any big protrusive movement in particular mandible has to occur surgically. So orthognathic comes into play at that point in time.
[Jaz]So what you do is very, a lot much multidisciplinary, right. Orthodontics, oral surgeons, what you do is very much a team-based approach.
[Jeff]Yep. I’ve got a practice where the first visit I ought to have like a rotating front door ’cause they come in, they see me and they go right back out to see other people. It’s just in and out from other consults. So I have most of my new patients that are interdisciplinary in nature.
[Jaz]That’s really the whole-
[Jeff]But you know, if I was, like I said, if I was smarter back in the day, I would’ve stayed doing ortho and I could have done a bunch of this ’cause I would’ve, the skills at this point in time to do for sure 50% of it, if not 75% of the stuff I’m talking about. I don’t think I would’ve ever taken on an orthognathic surgery case. I think that would’ve always scared me to deal with those cases. But I actually personally did the SFOT surgery and I put MARPEs in so that I can expand. So I’m expanding people.
[Jaz]So you’ve had all this done to yourself?
[Jeff]No, I had the SFOT done to myself, but I do it to other patients now.
[Jaz]Okay.
[Jeff]So I just, the other day, I always get this question in the classes, which is, where do you find somebody that’ll do that? Like, I don’t have any in my community. And the answer always was, well, if the guy that’s doing it right now doesn’t do it, go find someone.
Go find a younger guy, that’s hungry and has some new knowledge and such, and would like to establish his practice based on this and get a chance to work with you. I bet they would love to do it, but a lot of the people I teach, the orthodontist comes in once a month and does ortho in the town.
Right? So if that orthodontist says no, who are they supposed to go to? And so I got to thinking about that, like I’m spoiled by working in San Antonio and I am spoiled by having so many great teammates. And so I’m speaking from this position of well just go down the street and find another one, right?
And so it hit me one day and I was like, well do it yourself. And then I thought, well, if I’m gonna tell somebody to do it themselves, then I better be able to do it myself. So, I started doing a few and it’s not that hard. So.
[Jaz]What kind of changes have your patients experienced that you look back? A lot of my colleagues that I look up to that have been practicing for years, they say, the full mouth rehabs they did when they come back, 15, 20 years later and everything’s working well and it makes ’em really happy and dentistry and their smile looks great and whatnot. That’s the kind of stories I’ve heard. With your focus on the airway, what kind of changes have you experienced in your patients?
[Jeff]All right, so first thing is your colleagues are lying to you. Nothing looks good at 15 years. It’s still in the mouth and it’s not broken in 15 years.
[Jaz]Yes.
[Jeff]Ceramic ages. It always, you look at it go, ugh. So yeah, I don’t get much of a thrill at seeing rehabs. I always tell the story. Back when I was in dental school, people were so grateful. They’d like, you’d put these ugly crowns that you made and residency or in dental school, you’d put ’em in and, and in hindsight you go, man, those were ugly.
People were crying, they were bringing you presents. They’re like, oh my god, my whole life I’ve always wanted white teeth and you gave me, there is just like the greatest day ever in dental school, right? And then you get out and you charge a fair fee for it and they start like, wow, what about that edge right there?
I don’t really like that. So they complain a lot. The nice part about the airway is if you do it the way I am suggesting is you are transforming their lives in multiple ways. You’re giving them a great looking smile. You may be giving ’em a great looking face, right? You send ’em out for orthognathic.
By the way, if you do that, custom MARPE, their face will look better as well ’cause they’re midface will fill in because you’re actually expanding the whole maxilla up under the eyes, the zygoma everywhere. So you give ’em a great smile, a great face, you give ’em a great bite, they can function wonderfully and they feel good.
And then you give ’em this great airway. And the way they know great airway is whatever the thing that triggered you to say, you probably have a bad airway like bruxing, reflux, TMD headaches. Those are gone. And because it takes a while to get ’em through the whole treatment, a lot of times they forget. And so in the end I have to remind them, hey, you still get those headaches? And they’re like, no, those have been gone for a while. Oh, that’s so good. So yeah, it’s very cool.
[Jaz]I manage TMD patients there, Jeff. And what I also realize is they kind of forget where they were. And so at the very first few appointments I get them to mention all their issues and give it a score out of 10 about how much it affects their life. And then oh, as we go through, they’ll score it.
And then when they’re down to like a two or three as like, oh, that’s interesting. You were a seven. No, like eight months ago, whatever. So it’s very, very true to that point you raised. It’s amazing what the impact you’ve had on these patients through thinking in this way, but this level of knowledge that we need to upskill and we need to open our eyes to this and you’ve done great contribution education.
I’ll ask you and again at the end, where can we learn more from you and whatnot. So it’s our duty to upskill. But two things I want to just talk about for our younger colleagues. One thing is you mentioned a great bite, so what are some features that you look for? You look at a bite and say, that is a great bite. What constitutes a great bite?
[Jeff]Well, are you talking about a restored bite or because a restored bite for me is gonna be in a seated condylar position ’cause that’s what I work to. A great bite doesn’t have to be the teeth all in the right location either. It can be a bite that the patient is so adapted to that there’s no damage to the teeth.
I had an 85-year-old lady in not too long ago, and there were nowhere on her teeth at all, and they weren’t what you would call a dentoform perfect teeth. But yeah, that’s a great bite. It functions without damage. That’s perfect. now, that actually leads me to talk a little bit about one of the topics I’ll have at the AES meeting and its pathway wear or envelope of function would probably like, or envelope of dysfunction. People call it all kinds of different names. You have posselt’s diagram.
[Jaz]Well spotted.
[Jeff]So once again, just for younger people, I don’t know what term they use or where they’re in the world or where they’re in their education, but I’ll describe what we at Spear Education would be a person that actually comes in and we call it pathway wear.
Pathway wear. So pathway wear is that as you chew your lower teeth, nick the lingual surfaces of your upper teeth. So the lower anterior teeth will wear at an angle, so they’ll be higher in the back, lower in the front. They typically will create a shiny wear facet there. So if you took a photograph, you’d see the light reflecting off of this shiny area, and then the upper lingual surfaces will be hollowed out and they can be hollowed out in different paths.
They can kind of come in a lot from the side, or they can be tighter paths, but they can’t kind of just eat out the lingual without really taking away the length of a tooth. So the tooth still remains long. You just eat the backside out and as the backside goes away, tooth erupts. Not only does it erupt straight down, but it also erupts in.
So it keeps getting tighter and tighter over time. And with that tooth loss, sometimes at the very end, it’ll chip at the edges and you can almost see through the enamel ’cause they’ve hollowed it out so much. Very difficult case to take care of because we want to do everything restoratively.
That’s a huge flaw in how we’ve been taught as restorative dentists to work when teeth wear they move and if they move you need to move them back. And so we should always think in terms of orthodontics first. So a wear case walks in your office, you figure out am I gonna move them back or is the orthodontist gonna move ’em back?
But somebody’s moving these teeth back where they used to be before I fix ’em ’cause you can fix ’em so much more conservatively that way. The only other option you have is open vertical dimension, in which case you’re doing all the teeth upper arch or lower arch or both arches, right? So huge amount of dentistry and most of our patients don’t need it and or can’t afford it. So we need to learn to integrate orthodontics in that regard as well.
Alright, back to the topic, which is this pathway wear, where the teeth are getting worn out. So we have for years said, that’s what happens. And people just nodded and said, yeah, that’s what happens. They hit the backs of the teeth and they can’t be restored there.
And so then we talk about orthodontically moving the teeth and here’s you have to put ’em back in the right. But we just made the assumption that happens, and I have this weird thing that I do, which is if I ever have a question, I go to the literature and if I go to the literature and can’t find an answer, I do experiments on my patients.
Now, I don’t tell ’em really. I just ask. I got this new toy you wanna play with it. And I got a lot of patients that are really fun, been around forever, so they love being involved in that stuff. So here’s what happened to me. I heard it from a lot of people. I heard those patients being called, like they chewed like rats.
So they just keep chewing. And I just wasn’t convinced that people would run into their teeth ’cause I never honestly banged into my teeth when I chewed. So I wasn’t convinced. So I went to the literature and then, you know what the literature says? The literature says that if you give people that have tight bites like that, so class two div two type patients.
You give them food and they chew, they never touch their front teeth. They’ll do anything in their power including mess up their joint to stay away from their front teeth. And I’m like, well those two things don’t work together ’cause I’m being told by really famous people that they do bang their teeth.
But I’m also being told by the research that watches ’em chew that they don’t touch their front teeth. So I went in and did the experiment on my patients to mimic what they did in the laboratory and I found that no one touched their front teeth. So started looking for different answers like. You know, what could it be? What could it be?
Well, now airway has entered my world, so I’m now in this airway world and I kind of lose focus on this chewing pattern thing. And one night, about three in the morning, I wake up and I’m like, I wonder if those two things are related to one another. And I got on the internet and I’m searching through the literature on PubMed, and I found a group that actually did a study where they did exactly the chewing study I was talking about, and found that no one hit their front teeth.
And then they said, what kind of sandwich do you want to have? Because if you think about it, all the people that break stuff in your practice, they break when they’re eating a sandwich. It always has bread involved in it somehow.
[Jaz]Always a soft one.
[Jeff]Yeah. So occasionally it’s hard foods, but almost all the time it’s like tuna fish salad sandwich, right? Something soft. And it has bread in there. And so this study did exactly that. What they found is that during a chewing cycle, you have to be able to manage your airway. You have to be able to breathe through your nose. People that are constricted in their bites like this. If their maxillas are constricted, and if their maxillas are constricted, then their nasal cavities constricted.
They can’t breathe well through their nose. And so if you go from giving a small piece of cheese or beef jerky or a peanut to chew, they can manage their airway, have ’em bite into a sandwich with a bunch of bread and a bunch of stuff in it, they can’t. So their chewing cycle will move forward and they’ll hit their front teeth.
In addition, apnea patients make their soft palate numb to holding a food bolus, and so the food wants to slip early on them and so they actually get out of normal chewing cycles a lot. So airway explains a lot of the reasons for tooth damage that we never had an explanation for in the past. We always just called it, this is what they do. They just do that. And we never knew why, and now we know.
[Jaz]That was brilliantly explained. Absolutely love that. And it makes so much sense. You also talked about, when I asked about the great bite, you mentioned a seated condyle position and you also said that, okay, well, in that hypothetical scenario where you have someone who has a restricted envelope function or constricted or basically a lack of overjet, deep bite, and if you open the vertical dimension, then again, perhaps overkill, where ortho is needed and just bringing all those themes together.
Do we have a concern in dentistry that when we are doing a rehab type case or when we are choosing to use a repeatable joint position, i.e. stable condyle position, seated condylar position, centric relation, call it what you will, that we are making the airway worse. But from the bulk of this discussion so far, I like how you’ve been addressing it from the maxilla and you’ve been talking about the maxilla predominantly.
Whereas quite often in my learning as well, I made a mistake of perhaps being a bit too focused on the mandible. And so what do you think about, if someone’s got a huge slide or they’ve got a long way to go back and that could be making the airway worse, what advice would you give to dentists? When we look at the joint position, when it comes to the airway?
[Jeff]Two things. One is you’re talking about a dual bite patient. A dual bite patient will have greater than three millimeters between their maximum cuspal position and their seated condylar position.
Interjection:Okay guys, interjection number two. What are TADS? So TADS are Temporary Anchorage Devices. They’re also called mini screws. And I’m gonna explain it very briefly like this. Imagine you are extruding a broken down premolar and the way you’re going to extrude this premolar, and actually this topic is on my mind at the moment ’cause I’m going on a course next month exactly about how to do more of these kind of cases where you take like a broken down premolar and you extrude it orthodontically.
Anyway, imagine you are extruding this and you are relying on the two teeth next door to extrude. Now imagine that as an unwanted consequence. Yes, the premolar extrudes but the two adjacent teeth, let’s say the canine and the other premolar, they end up intruding. So the premolar that’s broken down, we extruded orthodontically and the other two teeth, they intruded.
You could say that you lost anchorage or you didn’t have enough anchorage. Now imagine if the two teeth next door to that broken down premolar were implants. If they’re implants, they’re kind of like fused to the bone. And what then happens is the premolar extrudes. But nothing happens to the implants because the implants give you lots of anchorage.
And this is how clever ortho folk, they use these mini screws and temporary anchorage devices to do all sorts of crazy movements because it gives them skeletal anchorage. It reduces those unwanted movements. Back to the episode.
[Jaz]I’m happy to talk about that, but also just generally, like, we know that for most patients, their seated condyle position will be further backwards, further distal. So how do we know which patients can be making worse?
[Jeff]But not much. So my take on this and to my knowledge, there hasn’t ever been a study, so I don’t know of a study. So I’m gonna base this on my opinion ’cause I don’t know of literature. My opinion is that the patients that you and I deal with routinely, that all we’re doing is seeding and equilibrating to and keeping the vertical essentially the same.
Those patients that has no impact on their airway at all, the patient would do a dual bite. Absolutely is gonna have an impact ’cause you’re gonna drop ’em back significantly. But the one that people forget is, you were talking about doing a rehab, I would assume you were describing doing a rehabilitation in a seated position at an open vertical dimension.
[Jaz]Usually yes, we need the space. Teeth are worn right.
[Jeff] So when you open the vertical dimension, it will absolutely have an impact. And it’s usually negative.
[Jaz]So I guess what you’re trying to say also then is, sorry if I’m putting words in your mouth, but you know, correct me if I’m wrong here, is it’s the opening of the vertical dimension that is the sinner rather than the seating to a seated condyle position.
[Jeff]Yes, unless you’re talking about a dual bite patient. Okay, so if we take that case out of play, then yes. It’s the opening of the vertical dimension that is the problematic part of it. And unfortunately it hasn’t been studied a lot, but there have been three studies and every one of them shows when you take patients with mild to moderate apnea.
And you make ’em night guards and we’re talking just a classic one to two millimeter opening posteriorly, five millimeter open anterior, the one everybody makes that at least 50% of those patients are gonna get worse. And it’s usually somewhere between 60 and one study at a hundred percent of the patients.
Now the a hundred percent didn’t get much worse, but they got worse. So if you have a class two patient and you open their vertical for whatever the reason happens to be, there are airways already constricted anatomically, and now you, doubling up on, ’cause they’re actually down the arc already and you’re even like really gets bad fast.
Class two even worse than class one patients. So the vertical is the killer. Bill McCor taught me resolution before reconstruction. So McCor is a big gnathologist, lectured at AES and his idea was you need to get the joint healthy before you actually reconstruct. And so he would make orthotics before he would do reconstruction.
And his logic was that if opening the vertical dimension was a bad thing, then the patient would react badly. Well, that logic has gone away a hundred years ago. I mean, it just, no one believes that anymore. ’cause that if a person comes in in pain, you make ’em an orthotic and you open the vertical and so you’re making the thing to make ’em better that he thinks might have made it worse, but now that we have this airway data, you go, well, maybe there is something to it. ‘Cause maybe we go old school on this and make an orthotic at a proposed vertical dimension and see how they react to it. If they’re grinding really aggressively on the orthotic, you just made their airway worse.
If they get headaches, if they, whatever. I haven’t gotten there. I actually now watch my provisionals more than I used to in the past. I don’t trust my provisionals up front. I tend to stay with them longer if I’m opening the vertical a fair amount, so significant opening of the vertical dimension or more class two type of patient that I’m opening. I stay in provisionals longer just to see how they react ’cause I know I’m gonna probably be messing with their airway.
[Jaz]One school of thought that’s been shared to me is in those patients potentially with a dual bite or those who are, you are opening up significantly. So your vertical dimension increases quite significant due to the level of wear and compensation that’s happened.
And because you are opening up so much, there is a concern about the airway. And then therefore you may then not be choosing to use a repeatable condyle position, a seated condyle position. You’re using what they say, an arbitrary position, which could be further protruded or the mandible be set further forward. Do you have any concerns about using such a joint position, which many people with a dual bite may function on?
In terms of stability? Mostly in terms of stability ’cause I always think, okay, you build them there, but what’s gonna keep ’em there long term? Is that a way that you’ve managed your patients? What would you recommend to people who who’ve heard that advice?
[Jeff]Okay, so you had a lot of things in there. The first is people that had a lot of wear, they can either lose vertical or they don’t lose vertical, they just lose tooth structure, right? So if a person doesn’t lose vertical, just lose tooth structure, and then you open the vertical, now you’re impinging on the airway. If the person loses vertical and you open vertical, you’re actually just making ’em normal again.
[Jaz]You’re reestablishing what they had.
[Jeff]Potentially. You’ve normalized anatomy rather than altered anatomy. The dual bite patient, I tend to work to the bite, to the MIP position, and I remember having this epiphany and I had two denture patients in a row that had an old denture in like a class one setup that were all worn out, and I was making ’em a new one, and I put ’em in centric relation and they fell way back.
I was like, holy crap. And so I started trying to make their denture in that position and they go, I don’t like it back there. I don’t go back there. And I’m like, well, I mean, I was cocky.
[Jaz]I’ve been to this exact same thing, one year outta dental school. I remember this exact patient and how much he hated it and it was a huge slide. So yeah, definitely been there.
[Jeff]I’m the dentist. I know it was fast. I can’t control your occlusion unless I worked at this position. It was horrible. And finally, I remember in the end there were two patients in a row. It was weird ’cause it was like God was smacking me twice. You didn’t learn. Here there’s another one, there’s another, all these, keep sending ’em.
And I finally learned, right? The second one, I remember one day going, just bite wherever you want. And so she bit down and I made her denture there. It was fine. So I then like went, okay, I don’t need to work to a seated position. I can work to their maximum intercuspal position. What disadvantages are there when they chew hard foods?
The chewing data. Remember I said I kind of got into this looking at chewing data. The chewing data on hard foods says they seat their condyles, and so that’s where you damage second molars a lot is they put a piece of beef Turkey in their mouth. They have to load through the food, they will seat their condyles, they’ll hit posteriorly.
And so I try to mount them in the seated position and see if I can adjust that on the articulator. But I worked in the MIP position, so I just see if I can provide myself a little bit of a lack of interference in the seated position. But everything else is focused up front. The other one that’s interesting is since I got into the airway part that kind of feeds into this as well, is I went and took some courses in neuromuscular dentistry.
And so I started using. A TENS unit on patients that were those rat chewers, the pathway wear people that needed freedom-
[Jaz]Class 2 Div 2 type.
[Jeff]Yep. And then I married that information with MRIs on them, and what I’m finding is that the cases that work really well for neuromuscular dentistry are actually disc displacement cases where the condyle is back and down and the disc is slipped forward and is crowding the condyle out.
And if I either tenses them or I can just relax ’em on an orthotic, either way they tend to get to the same spot. But we’re not working down and forward on the eminence. We’re actually centering the condyle by giving ’em the freedom to go there. So, I don’t know, the airway stuff’s kind of opened up a lot of really cool different avenues to look at for like why things work.
Because you know, there are too many people that I think are smart people that do things differently than me that I just can’t understand why you would do that. And like, that’s not how I was taught. That can’t possibly work, but they’re smart people and they’re running good practices and I can’t believe they would just like do it wrong.
There’s gotta be something to it and airway really feeds a lot of answers or at least can. And so little things like that, like the neuromuscular people got such a bad wrap over here and were just berated every time they did anything. And I was like, those guys, they just can’t be wrong on everything. I do think they overuse it, but I think in the right cases it’s great. It works out perfectly. So I’ve done a few cases like that as a proof of concept.
[Jaz]What you said is very validating for me personally as someone who’s always wanting to learn from the different occlusion camps. And it ties in very nicely what AES is about nowadays in terms of bringing everyone together, sharing knowledge, different camps coming together, if you like.
And I always say that listen to everyone, but do what feels right to you. One of my listeners actually sent me that advice and I always like to share it. And so I always find that certain cases, some of the principles I’ve learned from the course of philosophy, they work really well here. Some things that work in this philosophy really well.
Just like you notice that okay, certain patients, what you’ve learned from neuromuscular dentistry can be applied well on those patients and I really admire that we can learn from everyone and then pick the right time to use that skill where it makes sense to you the most.
Jeff, we’re coming to the end of the time, I just wanna say, wow, that was just absolutely packed full of stories and interesting anatomical explorations. We focus a lot on the maxilla, which was very good for me. This is all learning for me as well, which is fantastic. Can you give us a flavor of what you’ll be talking about at AES in Feb 2026? I’ll put the links and everything below obviously.
[Jeff]Yeah, I’m gonna build on the idea almost exactly what we ended up with, which is questions you’ve always had in your practice that airway might explain and sort of a medical dental connection that the airway could be the component that we’ve been missing all along.
At least in my dental school, we didn’t study how people chew. We studied how an articulator moved around, right? So we forgot the biologic part of it. And we talked about my patient, bruxist, but we forgot there’s might be like, why? Why would they do that? And we really didn’t spend a ton of time, we talked about how to make a splint, right?
My patient bruxist is let’s make ’em a splint like we always are jumping to how do we fix something rather than asking why. Because if I can figure out why I might have all kinds of cool ways of dealing with the situation. So we’re gonna ask a lot of why questions. Why did this patient do this? Why did this patient do that?
And obviously because of the topic and the title, the answer’s gonna be airway. So if at any point I ask the audience like, well, what do you think? Just answer airway, you’re gonna probably be right.
[Jaz]That sounds amazing. And over the years, what does the AES mean to you and why should some of our younger colleagues around the world visit this conference in Chicago?
[Jeff]I have to get ’em to add it up. I’ve at least lectured five times, maybe way more than that. I probably have lectured there more than anywhere else in any big conference. And so I’ve gotten to watch it evolve over time. If I was to kind of give you an idea, actually you summarized it really well, it’s because it looks at the broader scope.
It’s not exclusionary to any different perspective, even some that you would consider sort of out there. Neuromuscular has been at this conference a lot. Like the best people in neuromuscular have spoken a bunch at this conference. And the other beautiful thing about is they’ll put ’em on panels with people like you were talking about today.
We talked a lot about the maxilla. Well I was on a panel with Jim McKee and Mark Piper, they’re the mandible. And so I just kept saying, you gotta get the maxilla in the right place. You know, the mandible follows the maxilla. And so we have this debate and then the audience gets to be involved in that debate.
So I don’t know of any other conference that allows that unique of a format and breadth of information. Like AES. So if I was, coming to Chicago, absolutely, the AES starts the week. So it’s a Wednesday, Thursday conference, and there’s no better way to start the week than at the Equilibration Society.
[Jaz]And most importantly, Jeff, where is the place to eat when they’re in Chicago?
[Jeff]So this one’s one that it’s, you need to save for a long time. Alinea is the best restaurant in Chicago, and it’s gonna cost you so much money. It’s crazy.
[Jaz]But it’s all tax deductible. It’s fine.
[Jeff]Alinea is phenomenal. It’s a, actually everyone needs to have one of those kinds of experiences and then go back to your practice and try to make your practice like Alinea, because it’s just service at a higher level and thinking about every detail instead of, you know, like I walk into my practice and every day I enter from the back, but I try to go to the front and walk through my practice as if I’m walking through as a patient.
And I’m looking at everything. I’m looking at it as a trashcan full. We need to get rid of that. Is anything dirty? Is there a book out of place? Is there I looking, is there anything that a patient might see? And then I listen constantly to how do my staff talks to people and Alinea does a beautiful job. So that would be-
[Jaz]There we are another learning experience through that. Thanks for that share. I’ll make my reservation well in advance before people listen to this podcast and it’s oversubscribed on that Wednesday night. Jeff, for those who are hungry to learn more from you, I know you’ve got so much, you’ve contributed in terms of, in the form of education, so many programs that you deliver. Where’s the best place to book some of your courses and learn more from you?
[Jeff]So it’s my main place to lecture about this is at Spear Education. Spear education’s in Scottsdale, Arizona. It’s a beautiful teaching institute, and the seminars are two days long. The workshops are three days long. But for a lot of your listeners, that’s gonna be quite a bit of traveling to do.
And me personally, I’m cheap. And so, although I just told you about expensive dinner, but I’m really cheap if I’m trying to make a decision about continuing education or whatever I want to know, I’m gonna have value when I get there. One of the things you can do is go to Spear Education and get in the online platform, in which case you’ll see all the videos, we produce all the courses, and you can actually watch some of the stuff in advance of coming to Spear and you’ll see the value behind the education that we give you at Spear.
So that’d be the introduction I would have if I was living somewhere else. If I was in England, I would watch the online platform and go, okay, that’s something I want to do. Or, I mean, we’ve got courses and everything, so if you happen to be working tomorrow and you’ve got a horizontal root fracture and you want to know what to do about it, we’ve got courses that you just pop on, like a YouTube video and you’ll find out in five minutes what to do with that particular case. So we’ve got all kinds of things, but airway is part of it.
[Jaz]Amazing. I can definitely vouch for the quality of educational videos on Spear Education website as well. So I’ll put the links on there, especially to your stuff on there as well.
[Jeff]Oh, you know what else I got coming? Oh Jaz, I forgot about this, that global diagnosis textbook I wrote with Bill? We got a second edition coming. It’ll have airway in it.
[Jaz]When’s it coming out?
[Jeff]Oh, I don’t know. Whenever I finish writing my chapters, he just yelled at me last night about it. I’m thinking probably the end of the year. So Quintessence and handles it and so they’ll Bill announce it.
[Jaz]Amazing. I can’t wait to get a copy and I’ll get signed by you personally when I see you in Feb. Awesome. I’m very excited to meet you in person, but thanks for giving up the time to speak about something that’s so dear to your heart. And I think we can all just learn more about this because the impact, like you said, will have on our patients will be so great.
And anyone out there in a position of which way to pivot their career, the early in the career, which way to pivot, then what a wonderful direction to go in, with a health focus and the ability to help children in all ages actually. But such a positive influence you can have. And I think that’s something definitely I’ve picked up today. So thanks so much, Jeff.
[Jeff]Oh, you’re welcome. Thanks for having me.
Jaz’s Outro:Well, there we have it my friends, thank you so much for sticking all the way to the end. Some really great points that Jeff raised there, how the airway is there to explain so many things that are almost unexplained or unanswered.
So I’m really looking forward to his talk next year. Also, highly recommend his textbook Global Diagnosis. I know the second edition will be coming out probably, I think at the end of the year. But I’ll put a link to his excellent textbook. If you have access to it, please do check it out. If you’re like a student and you have this book in a library, then please get it.
If not, then tell your librarian, you need to get this book. It is phenomenal. Once again, this was an AES takeover episode, so please do consider coming to join us in Chicago in February, 2026. It’s on the Wednesday and Thursday. That’s the AES conference, 18th and 19th of Feb. And it’d be great to to see you there. Come and say hello. If this podcast is the reason you ended up at the AES, please do come and say hello.
Now, just to wrap up for those Protruserati who are subscribers to Protrusive Guidance. Thank you so much. This episode is very much eligible for CE Credits or CPD. We are a PACE approved education provider.
As you’re watching in the app, just scroll down, answer the quiz, get 80%, and our CPD Queen Mari will email you a certificate. In fact, what we do is every quarter we’d email you your personal dry folder with all the certificates that you’ve collected from the podcast episodes and our mini courses on the Protrusive Guidance platform.
More than the education, it’s about the people. Now we’ve really attracted the nicest and geekiest dentist in the world. The reason I specify that is I’m trying to attract people who listen to the podcast, but who identify themselves as nice and geeky. And for those who don’t, they stay away. And that’s amazing ’cause I’m trying to build a special group of people, people who can share failures with each other, be a little bit vulnerable, and it is very much a protected space.
We have to manually verify each person who applies to come on Protrusive Guidance. So if this sounds like your bag, then check out Protrusive app that’s www.protrusive.app sign up, and it’d be great to see you there. Whether you want to get the CPD or just join the community, it’d be nice to have you.
Thanks for listening, watching, or wherever you’re tuning in from today. Don’t forget to leave a review. I read every single one, whether that’s on Spotify or Apple Podcasts, wherever you are checking this out today and a thumbs up button on YouTube. Thank you. Once again, Protruserati. Catch you, same time, same place next week.
Bye for now.

Jun 19, 2025 • 1h 19min
Why Injection Moulding Composite is Superior to Layering – PDP228
Have you actually looked back at your long-term cases to see how layering compares to injection moulding?
Is traditional freehand layering still your go-to for anterior composite aesthetics?
Are you using it because it gives the best result — or just because that’s how you were trained?
In this episode, Dr. Marco Maiolino joins Jaz Gulati for a meaty discussion about injection moulding—a technique that’s changing the game in anterior composites (and posterior!)
This isn’t about trends. It’s about clinical outcomes.
We’ve all admired the beauty of layered composites—translucency, halo, the “natural” look. But after 5, 7, or even 10 years… do they hold up?
Dr. Maiolino brings over a decade of follow-up data—and the results might surprise you.
https://youtu.be/wHs8QQkgPhU
Watch PDP228 on Youtube
Protrusive Dental Pearl
When in doubt between two shades (e.g., A1 vs. A2), always choose the lighter shade. Higher-value shades blend better and result in higher patient satisfaction.
Techniques: Use the composite button method and black-and-white photography to objectively evaluate shade blending.
Outcome: Lighter shades minimize the risk of patient dissatisfaction and rework.
🎁 Download the full Premium Notes for this episode—including clinical comparison of injection moulding and layering technique, long-term before/after documentation, and Marco’s complete injection moulding protocol: 👉 protrusive.co.uk/im
Need to Read it? Check out the Full Episode Transcript below!
Key Clinical Takeaways
Injected composites often outperform layered ones in long-term follow-up.
Color stability is as much about technique as it is about material selection.
Edge bonding requires careful occlusal planning and respect for functional dynamics.
The biologic cost of veneers is frequently underestimated—additive approaches can be more conservative.
Composite thickness and occlusal harmony are critical for restoration longevity.
Rigorous documentation and honest case review matter more than dramatic presentations.
Failures are not setbacks—they are opportunities for professional growth and better patient care.
Episode Highlights:
0:00 Introduction
02:45 Protrusive Dental Pearl: Practical shade selection hacks
08:54 Dr. Marco’s journey into injection moulding
15:44 Why Marco transitioned away from layering
18:00 Edge Bonding and Occlusion Considerations
25:20 Layering vs. Injection Moulding
29:15 Variations of Injection Moulding Techniques
32:32 Injection Moulding for Edge Bonding
39:29 Edge Bonding Protocol and Materials
49:18 Understanding Failures and Diagnostics
53:23 Managing Tooth Wear with Injection Moulding
55:47 DAHL Approach Complexity and Cost
56:41 Swallowing Patterns Affecting Treatment Success
01:00:07 Importance of Case Selection
01:01:08 Rubber Dam Use
01:03:17 Flexible Use of Techniques
01:17:24 Outro
📅Upcoming Talks & Courses
Dr. Marco Maiolino will be one of the notable speakers at the Injectable Restorations European Summit 2025, taking place on November 7–8, 2025. This highly anticipated event gathers leading experts in the field and will be held in Europe. For more information and registration details, visit the official website: injectionsummit.eu.
If you loved this episode, be sure to watch Stop Being a Perfectionist – it’s OK to Fail – PDP184
#PDPMainEpisodes #OrthoRestorative
This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.
This episode meets GDC Outcomes C and D
AGD Subject Code: 250 Operative (Restorative) Dentistry (Direct restorations)
As clinicians, we’re constantly challenged to balance esthetics, function, and longevity in our restorative work. In this episode, Dr. Marco Maiolino joins Jaz Gulati for a candid, evidence-driven exploration of injection moulding—a technique that’s rapidly shifting the paradigm in anterior composite restorations. This isn’t about chasing trends; it’s about critically evaluating what truly works for our patients over the long haul.
Dentists will be able to:
1. Understand the indications, benefits, and limitations of edge bonding and injection moulding.
2. Recognize how minimally invasive dentistry can provide reversible, conservative treatment options. 3. Appreciate the importance of proper planning and case selection when using techniques like injection moulding.
Click below for full episode transcript:
Teaser: More layers you do, in my experience, more aging, you will get on that restoration. So if you see in my office, I have just three comp, I have a A1, A2, A3. So injection moulding is a way to apply composite that for me is the best.
Teaser:I’m glad you mentioned it, that you are so convinced and dedicated to the injection moulding way to deliver a restoration that you’ve pretty much now found ways. As long as you can make your scaffold.
On the mesial distal, you have some composite with just one shade. Now this brown area is much more evident than before. So the patient completed the appointment. Saying, I am very happy. I have no more black triangles. I am very happy. But when you’re doing a study patient with the worn dentition because of occlusal problem, if you are going to do, for example, an important canine guidance, an important incisal guidance, they’re going to break everything after a while.
But honestly, when I see with air drying the restorations with magnification, and I see the interproximal surfaces in comparison to the surface that I have with injection moulding with matrices. This surface-
Is there a composite that you found to have superior longevity in terms of color stability, polishability? Is it a 3M Filtek? Is it Estelite? I dunno, what are you preferring nowadays?
Okay. What I use every single day in my life is I use-
Jaz’s Introduction:Protruserati, there’s been a big shift over the years towards injection molding. Now, some of this has been driven by the industry, of course, right? So we always have to be careful about biases.
Biases are everywhere. Now, use this technique, use that technique because there’s a lot of money involved for these companies. But what I look for is clinicians that change, that pivot from a technique that’s perhaps established and we know of, and they pivot and change to a different technique. And if they can justify why they’ve made that change and share the science or the rationale, I like when something is justified.
There is a clear science behind a decision that’s made by a clinician that’s fantastic. Rather than, oh, this company’s paying me. So I’m talking more about this product. This is why I really respect today’s guest, Dr. Marco Maiolino. We’ve had him on as a guest before on the imperfect dentist. He is such an authentic character.
He talks about his failures very openly, and it’s his failures in layering over time, right? He shares the long-term data of seeing his composites and he is a very good practitioner. High quality isolation, high quality materials microscope, everything. But what he noticed at the eight, 10 year mark is that his layered composites were not looking very aesthetic despite using the best materials and best techniques.
They certainly did not look as lovely as they did at day one. So many years ago. He moved, I believe he said 2014, he moved towards injection molding. Now when I say injection molding, you guys probably think, oh, exaclear or memosil stent, and then you inject the genial injectable composite or any other composite that may be available.
But actually, injection molding is just the name of the technique, the act of injecting into a space. So this could be bioclear or these transparent matrices. It could be just a humble mylar strip behind a tooth, and then you inject the composite into that space once you’ve made your scaffolding.
So really, this episode is about the process of injecting that material and why the injection of composite is superior according to Marco than layering bit by bit and some of the issues that you can face with that, and why in the long run, whilst your layered composite may look a little bit more beautiful, a little bit nicer on day one compared to your injected composite, when you look at them at eight, 10 years, the injected composite looks more consistent, more stable, both types of color. Luster, shape, all those things. So there is a science behind it. And to discuss that science we have Dr. Marco.
Dental PearlHello Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode I give you a Protrusive Dental pearl. Today’s pearl is something I shared a few weeks ago on our community Protrusive Guidance, the home of the nicest and geekiest dentist in the world.
And it’s about my thoughts on shade selection on composite. Now, in previous pearls, I have discussed the button technique. Getting a small button of composite, curing it, and then having a look. Hmm, does it match the adjacent tooth? Is this gonna be the right shade to use for my patient? And in another episode we did with Dr. Jason Smithson, he talked about using a black and white photos.
So as you’re doing the shade test, you taking a black and white photo of your patient, you can use a phone for this and see, hmm, what’s the blend looking like in this black and white photo. But I’ll tell you one thing I’ve picked up through experience call it wisdom.
Call it Learning from Failures, is that if I’m not sure, between, let’s say an A1 and A2, just to make it really easy to understand and clear if I’m unsure. Ah, it’s kind of A1. It’s kind of A2. They’re both matching. Please, for the love of God, use A1. Okay, use the lighter shade.
In my career so far, every time I’ve opted for this, slightly darker, ’cause this will match better, it’s been more risky and in some occasions it just wasn’t light enough. I’ve been disappointed at the end, and there’s more risk that the patient will say something that, ah, they’re not a hundred percent happy. But where I’ve used the whiter shade, then you know what, no one ever complains.
Everyone’s happy. I’m happy. And I just made it a rule. Okay? My rule is if I’m undecided between two shades, whichever one has a higher value, that’s the one I will use. It’s a really stupid thing, really, but sometimes when you are stuck in that scenario thinking, Hmm, what do I do? Just remember this rule and make it easier for yourself.
Pick the lighter one and you shall be much happier, or it’s gonna be just a more predictable decision. Now one more announcement, my friends is with Protrusive, we’ve grown so much over the years, and I’m constantly looking to strive for better. How can we serve you better? How can we serve our community better?
How can we make learning more fun, more impactful, more actionable, easier to implement? And so some years ago, we introduced the Premium Notes. The revision PDF we have accompanying each episode as like a cheat sheet, a guide, an aid memoir, a quick reference to the main lessons that you picked up ’cause sometimes there’s so many lessons you might pick up in an episode and it’s difficult to implement.
But when you have it also in writing that you can highlight, it can follow along. It makes it easier for things to stick. But I’m pleased to announce that we’ve taken this to the next level. Now we now have a section called PITC. This is called Patient in the Chair. The best example of this is when you have a patient who’s had trauma in the chair, like an avulsion or something, what do we all do?
Even though we all kind of know what to do when there’s an avulsion, we still look at the guidelines ’cause we just want that quick reference and we wanna be sure that we’re doing the best thing. Now, anytime something is shared on the podcast, which is like really important, really worthy of a quick reference.
We are gonna put it right at the top, and we call it PITC. These are the one to three things in this podcast that you just need to know, and it makes it like a lovely quick reference. Oh, what’s that thing that Marco and Jaz said in that podcast? Now you’ll see it right at the top. You’ll also see that our Premium Notes are more visual than ever before.
And all the key takeaways summarize without any waffle. Think of that dental student that had the best notes at school, and everyone copied their notes is kind of like that. It’s like the revision notes of your favorite podcast episode. Now this is a paid feature, so if you’re on Protrusive Guidance, if you’re on a paid plan, you can access the Protrusive Vault, which has all of our infographics, all of our premium notes, all of our premium resources.
Every episode takes a team hundreds of hours to put together, including the PDF transcript, including this extra premium note with references and visuals. Now to celebrate the launch of this new style of premium note. I’m gonna give away this episode’s premium note for free. It’s a wonderful summary of everything that me and Marco discussed in this episode.
Complete with the visuals in case we’re listing on Spotify or Apple, and you want to see some of the visuals that before and after of how composites don’t look so good when you layer versus how good they can look when you injection mold. All the visuals stacked in there, any references that we think you might need, all the references that you should really read, all the key references, the key takeaways, the visuals that really add to the episode and enhance your learning.
Everything is there so you can download it for free as a taster, as a gift from Uncle Jaz to celebrate this upgrade that we’re doing. If you wanna get your hands on it, check out protrusive.co.uk/im just the two letters, right? Injection molding. protrusive.co.uk/im. If you are already watching this on Protrusive Guidance, don’t worry.
You don’t need to do that. You can just scroll down on the app and it is available under this episode as a download. But if you’re not on the app yet and you wanna check out this download really quickly, just head over to that site and you can download this news style premium notes for free. Let’s now catch Dr. Marco and I’ll catch you in the outro.
Main Episode:Dr. Marco Maiolino, my good friend, just every time I see your cases online, every time I see you come, I think of a wonderful time that we had at your course in Syracuse in Sicily. I still remember Granita, I still remember the culinary experience that you gave us. And if anyone wants to go on a hands-on course of Verti prep scene to check out Marco.
But another one of your passions, Marco, is injection molding, bioclear. And I really wanted to speak to you about these topics. Now, I’m gonna tell everyone to listen to our previous episode we did, the Imperfect Dentist. A good lesson you passed on is that if we strive to your perfect every day, we’ll be miserable.
And to aim for a consistent seven, eight out of 10 rather than three and 10 and three and 10, that kind of stuff. So just summarizing that episode. So I encourage everyone to listen to that. But Marco, just tell people who may be new dentists who haven’t seen your stuff. What do you stand for? Tell us about yourself, Marco.
[Marco]Okay. It’s a pleasure to be here again, also because with just, we had the wonderful experience of being in the real life together because we did the vertical course, the real one, the three days course here in Sicily, and we’ve been enjoying a lot of time together. So this has been a huge pleasure to see Jaz in the real life and to see-
[Jaz]And even though Marco has no interest in football, he still took us by the seaside to see the match.
[Marco]Yeah.
[Jaz]I think it was Italy, Switzerland. I think Italy lost. It was sad. But you were in the sea, you were having fun. You were with your family and friends. It was nice actually. So.
[Marco]For me, the course is not just the course about speaking and doing something about dentists, something like about enjoying. The reason, because I do the course is a small course with just six, seven people is because I really want to do a real connection with each one, because sometimes I do bigger courses, not in my town, but abroad with 25, 35 person. But for me, and even for them, I think this is not absolutely the same thing.
The connection that you have when you are in few people. You go outside for a dinner, you go outside for the lunch, and you spend time joking about everything. It’s the time that you cannot compare with other kind of situations. About me, just because of course. I just want to introduce a little bit. I am a general dentist, a real general dentist.
I do almost everything in my office. Of course, I do also wisdom teeth. I do implantologists, I do implants, I do soft tissue, I do mucogingival surgery, I do everything. But of course, most of the people know me for two main things because I have something that it is a little bit more different to say, and it is about restorative dentistry, because in this field I have my own ideas.
And about prosthetic dentistry because I started working now 15 years ago with vertical preparations. And so I have 15 years of experience and follow up. So on these two fields, I have something more to say. When just came in Sicily apart, the Granita Granola Pizza and all the other incredible things that we do in Italy, we spent three days talking about relations, Arancini.
And also, I love reading. I am an obsessive reader. I read something like between 40 to 50 books every year and I love to read about psychology, management, all these kind of things.
[Jaz]So what are you reading right now, Marco? Tell us what you’re reading right now. What’s the flavor of the month?
[Marco]Okay. In this month I’m reading a book from [inaudible]. He is one of the most famous anti-aging doctors that we [have] in Italy, because I am very well into these kind of things. I know cold shower, sports, fitness, nutrition, and all these kind of things. I am very well to these kind of things because I have to work at least until my 85 years old. I have to see all the other doctors in the coffin and I will gain in that way with my handpiece working on the, this is the plan.
After I am reading on another book that it is Martin Jan Stransky,. It’s about the collapse of our mind. It’s a book about how today, especially on children, the exposure that we have about social media, iPhones, these kind of things, it seems that our children are the first generation that are starting to have a sort of devolution in the last million of years.
We always went through an evolution, but this is that from this point on in this century, now we are doing a sort of devolution. So it’s something that is interesting about, it explains how the brain is working, all the psychology behind the brain and about what happens when, since you are very young, you expose yourself to social connections or social media connections. These are two completely different things. And I think that this will be also a challenge-
[Jaz]A real connection and a junk connection.
[Marco]Yes. We are living in a strange period. Like for example, just to say about the first topic. It’s a strange period because there is a lot of discussion about, for example, nutrition, about fitness, about all these things.
A lot of education of content. Yet the number of people with obesity is always rising. The number of people with diabetes is always rising. So there is a sort of mismatch between what we know and what we say and what really happens. And this is the same thing that happens in industry sometimes because we talk about that.
And this is also the reason because I’ve been lobbying the other episode about perfectionist, because sometimes this is the missing link. Because when there is a huge gap between what we say and what we do, it means that there is something that it is wrong about that. And what I want to do in my dentistry, in my life, this is me, you wrote me.
It is about closing the gap between these two things. This is reason because I’m not a perfectionist. I share my cases and I want to do perfect cases, but I am perfectly fine with doing good average cases because this is my real life. But when I am able to do an alignment between what I say and what I do, I think that this is the best example that you can give to people.
Honestly, because you can teach what you are. When you are teaching something that it is not your real everyday life, there is a gap and the message is wrong, in my opinion. This is the reason, because I have not very good relation with several speakers because for them I’m doing slightly more than average dentistry.
But for me, they’re doing something that’s different, that it is just a sort of cinema, because it’s easy to bring five cases in the near and to bring five perfect cases when you have the possibility to choose the patient, choose the case, choose the time. Because if you take five hours for doing two empty restoration, okay, of course you’ll be able to do to great restoration, but this is something that it is not real.
Also, the obsession that we have about photography. Okay, I cannot talk, I mean, I have bouncer, I have here, I have everything. But there is a huge difference about the approach because something is to consider the documentation in the real value that it is to follow up cases. I did this 10 years ago. Let’s say what happens now, and this is what today, for example, we share, because sometimes I joke about I am a layering survivor.
[Jaz]You’re layering what, sorry?
[Marco]Survivor.
[Jaz]Okay.
[Marco]To survive.
[Jaz]You survive layering.
[Marco]Survive. Perfect. Yes. Because my follow up on layering, for example, is not that great at seven, 18 years and it is something that I saw on a constant basis. It said my follow up injection molding that it is the main topic that we are going to discuss today, and this is also something that I’m going to organize something, you know in Milan at the end of the year is because I saw result that are less statistic.
Of course we are talking about a more concrete dentistry, but the result is much more stable over years. And I’m much more interested in the long-term follow up than on doing the artist day zero. When you do just the fourth at the end of the work and nobody knows what happens after five years, seven or even 10 years.
Most of our patients are much more connected with the long-term result and for the result that they are able to perceive. Because honestly, I have never a complain about the lack of opalescence about an intensive milky on one mamelon. Never. I have complain about the shape. I have complained about the triangle.
I have a complain about the leg of in insiders. So there are things that are much more important if we want to talk about real dentistry. Real dentistry, I mean the dentistry that you need to be successful in the real life of your town. There is another dentistry that, it is the dentistry that we like to share instead of social media on congresses. But it’s like real life and cinema. I am much more for real life. I’m not the guy aiming for the cinema’s approach. It’s just me.
[Jaz]It’s what I love about you, Marco, is the word to describe. It would be authentic, authenticity is there and that’s so, so important in today’s world full of social media dentistry, and I love this fresh injection of authenticity.
Now, you mentioned about following up these cases and how people don’t actually care about the tiny little details is the bigger picture, which makes sense. And it’s like the Pareto principle, right? 80% of the magic comes from the 20%, the overall shape really, and how you finish it to a seamless transition.
And then with that you get 80% of the benefit and then you can follow that up long term with success. And that is the definition of success. Now, today’s episode I want to just cover ’cause there’s so many different ways we can approach the different ways that we can do an anterior composite buildup.
So what I wanted to present with you, maybe I thought this structure may be better, is that if I give you three to five real world examples, and if you suggest, okay, in this example my preferred technique is A, B, C, or D, and then you say, why. Now obviously there’s so many ways to do it, but people may be inspired or maybe they have, ah, okay, this makes sense.
So if we start with edge bonding, every time I post about edge bonding people in the US they say, I dunno what that means. What is edge bonding? Okay, so just to clarify guys, what we mean by edge bonding is the patient has finished aligners, the teeth are a little bit short, maybe they’ve had a bit of incisal wear and you are just lengthening the teeth without having to veneer the entire labial surface.
It’s just composite on the edges. Yes, you will do a transition, but in your edge bonding cases, Marco, what kind of techniques and tools do you like to follow and use? Is it freehand? Is it led by a wax up always? Is it led bioclear, whatever it could be? How do you like to do your edge bonding, let’s say after aligners?
[Marco]Okay. The problem about edge bonding is that most of my cases about edge bonding are cases after orthodontics because the problem that I see is that when you have patients with some wear, with some fractures, there is 99%, unless there was a trauma, there is a problem of occlusion because my worst failures have been when I’ve been dealing with patients with worn dentitions and have been working just from canine to canine, doing an increase of the length doing veneers in these cases without changing the vertical dimension of occlusion.
So before, to talk about the technique about edge bonding, injection molding is about talking about little bit about occlusion and and I know that an occlusion you are one that it is very well into this kind of field. What I see is that because my experience is that you have never increase the overbite of a patient.
Especially if there is a patient with some parafunction or with some wear. So the main problem is to say, I do edge bonding when I have this kind of patient, but after orthodontics. So if there was, for example, a deep bite, I’m opening the bite and I’m opening a bite a lot, at that point I can edge bonding about edge bonding.
The same is about anterior restoration. The most important part, and I did this mistake despite of this just two days ago, is about the color of the tooth. Because we can do edge bonding, we can do parts restoration when we have easy shades. I mean, you take the Vita shade, A1, A2, A3, and you have the surface of the tooth that it is matching with that color.
In this way, doing just a little bit of bevel is very easy to do a nice transition, even if we have to remember always that composite is material, especially when we are going to do addition on dentine that you need certain amount of thickness. And this is another point that people doing layering many times in order to get a little bit more of transparency, they’re doing very thin restorations.
And when I was doing these thin restorations, the typical outcome after one or two years, that was a small chip of the incisal margin, the incisal margin, asked to be thick, big goes composite is not ceramic. David Clark, that many things, he has been a pioneer, says that composite has to be minimum two millimeters thick on incisal margin.
Of course. When you have two millimeter with two millimeter, of course you are going to struggle if you want to do all these special effects in the incisal term. But if you’re going to discuss about the long term longevity of this restoration, you are not able to match the result of David does because you know the problem is the approach in your dentistry.
You want to be the artist or you want to be the engineer. In this moment, I’m doing a new office. You remember when you were in Syracuse, in my office, every single week. I have a struggle between my architect that it is focused on the static of the office, and he said there is the engineer that it is focused on.
For example, said on the stability at 10, 15, 20 years of the office, the same problem we have in dentist. The problem is that in a villa, in an office, in a house, the aesthetic is very important. Instead in the dental office, how much is important, the aesthetic for the patient, because aesthetic for the patient is completely different from the aesthetic for the dentist.
There is a mismatch between these two things. So what I did in these years has been two find tune my aesthetic perception to the real one of the people that it is paying for the work. So most of the times monolithic restoration are more than enough for this patient and they reserve veneers for some of them, but just for some of these patient, fewer of our patients really needs the plus value of indirect ceramic veneers.
Also, because there is a different biologic price. When I’m working with direct restoration, most of the times I can work in a very minimal approach or no prep approach when you’re doing veneers, that with veneers, there is the problem of the axis of insertion, and there is a huge biological price sometimes.
There is always this sort of legend about veneers that you can do. Always minimal veneers, no prep veneers. But in the reality, the cases that are ideal for no prep veneers or minimally invasive veneers are not so many. They are the exception. And when you are dealing with diastema or black triangles, the coverage for veneers in this cases is quite invasive because in order to manage the diastema or a black triangle, the preparation to arrive on the palatal side.
And you have also to go in the sulcus, subgingivally because in order to shape the emergency profile. So I think that sometimes we complicate our life to we as dentists and to our patients more than we need. And the layering is something that in the last years I realized that most of the layering in the restorative dentistry is much more complication than something that helps us.
Especially because that I have some cases that I can show you. Okay, so for example, okay, in such cases when, for example, anterior restoration, this is restoration a case of with 10 years of follow up, what is interesting to see is what? I did the conventional restoration layering, in this case, after a conventional preparation with a small bevel, I did all the steps that we know and I did what? I placed two layers of dentine.
One layer in the parallel shell of enamel, another layer of enamel in the top, and they put some special effects. The result at the beginning of the work in 2014 was quite good, but if you see what happens after 10 years, it’s something that is unbelievable because this is something that I realized very well with David Clark, is what composite is a material with a strange behavior.
If you see, now, I can show you, for example, if you see the surface that we have when we work with composite, just with the spot, just putting the composite in such a way, and you see instead the composite that we have with injection molding, it seems that you’re working with two very different materials.
With injection molding, you always get a surface that it is like glass, it’s shiny. There are zero bubbles, zero void, and zero porosity. When you’re working, say with your puddle, you always, this is my experience several times, even outside of the mouth, you know there also to collect cases, to do some documentation, you have always bubble void proposities, and the initial layer that you do there is a sort of transition between the layers that exposes the composite over time to water absorption and to accelerated edging.
More layers you do, in my experience, more edging you will get on that restoration and I can show you several cases like the one we’ve been discussing now, several cases and up 10 years. The outcome is always poor. When I do the same instead of injection molding because I started injecting my cases in 2014, so now I am close to my 11 years follow up.
I can show you some cases if you want. The follow up at 10 years of this case with injection molding. They are very similar to the first year of work, so injection molding.
[Jaz]I think the lesson here is the way that you choose to handle composite has a significant bearing. You could use the same composite handled in two different ways and then-
[Marco]Yes, the same composite. This is the case that I did for example, in similar case, it’s very similar to the other one. On this incisor, there is a restoration always with, but injection molding, one layer. And if you see the follow up at 10 years, this is the 10 years follow up on two to 1.1. You see that the edging of the incisal area is almost zero.
[Jaz]So for those listening on the podcast, he showed a layered case, and Marco’s a very skilled, gifted dentist. And no offense, Marco, but that 10 year case looked like maybe a student had done it right at 10 years. And that’s done by a skilled practitioner. The injected case you showed, it looked flawless at 10 years. And so the comparison there is very stuck.
[Marco]Yes. This is another case just to say, it says, with a broken incisor of such a way, look, the difference that we can get. This is at one month. You see, I did the layering with three dentine. I did the primary anatomy, secondary anatomy. You can see everything here. I did the opalescence in the incisal third, but the look after 10 years, again, this is short, very short.
And the opacity that, the etching that you have in the composite is something that it is unbelievable. And if I do the same case with injection molding, instead the composite is able to preserve its optical and physical properties in completely different way. This is the reason because I said that I am a layering survival.
And because I stopped layering my cases now since many years because when you start to collect your follow ups, and this is the real value that we have in using every single day, our photographic machine, our camera is this, not using the bouncer to improve our cases just with proper lighting and transform a dental office in a photo studio with the papers bouncers five, this is craziness.
Sometimes it seems that we lose what is the main point of our work. The main point of our work is not to the show. The show is just for the dentist. It’s something that, it’s very true. Sometimes I think, yes, sometimes we are the push from social media, from courses, congresses, where you raise the bar, but you raise the bar in a bit different direction.
It’s like, for example, I am passionate about fitness. But if you go on social media about fitness, you see just people with six packs, arms like this. But we all know how you can get this kind of body, and it is not just with training and nutrition. It’s adding other things that I don’t want to discuss, but you know that when you do that, I do fitness in order to be able to work at 85 years old just to say they are doing, just in order to have an aesthetic boost.
But after 10 years of that life, what is left me is fitness for longevity. Fitness for health. This is fitness just for aesthetic. It’s the same thing. And in dentist with social media. And also I am sad to say that the most of scientific association, the push is always in the bad direction. It’s always about the aesthetic.
This is my feeling is that if you look at injection molding, another case with injection molding, this is the follow up at 10 years. This is two restoration on the distal part of the lateral and on the medial of canine. This is a patient that it is not a very good patient with is plaque. You see that the edging of the restoration is almost zero. Another patient with a very complicated case with subgingival margin, with very tough cases. But at six years, this is the follow up that we can get with injection molding.
[Jaz]So this is with the bioclear technique though, right? That would be a posterior bioclear, I imagine.
[Marco]Yes. This is a posterior bioclear, but it is not about bioclear. The point is a one there is injection molding is a way to apply composite in your restorative workflow. At the beginning in 2014, I was doing injection molding also with metal matrices with the TOR matrices with saddle matrices. So injection, of course, with the metal matrices, we have to change a little bit because the polymerization is different, but injection molding is a technique.
How to apply composite? After is what is your restorative workflow, and here we can discuss about metal matrices, TOR VM Matrices, bioclear matrices. Of course, bioclear have been designed in order to take all the advantages of injection molding, but you can do injection molding also with other techniques, honestly.
So injection molding is a way to apply composite that for me is the best. If you have to work with the composite, of course, after we can discuss about the restorative strategies, because what is interesting is that nowadays we have several strategies because you can do injection molding with bioclear matrices.
And I am a Canadian leader about this technique, but there are several interesting techniques. There is the iVeneer technique of an Israeli guy Itay Mishaeloff did other kind of matrices that are very smart in the idea. I don’t know. Do you know iVeneer ?
[Jaz]No.
[Marco]It’s another technique. Itay Mishaeloff , This Israeli doctor did different veneers that are going to shape all the buccals of face. I have some video if you want. I don’t know if we lose something about people that will listen, but I have some video about this technique. However, it’s a matrix that it is covering the buccal wall and you are going to print with the ready premade matrix. All the buccals surface. So you have what? You have in your kit, you have matrices with whom.
You can shape the buccal surface in a very good way using always an injection molding technique because the matrix as a whole where you can put your material, or like for example, Marco, because it would be the spear in the summit that I’m going to organize about this topic in November. He is doing what he is doing an impression of the patient.
They are also also [inaudible], you know, he is another speaker about this topic. They’re going to do what? They do an impression and you can do the impression digital or analog. You are doing the wax, again, digital or analogic of the case. They are doing the silicone matrix with the transplant material and they’re using the silicone matrix with some holes in order to inject again the material.
So you see injection for me is the way to go, but how to inject is very interesting because all these techniques have pro and cons. And this is what a lot, because in the recent years we had an evolution of all these techniques and there is always a growing, a growing interest. And what a lot is that all these techniques are something that you have, you can use in your daily work, not just for doing the case.
Because nowadays in my dentistry, I hate to do the case. I mean, it’s nice. The case, but if your dentistry is focused on the case, there is something that it is wrong. My dentist is focused towards everyday dentistry. Sometimes I’m able to do the case, but it is not my main focus.
[Jaz]That one nice one. The unicorn one that comes along. That you get to have lots of fun, but you’re a real world dentist. Just so I can get the structure of this podcast, Marco, edge bonding. Okay, so you’ve discussed that injection molding as a way to deliver your composite has some advantages and I can see that compared to layering and what you’ve done is shown clear examples, follow ups whereby the injection molding looks superior.
At day 10 years, maybe on day one the layers maybe looks a bit nicer, a bit sexier, but at 10 years the injection molding technique is superior. But do you, after aligners to get a better occlusion, let’s say, do you utilize injection molding for edge bonding or do you think this is such a simple, direct free hand that you still use your paste and you try and do edge bonding without the injection molding technique?
[Marco]Okay. I think that injection molding is mandatory for me. So what I do is we do watch bonding. I always want scaffold. Of course, when the case is easy, you can do the scaffold also with transplants matrices or something like that. But the problem is one, for me, free-hand there is not the pressure that we need in order to put the composite in the best situation to perform.
So I never take material with a spatula and they put some work. So if I have to do edge bonding, what I do, I want always to have some matrices. In easy cases, I put varistrip, for example. You know the blue transparent matrices, they are very easy. I put that by Garrison. So that I do what?
I always want to have David Clark talks about adding an aquarium, a chamber, a place where you can inject with some pressure, heated material. So what we do in all my cases, small restoration, big restoration, I always want to add something like a chamber and aquarium where I can inject. Of course, in the simple cases, this, most of the design means to have maybe just a varistrip matrix just wrapped around the tooth or in the rounded area, and maybe I just stabilize with some teflon, some liquid dam or with some flowable in order to have, but I always try to do a small chamber also, because when you start to be in this kind of rationality to put a matrix and build something that it is like a small chamber, it’s something that you need 20, 30 seconds.
I do even class five in this way, for example. See, I have a technique about doing class five because doing class five, for example, is the same problem with class five. I was doing the action with Teflon and I was applying with my spot, but there was feeling that after seven years I was seeing that the follow ups on class five, it was not the same of restoration made with injection because when I was applying with my spatula, I was missing the pressure of the composite in order to put the composite in the best situation.
Now instead, I have a technique, a very easy one, where I use an automatrix or unica matrices, but I always build a scaffold where to inject my composite. This is my way to go nowadays in all my restorative work. And it is something that you can do in your everyday cases because to put thematic in that way, one minute, one and a half, it’s something that I’m not discussing about two hours appointment, three hours appointment.
If I see my scheduling nowadays here in the office and I’m working, most of my scheduling is based on one hour, 75 minutes appointment. I have not long appointments in order to show my artistry. I am a very basic dentist, but I do something when I say that this thing works every single day in very good way on the long term. And for me-
[Jaz]What I like about you, Marco, is when you talk about a technique and it’s a bit like, you know, at one stage you are enjoying your layering, you’re doing this, but what you do is you’re not afraid to look at your own work and say, hey, you know what? We can do better. I need to change something.
And then you can put your hand up and say, I was wrong. I was wrong to do it that way. I think this is the best way. And maybe in 10 years you’ll refine that even more, and something new might come out. And it’s important to be open to change. And that’s something attractive to do is being keep your mind open that hey, you know, this is working, but I’m willing to change if something better comes along.
And so far, I am injecting in some cases, like anterior wear, we’ll discuss that. But for class fives, sometimes I inject, sometimes I do freehand with like PTFE retraction. And I agree. Once you get that scaffolding, I love that the aquarium, the chamber, the scaffolding. It just makes so much sense.
I’m surprised you actually said about edge bonding. I’m glad you mentioned it, that you are so convinced and dedicated to the injection molding way to deliver a restoration, that you’ve pretty much now found ways as long as you can make your scaffold, you can inject. So I’m imagining you now, when you’re doing edge bonding, you used a various strip, for example, you create your scaffold, you inject in now just tiny geeky details that dentist love.
Do you like use a tiny drop of a flow and then you like a snowplow technique and then put your heated composite like that? And what’s your preferred composite of choice for let’s say edge bonding?
[Marco]Okay. During monolithic restoration, the other good part that my assistant, the assistant that it is working for the storage is very happy, is that I reduced the heavy way, the storage composite.
Because if you see my office, I have just three comp, I have A1, A2, A3, and I have a bleach. And it’s easy in this way to manage because the problem is that if a tooth has a strange color for me, what I have to do is to cover all the surface. It’s much easier because too much your composite shades with the French colors, like you know when you have a sort of orange, a sort of brown, it’s MS, I saw on the book layers of the group that they start to combine a little bit of A2 shade with a little bit of brown, super thin, super core in order to create another. This is not everyday dentistry that you can practice also, because when you have to mix in a different way for every single case, it means that there is a question mark everywhere.
Instead, I want my dentist to be fast, reliable, predictable. When you have strange colors for me, you have to go over the bucket surface. Most of the times it’s much easier to get a good result and all the patients also love the aesthetic result when you’re doing that. So you have something that patients love.
Doing injection molding, I have ecosystem result under long term and it’s very easy for you also to manage, so you have not to get crazy about matching the color, the composite to a strange substrate to a strange color. You do the opposite. You go over that and you close.
[Jaz]The shade system just makes so much sense in terms of simplifying, and this is why your team now loves you even more because of this simplification there. Is there a composite that you found to have superior longevity in terms of color stability, polishability? Is it a 3M Filtek? Is it Estelite? I dunno, what are you preferring nowadays?
[Marco]Okay. What do I use every single day in my life is I use 3M materials that they are no more 3M, but because they did a change. Now 3M became Solventum and I’m also speaker for them. But between all the materials that 3M is doing, I use for all the cases, whether I want aesthetic, both anterior and posterior. I always use supreme material. I know that supreme is not the newest material that 3M did. Even if there is the technology, it’s always nanoparticles.
This kind of technology, but supreme in both posterior and anterior cases in my hands, gave very stable results over time. So what I use is I use supreme flowable always after warming the material. I put a little bit of flowable. I don’t use the light lump at this stage. And after I inject again, warm composite, the heat that I have is bringing the composite to 70 degrees Celsius. I don’t know in Fahrenheit how many degrees these are, but I warm a lot of the material, especially because supreme is a little bit viscous material.
[Jaz]Is it stiff?
[Marco]Yes, it is deep. So I warm a lot, but I love the aesthetic result and the consistency and also the how you are able to polish this material. Instead, for example, there is for people with a heater that it is not so strong. There is, for example, the universal restorative is much more creamy. So it’s enough to do just a little bit of warming and the material is already flowing everywhere because injection molding is also, for me, the only way in which you can manage claustrophobic restorations.
Interjection:Hey guys, it is Jaz with an interjection. So firstly, thank you so much for approving the interjections. I did it for the first time on the Lukasz Lassman episode. We did occlusion miss and red flags just a few weeks ago. And sometimes what happens that the guest is on a roll. But I’ve got so many questions in my mind and the guest is going for it.
And so I kind of hold back, but I know that I want to talk about something ’cause I do feel to make something more tangible, it just deserves us to go slightly down this rabbit hole just to explain something or to put some more clarity on something. And I’d asked you to write in the comments what you thought about the interjections.
And thank you, Joyaffif, Emily, Joseph, Barbara, so many of you said, and the interjections are good and approved, so they are here to stay. So the first interject one of two for this episode is just heated composite. I think it deserves just a few words. Many of us are already using heated composite, but if you’re not using heated composite, you might be thinking, what’s the point?
Why would you use a heated composite? If you want it to flow more, why not just use a flowable? And I get that. But a flowable is different to a paste composite. A paste composite has a much higher percentage of filler particles. It is categorically a stronger and a mechanically superior composite to a flowable.
And yes, the number one reason why I use heated composite is ’cause I don’t like working with stiff composites. I like them to go a little bit soft. It just makes handling better for me. And adaptation as you are dispensing that heated composite from the compule into the cavity, for example, it’s just smoother.
And the way that that composite adapts to the cavity walls, it’s more seamless. It just flows better overall. So it’s the handling that I love the most about it. Typically speaking, composite is heated to 55, 60 and Marco is 70 degrees. I also do about 65 to 70 degrees Celsius. All that kind of range is totally fine and sometimes if you’re using something like Estelite, which is a softer composite, you probably wanna go for that 55 degree region.
But if you have a stiffer composite, like I use a lot of Venus really enjoying Venus Pure at the moment for my aesthetic work, and that is a stiffer composite, so I like to go to 70 for that. Again, for me, a big part of it is improving the way the composite handles in my hands. When you look at the literature resoundingly, it’s mostly good stuff when it comes to heating composite.
It does not negatively affect the strength. In fact, it actually improves the flexural strength in some studies and you get a higher degree of monomer conversion. So is there any bad stuff out there? Well, some studies say that repeated preheating cycles have a detrimental effect on color stability of composite resin.
So basically the takeaway here and what the manufacturers are saying as well, is to use the small compules when you’re heating. ‘Cause when you use it, it’s done. You throw it first to those large composite tubes, then the manufacturers are saying, look, it’s probably not a great idea to heat. And allow that to cool.
And then heat again and allow that to cool. And listen, if you’ve been doing this, don’t worry. I’m just saying it’s one of those things that we just don’t have enough data for. Like definitely a bad thing, I don’t think. But it’s just much safer to be heating the small compules than to heat the entire slab, the entire tube of composite that might be going for several months constantly heating, cooling, heating, cooling.
And in my mind, yeah, that could potentially have an issue, but I at the moment use compules have doing so for years and I’ll continue to, because I love using heated composite and from the literature that I’m reading, it’s totally okay to do. Just one more little nugget is that yes, you heat the composite, but it cools really fast, so don’t worry about you thinking that you’re gonna cause the tooth to burn and the pulp to burn.
Usually we have enough remaining dentine thickness. It’s really not gonna be an issue. And also as soon as you take that composite out of the heater, it’s gonna rapidly cool. This is why I sometimes will actually heat my metal instrument as well to just prevent it cooling so quickly. So heated composite. Big thumbs up. Crack on guys, let’s get back to Marco.
[Marco]Like for example, do you see this case just to say?
[Jaz]Yes.
[Marco]Okay. For example, when you have a claustrophobic restoration, like for example when you have, let’s say less than one milimeter diastema, that you put your matrices and you have two restoration of three 0.4 millimeters. How you can be reliable about being able to layer and bring composite to go around the tooth and behind the shoulder of the tooth when the space is just 0.3, 0.4? Or when you are doing, for example, a small black triangles and you are dealing with 0.5 millimeters restoration, very close to the gingival margin.
Injection molding also is the only way in which you can be reliable about getting this kind of restoration in a very smooth way. And this is the follow up of the cases that you can get. You see when you are starting, like in a case that I’m showing with a normal color of the teeth, you can do just the restoration of the diastema or of the black triangle without any kind of problem.
Honestly, composite here is supreme. Composite is very biomimetic material. It is very mimetic, but when you are dealing a study with the fit with strange colors, I did a mistake last day. There was a patient, and I’m going to post this case in the next days. I have the appointment Monday. And after I will fix my mistake because the main mistake was on my side.
I will post the case. There was a patient coming in my office for black triangle after orthodontics, but there was in the third medium of the center incisors. This was a sort of brownish area, not so much. I told to the patient about this area and you told me, okay, I never realized this, but this is not, has never been a problem.
I’m coming from black triangles. The problem must be that when I did black triangles, and so you have on the mesial and distal, you have some composite with just one shade. Now, this brown area is much more evident than before. So the patient completed the appointment saying, I am very happy. I have no more black triangles.
I am very happy. But we called back again saying that the brown area that he never noticed before, now it was more evident. It was much more important. So he asking me to solve again this issue. So Monday I will go back in this case. So the diagnosis of the case, for example, about all the edge bonding, what is the reason behind the chipping and the fracture?
It’s the occlusion. And what do you have to do many times orthodontics or when you’re going, for example, with patient with worn dentition. It’s about because of abrasion or it’s about erosion. These are two complete different situations with a complete different solutions because on patients with erosion, as long as they have enamel, a sufficient amount of enamel, I am always successful regardless.
We can say with the occlusion, okay, not, but it’s less important occlusion. But when you’re doing a steady patient with the worn dentition because of occlusal problem, if you are going to do, for example, an important canine guidance, an important incisal guidance, they’re going to break everything after a while.
So there is much more that we have to discuss about why the patient is in that situation before doing the treatment. And this is something that honestly we can understand, just sharing our failures, because many times the failure is not in the technical part, but the failure is something in the diagnostic part.
But the failure is coming after three failures. For example, I have not a great outcome with very compromised teeth with fiber posts. Okay? But most of my failures are after six years. Most of my failures with fiber posts in compromised case, we scarce failure are between six and nine years. So the problem is that how many times do you follow up your patients for six, nine years and you start to collect all the first that you have?
Few are doing this because if you see on social media, on congresses, you always see short term follow up most of the times. Like for example, with shoulder, we know and there is something that you find out some papers that soft tissues on shoulders are easier to get recessions. Easier to get recession.
Instead with vertical, it marked more easier to avoid the recession, but in the past you were never able to discuss this because people was not going to show 10 years cases with horizontal, with recession of courses and congresses. They were showing all the artists of the technician at the 10 0 6 months and after they were going to the next case.
We have a disease about showing our best. Instead, what would be interesting would be showing what is not going to work. I understand that people, that it is starting to introduce themself in this world. They want to show their best because I did the same, honest when I started 12 years ago, to be a speaker, to speak to lecture, I was doing the same.
I have to be honest. But after a while, I think that it is the responsibility of those that already showed that they are good dentists to show what is not working. I think that I can forgive easily people that is starting now. If you’re starting now lecturing, you have to show your best because you have to show the people that you’re good dentists.
But after 10 years, I think that it is your responsibility to show your best, but even what is not working, because I’ve been learning much more from my failures than from my best cases.
[Jaz]One of the best lectures that you do, Marco, as you know, is in your course in Sicily the last few hours dedicated to all the failures and lessons, and that’s always very special. Shout out to Costas Koleonidis, who currently I believe is a Greek dentist in Switzerland, who’s one of your alumni as well. That’s right. Before I went to Sicily, he told me, watch out for this one lecture. Watch out for this one lecture.
And I can say it’s so lovely. When people share their failures and mistakes. And open like an open book to everyone. So appreciation for that for sure. Now we discussed edge bonding and you’ve convinced me that yes, the way to deliver the composite to not get so much air is perhaps not with the spatula to make the scaffold.
I love the scaffold. The chamber, the aquarium. That makes sense. You mentioned composite veneers with that technology. Now, just for the interest of time, black triangle closure is kind of like that claustrophobic area and you use an injection molding just makes so much sense and something like Bioclear is amazing for that.
Some colleagues are using metal matrices and they burnish them out and then they create their scaffold. So there are many ways that you can create your scaffold, not just the bioclear, but the thing is, as long as you then create the scaffold and then you’re able to inject into it and place into it, it makes a lot of sense.
When we think of injection molding, Marco, most colleagues are thinking of using the genial injectable gold one into a clear stent like Exaclear that, usually we think of that as the injection molding, but you are right. All the other applications we discussed are the method or the technique of injection molding. How often are you using this technique as your favorite technique for managing tooth wear?
Either erosive attritive, or usually combined erosion and attrition. What are your thoughts on the exaclear technique with the GC composite?
[Marco]Okay. The problem, I use this technique, but in my practice I work something like 80% to 90%. I work with the Bioclear and 10% to 15%. I work with this technique with Exaclear, the main point is what?
The problem is, the inter proximal control. When you do this kind of technique, there is a huge problem about the interproximal areas. So if I have a patient with no black triangles or very small black triangles that I’m going to keep putting little bit of Teflon, and so the biggest problem is on erosion of the buccal wall or abrasion of the palatal wall.
I’m doing what I am doing the waxing with my technician being zero point something short under the proximal wall so that I’m printing my composite on the buccal or on the palatal and incisal. But I’m going to do zero invasion on the proximal wall because when you are trying to do, in my opinion, when you are trying to close something like a diastema or even worse like triangle with this technique, the problem is that after you have to spend a lot of time about finishing inter proximal areas, the problem is what that in the photos, I have to be honest in the photos.
It seems that you’re able to get a decent result, but honestly when I see with air drying the restorations with magnification and I see the interproximal surfaces in comparison to the surface that I have with injection molding with matrices is surface is — honestly. So the problem is when you are doing with these cases, what is the critical part of the restoration?
The buccal wall, you can do the exaclear. Palatal wall, you can do the same, but when there is a huge interest in shaping the interproximal wall and especially the inter proximately the subgingival wall, at this point I’m starting to maybe start on other techniques. So it’s about the involvement of the interproximal area.
The most important part that is driving me towards the decision between the Dahl technique, maybe with bioclear matrices or the injection technique. This is the most important part, the control that you have. There is also the problem that we are discussing about occlusion, because again, I never increased the bite.
So most of my cases are cases with the increase of the vertical dimension. And there is, I think also something that in UK I think that you’re doing a lot. But in the rest of Europe studies less used is the DAHL approach. DAHL approach is a very smart technique because most of the times we have rise the vertical dimension.
But economically speaking and technically speaking, it’s completely different. The work, if you have just work from canine to canine and after, wait for the extrusion of the posterior teeth and instead if you have to place also overlay on premolar, premolar, molar and molar, the cost is almost doubled because from six tip you are moving to 12 tip.
So there is also this, even on this topic, there are other interesting considerations that I never heard about because I had what doing DAHL approach you have to be careful about. One thing, there are people with atypical swallowing. Most of the times when we talk about atypical swallowing, we always talk about the anterior open bite. There is these people pushing the, what is the name?
[Jaz]Tongue thrust.
[Marco]Okay. They do that. And you have open bite. And so it’s easy for most of the practitioner to understand that with the tongue thrust, you have open bite that you’re able to close. But there are other people that have another kind of atypical swallowing.
They put the tongue or the posterior tip doing something. They are in the age of development. They develop a sort of deep bite because the tongue is keeping the molar in the position and you have the extrusion of the lower incisors. But if you’re going to do the DAHL approach on this patient and you’re opening a little bit more that the tongue is able to come, right, that position.
Interjection:Hey guys, it’s Jaz again with the second and last interjection for this episode. So Marco just mentioned something really interesting, right? Typical versus atypical swallowing. It’s actually a really interesting thing and a really important thing that often gets overlooked. Normal or typical swallowing.
What we do with our tongue is we rest it behind the upper incisor, so in the incisive papilla region and the teeth are able to come together usually in your normal bite, AKA maximum intercuspal position. So teeth come together, usually lightly, and then we can continue with the swallowing reflex. The fact that the teeth are now together, it kind of stabilizes the jaw to allow you to swallow.
And it’s important to stabilize the mandible because if you try and swallow with your mouth open, just try it for a second, right? Keep your teeth apart and just try and swallow. See, it’s much more difficult. You need your mandible to be stabilized. Hence why one of the functions of teeth is to help with swallowing anyway.
So that’s a normal swallow in atypical swallowing, which usually happens in kids, and they grow out of it by age nine onwards. And what the tongue can do can actually do many things, right? The classic one is like the anterior tongue thrust. And so now instead of the teeth biting together, there’s your tongue in the way.
You’re kind of biting on your tongue and then swallowing. So your tongue is being used to stabilize your jaw. And what Marco’s saying is that there’s a variant of this tongue swallow whereby tongue is like spreading laterally and it makes sense ’cause I think we might have all seen patients with these like posterior open bites and you’re thinking, why are these teeth not settling back into occlusion?
Well, how can they? If every time the patient swallows the tongue comes in the way and stops the teeth from meeting together. And so it makes sense that if you open the vertical dimension on these patients and you do a DAHL type treatment, if they do have an atypical swallowing, that this will interfere with the dental alveolar compensation eruption.
Call it what you want. And actually the tongue, we know the tongue is the strongest muscle in the body. And I see some patients in my career so far who have destroyed fixed retainers, i.e. These metal fixed retainers typically bonded to the palatals of their upper incisors, right? So it’s upper fixed retainer.
They just snap, snap right in half and their teeth start to splay because of this all mighty tongue and this atypical tongue swallowing. So if you see something strange going on, have a look at their swallowing again. Once again, let me know, guys, are you enjoying these interjections? I’m happy to continue them. I love doing them. I learn a lot and I love to share it. Thanks for listening to far. Let’s continue your almost to the end.
[Marco]These are the cases where I had huge failures about doing a DAHL approach and keeping the posterior open bite without end, we can say. So but again, talking about failures, this is the main point because it’s easy to say, do DAHL approach and it’ll extrude.
Yes. But what if they don’t? Because this happens. And why? Because if you’re able to understand, sometimes it happens, but there is a reason you can select the cases. Cases selection is the most important part of our work. The patient has parafunction. The patient has erosion, the patient has abrasion.
The patient has strong thrust the patient that there is enamel or not. Because even on adhesion, I get aggressive. I’m doing mainly adhesive dentistry, but adhesion is not the religion. For some people it seems that addition is a religion. They do adhesion everywhere. You see teeth with zero enamel and chronic sclerotic, dentine, and they are doing adhesion.
Adhesion is not the answer to all the problems that we have. Sometimes we replace things that work, like for example, a cuspal that sometimes is the best solution with things that seems more modern is the difference between science and scientist. Science is science and we know. But scientist means just because something is more technological, we think that it is better.
There are a lot of wrong messages that you are exposed every single day. Like for example, rubber dam, I use rubber dam, you see my cases, and there is always the rubber dam, but sometimes rubber dam became a sort of indicator of quality of dentist. You are not accepted in a scientific society unless you put the burden in a graphically perfect way.
So there is something that was born for a news and we have to say when the dentist that started using the rubber dam started, you know what the reason they were working with amalgam, there was no suction available. That was the reason because there was suction available.
When suction was available, they immediately discarded rubber dam immediately. So when they say they were smart because they started working with rubber dam 150 years ago, they were not smart. They had no suction because when suction arrived at the beginning, it was much easier to work with suction after of course with composite hydrophobic materials adhesive that are not friendly with saliva is rubber dam again became useful.
But again, from something that is useful to something that became mark of excellence, there is something that it is missing between these two things because you can do excellent dentist, for example, without rubber dam. I do most of my class five, for example, in class five, placing the rubber dam sometimes is a mess. It’s much easier and reliable and predictable to do a class five sometimes without the rubber dam.
[Jaz]But I agree. Rubber dam is helping you and then use it if there’s a tongue in the way, if there’s a tricky scenario. But if rubber dam is hindering you and making your access more difficult, then why bother?
[Marco]Yes. The problem is that when you are exposed to courses in congresses, all the speakers say that they play rubber dam in 100% of cases. They say that the rubber dam is mandatory for the success. I know that we humans don’t like uncertainties, so we like strong messages. The point is that sometimes these strong messages are leading in a very wrong direction.
So if we were able to share more our failures and problems, this would be a very good way to improve our life. The life also of most of the majority of dentists, because they are exposed to very different messages.
[Jaz]We can’t be dogmatic about anything. Yeah, it’s a key lesson there. Marco, as we wrap up, we’ve got a few questions in that scenario with generalized wear. I’m just trying to visualize it makes sense about the interproximal success you get by using something like a bioclear, right? Because I agree when you use the Exaclear stent and how messy, even if you use the every other tooth there is finishing to do. And I agree that under magnification and when you dry it, it’s a surface that leaves much more to be desired.
I agree with you. But when we have to add material to the palatal surface and we want to be guided and directed by a wax up, by a planning, how do you do that with bioclear? Do you make a scaffold palatally first and then do the bioclear? Or how can you do that part?
[Marco]Yes, because the nice part is what, because if you start to be much more horizontal, I say about our techniques, you see that the indication, like for example, if I have a patient with a lot of palatal wear, let’s say, and then black triangles, why not to do just let’s say an index for the palatal wall without the embedding interproximal space?
And so you do the injection of the palatal wall so that you have right vertical dimension, you have the right anatomy of the syndrome because this is extremely challenging you to do the right anatomy of the palatal part, the free end, and after you can work instead on the black triangles and the buccal surface, maybe with a direct approach or sometimes you have, for example, in the posterior you can work with injection for example.
I have a case that I have to do by two weeks and I will do injection with the Exaclear in the posterior teeth because there is a problem of loss of vertical dimension plus erosion. This is a patient with erosion. So I’m going to increase the vertical dimension, injecting like table top, the posterior with composite, and after I will do just bioclear instead on the anterior, this is the case of a lower arch, and I will do from canine two canine, I will do just Bioclear.
If we are a little bit more flexible, we can combine and take the best of this approach. Even the other approach, I have to start with the technique of Itay, but I think that also the technique of Itay, iVeneer, there is something that it is very interesting and smart about this technique. So the best is to master different things so that you can mix all of them in order to fit the case.
Because if you want for a man, if you give to a man and a hammer, everything will be something that has to crash, you know? Instead, if we have several horrors in our work. We can use the best for each case. Also, because again, now we are discussing about composite, but you know that I am also a speaker about [inaudbile], so prosthetic dentistry, so the decision is even before when ceramic and when composite.
So the topic is even, there are even more nuances about this topic. But again, the decade is well show your case with ceramic and the failures that you have show the case with composite and the failures that you have. There are problems about the technique or there are problem about the choice of the material.
Again, we have to discuss failures, but this is something that I find extremely challenging. Now for example, with the summit that I’m organizing in November, I am quite picky about all this speakers about, show some problems, show some problems. I don’t want. Sure you have.
[Jaz]It can’t just all be fairies and rainbows. You gotta show your struggle. You gotta show. I am asking, I knew when you were organizing a conference that you would bring this ethos and make sure that people have this on board.
[Marco]The conference that I’m organizing is because it’s not for economical reasons, because I’m mainly recollecting expenses, but it’s because I want to give a message. The message is what I’m discussing in this podcast with you. But the point is that I have to make that all the speakers more or less because of course they are not like me. But more or less, each one of them has to deliver some problems why these things happened and now they have been solving this. Otherwise it would be just again, another show. So it’s about-
[Jaz]Tell us more, my friend. Remind us of the date. And it’s in Milan, right? So tell us, because this sounds amazing. I mean, I had a look at the date personally due to family reasons I can’t attend, but it looks amazing. You got some brilliant speakers. I mean, you mentioned Veneziani, Sakowski, our good friend, Johan Hagman, what a great dentist he is. Yeah, lovely guy as well. You got a great list.
[Marco]Okay, this is the summit about, because there has been an expansion and the growth of all these techniques about injecting composite, I start to think about doing a different event, doing a sort of point of the situation, collecting all the different techniques we will get David Clark, of course, is the founder of Bioclear and he is a man with several interesting insights.
So is a math that David is coming. After we have José Roberto Moura. José Roberto Moura is a Brazilian. He is an excellent dentistry and he’s combining in his practice injection molding plus layering and is combined these two techniques.
Also, it’s nice because José Roberto Moura is working always with microscopes, so we will see a lot of videos and so we have a very good perception of his work. Ronaldo Hirata is a very famous Brazilian dentist. I don’t know if you know Ronaldo.
[Jaz]Yes, yes, I’ve seen him. He was very well known. International speaker. Absolutely.
[Marco]Yes. Ronaldo is a very famous speaker and he will come in Milan and showing, even in his case, because is working both with injection molding and is working also with layering. So it could be nice to see how to manage all the indications for different things. It that it is the speaker next to me is instead the inventor of I veer matrices.
So he will show this other approach if you want to have a small video about this technique. But the problem is that for people just listening this episode, however, these are matrices that are covered.
[Jaz]I’ll put it at the end of the video. For those who are watching, they can stick around and watch that actually, yeah.
[Marco]Okay. After we have Marco, Marco is one of the most renowned I speakers. Marco is doing excellence in the dentistry. He is working with the index technique, the Exaclear, but he has his own protocol because he did some modifications in order to improve all the workflow. And this is something that he will be able to show in our summit.
Albar is doing something that they love. Alvaro will show just cases with minimum five years of follow up composite restorations made with different techniques. What happens after five years? So love it. Alvar. We will sue the truth about composite, and this is something that I will really love after we have another speaker that it is Abdurahman. Abdurahman is a Egyptian speaker. He very close friend of mine.
[Jaz]The Prince of Egypt, I call him.
[Marco]Yes, yes, he is. He is. He’s the prince of Egypt and we will talk about his, that treat situations that we never discussed and it is how to manage composite restoration close to implants. And this is some, because there are several complications because when we have decay or other problems close to implants, usually decay is more cervical than usual.
There is the problem of the separation. So we will discuss about all the restorative strategies that he has been looking for in these years about how to manage these tricky situations. With John, we’ll discuss a evergreen topic, especially in real world dentistry that it is subgingival margins because this is an evergreen topic.
With Matt. You want know is that this is the French print. We can say, Matthew is interesting because he started working with the printed composite because the printer in his office and he will discuss the difference between working with printed composite and direct approach about time efficiency. So I am not the printer in my office, but when you start discussing about being efficient and being productive, it is something that for me is very an actual topic.
And after we will get workshop so people will be able in classes of 20 persons to touch together with upper and tadi, she’s a Biore speaker from the south of US and Claire Vargas that it is the Biore speaker for UK.
[Jaz]UK. Woo.
[Marco]Yes. UK. Yes, Vargas is the bio center in UK. People will be able and together with also Marco Ani for their technique. So we have three tutors. We’ll be able to organize workshops so that people at a very low price because we are discussing something like 100 euro for two hours.
[Jaz]Oh wow.
[Marco]Two and a half hours workshop. We’ll be able to touch with their hands, the material, and so to feel what is injection molding, what is to inject on Exaclear. They will be able to touch with their hand. Everything in the wonderful place of Milan that the problem in Milan is just the amount of mind that you’re able to spend going outside and will do also gala dinner will do also some social activity because again, it’s something that-
[Jaz]Wish me luck. I know I have some family commitments, but I’m gonna do it. I’m looking these speakers again and just how excited you got me about injection molding and why I realized, okay, I need to be doing more of this. I’m gonna ask my wife today to see if I can get her blessing level one permission. So wish me luck. But you missed the most important speaker, Marco, as well as yourself. You missed the loveliest person, honestly. Just absolute sweetheart of Aara Aara.
[Marco]Yes. AP is the tutor and she will be the tutor of the Biore approach. We’ll do anterior restoration.
[Jaz]She doesn’t drink alcohol. But she came to your course in Sicily and she brought everyone a bottle of rum, right? And she’s just the loveliest person you’ll ever meet. And I’m always a big fan of not only going to the educators that inspire and show excellence, but their human side. They are beautiful inside as well. Right. And so I’m just very, you, it’d be nice to connect with Aara. So wish me luck. I’m gonna ask my wife if I can get a day off seventh and 8th of November, 2025.
[Marco]Two things, just because this point I have to say something more aara together with me, the one that will manage all the speakers will be the, I don’t know, master of ceremonies is something that you say.
[Jaz]Okay, MCs nice.
[Marco]Okay. She will help me on the stage, introduce the speakers. Because what we want to do is something that it is new. Nobody will come on the stage talking about their curriculum. I will never say, here is doctor Jaz Gulati, got his degree. Nothing. Everything would be about the person, the approach, the philosophy. We want to do something. It is fresh. And also, there is a dentist coming from US, Joshua Sullivan. He is a very, a famous pediatric dentist. And he was nice because he told me, I went home like you say, and I said to my wife, look, I would like to go to another congress. And she said, no, another Congress, no. But where is in Milan? Whatcha waiting for tickets? So this is another reason that it is. Yes, yes, yes. It was-
[Jaz]Maybe a weekend away I might arrange some childcare for the boys and I’ll whisk my wife away for a romantic weekend in Milana. And she’s a dentist, she’s a pediatric based dentist. But you know, I can tell her, you can learn something for your patients. In fact, I think it’ll be good for her.
[Marco]Yeah, also, because Milan is a very nice place. Also, the venue is called Grand is five minutes using the subway from the center. So we are in a strategic place also for a holiday. So I think that it is.
[Jaz]This is gonna help a lot.
[Marco]Yes, a good situation in order to connect a little bit of education and a little bit of fun because we spend a lot of time together. And also the possibility to visit Italy because Italy is Italy.
[Jaz]It was my first time at your course in Italy actually insisted my first time in Italy. I’m just, the food was just, everything was good and for those of you listening on Spotify and Apple and stuff, one thing you missed is the hands gestures that Marco like, it is true. Italians speak with their hands. It was very evident for those who are watching the video. Now I’m gonna put the links and everything in the show notes so people can check out injectionsummit.eu is the website.
And fingers crossed me and my wife will be able to come. If not me and my wife, then hopefully just me. Either way, I just really wanna come. So pray for me guys. Now one thing, unrelated a little bit, I just want your opinion, Marco, right, you must have seen on social media, right? Marshall Hanson in US is doing incredible work. Have you seen his work online?
[Marco]No. What is the name?
[Jaz]Marshall Hansen, he created the home of the 48 hour Smile makeover. So essentially what he does is, and I hope I’m not perversing this right, but essentially what he does is he brings one patient and he keeps him in his office for two days, basically.
Okay. And in two days they will leave with composite makeover, which is just phenomenal, I believe the way he does it, he’s the first day he just builds the shells, builds the base, okay? And maybe he’s doing some injection molding type technique. He’s using the Garrison Strip and whatnot and using these special matrices and he’s building the base all in monolithic, I believe.
Okay. If I haven’t got this wrong. And then the next day he will cut back and then well, from the cutback, he will layer and get everything looking great. So not only patients all over the world, but many dentists from the world are going, flying to him, staying for two days to have their makeover. But okay, if you haven’t seen his stuff, then maybe you cannot comment.
[Marco]But this is the same that Marco, just because you are talking about this, Marco is doing the same, Marco is doing two things. He started doing what? Using Xgl to doing the injection to the final shape. So it was injected with DC after he was doing a cutback and he was layering 300. Now instead he is doing what he do two different indexes.
One for injecting the dentine and the al shell after he is doing alce mammals, all these kind of things, and that he has a second stent for injecting the enamel. So he has also the texture, the anatomy.
[Jaz]So you get the both benefits. You get the polychromatic result. with the method of injection molding.
[Marco]This will be the election of Mark Marconi. I show you a case. This is Ani, this is the case that he is doing and this is the result that is able to obtain. You see, you can get both things of the world. Of course you need more time. You need two indexes, two Exaclear standard one. There are more steps, but for people that wanna go in the direction, we will discuss also about this.
Of course the workshop with Marconi will be about the single xgl, the workshop, because it’s a beginner workshop, but during the lecture you will see Marco’s technique. You see the innovative customize, the ebr, the hind index and updated clinical procedure. So this will be the lecture from Marco. It will show about also this technique. So it will be the summit will see all, everything that it is around injection molding concept plus some modification about layering for people that it is into these kind of things.
[Jaz]And of course I know we talk about Injection Summit, but you know, you also do the Bioclear course in English and in Italian, so maybe I’ll put some links for that, for those who want to learn that. Definitely. Again, I wanna take a group of dentists back. The same group actually there, our WhatsApp group, we want to actually learn from you, so maybe one day we’ll arrange that as well. So I’ll put all the links. Marco, thanks so much for your time, for your passion, for your authenticity, for your philosophy, for your kindness. And fingers crossed we meet again in November and I can convince my wife.
[Marco]You know, the film in Padrino. The Godfather.
[Jaz]The Godfather film. Yes.
[Marco]I am sending a gift to your wife. She will not be able not to accept.
[Jaz]An offer she can’t refuse. Let’s see.
Jaz’s Outro:Well, there we have it guys. Pray for me for, I shall ask my wife today if she’ll let me go. And I mean that in a nice way, right? I mean, it’s one of those things, right? That marriage is a partnership. So it’s a joint decision. Whenever I go away or she goes away and it’s work related, it needs to have some sort of synergy. It needs to be planned. I’m gonna get a little bit philosophical here, right?
‘Cause you know, one of my highest values is family. And to give you some context, right? As a father, like you get woken up by your children early morning, 5:00 AM sometimes, or in the middle of the night. You’ve all heard me on the podcast talk about how my second born son in my firstborn, terrible sleepers, I’m up a lot at nighttime.
Either getting a milk feed or calming my children down. And it’s a common thing amongst us parents and those of us committed to a partner. We have to have that dialogue. We have to kind of get what we call level one permission. And so let me read out this quote to you. When nobody wakes you up in the morning and when nobody waits for you at night and when you can do whatever you want, what do you call it?
Freedom or loneliness? Right. So to be able to be in a position where I’m gonna be able to check, hey, can I go through this event or not, is what family is all about. So I’ll keep you posted if I will be going to Milan, but for those of you going super jealous, for those of you interested, again, I’ve put the link below, check it out.
It does sound brilliant. And hey, if due to family reasons or whatever, you can’t go. Don’t worry, there’ll be plenty of more opportunities always. But whenever you can, I’ve just learned that whenever you can go somewhere and feel energized by the people and that magic of in-person events is just, you can’t beat it, right?
It’s one of the times that, like me personally, when I go to like a music concert, I’m excited, but I’m actually so much more excited when I’m going to a conference. I feel energized. It is always a highlight for me. So for me, call it sad, call it geeky, whatever. I am far more energized when I’m going to a dental conference than I am for when I’m going to Wembley to see a singer I love.
So let’s keep the magic of in-person learning alive, my friends. Go and support these conferences that are out there and always keep learning. Thanks so much again for listening to the end. You can claim CE or CPD for this episode. You’ve just done all the hard work. You’ve listened, answer the questions, get 80% and Mari from Team Protrusive will send you your certificate.
You need to be on the app to be able to do it. You can make an account on www.protrusive.app and unlock 380 plus hours of CE or CPD. Don’t forget that you can download the premium notes for free. The new and improved the elevated premium notes for this episode by visiting protrusive.co.uk/im.
I’ll put that link in the show notes as well. I hope you absolutely love it. Please do comment if you did download it and what you thought about it, and of course, join us on the app. As always, thank you to all of team Protrusive, without whom this podcast would’ve died many years ago. But thanks to their support and your support Protruserati, we’re going from strength to strength.
We’re making learning fun. We’re making you fall in love in dentistry all over again. In fact, this reminds me of an email I literally just got yesterday. I won’t say his name ’cause I didn’t get his permission to read this out loud, but he’s a board certified prosthodontist. I won’t say from which country.
And we had a little email exchange about occlusion and stuff and he said, by the way, I love what you stand for. For a long time, I hated being a dentist. It caused me so much stress. This is a prosthodontist, by the way, guys. I recently found my passion for it. And your attitude and passion towards dentistry is what I am striving for.
My friends, this is what it’s all about, right? There’s no point being in this stressful profession if you resent being in it. You need to change something to change your environment. You need to change who you hang out with, you change what you listen to. If you are not happy, something needs to change.
This could be your practice. This could be your working hours, your working days, the techniques you’re using, the education you’re receiving. There’s so much to do and that’s why Protrusive is dedicated to your success. I’ll end with that, my friends. I’ll catch you same time, same place next week. Bye for now. Do not forget to hit the subscribe and the like button.

Jun 12, 2025 • 54min
Zirconia vs Metal Hall Crowns vs Conventional with Dr Tim Keys – PDP227
Should we really restore primary molars without local anaesthetic or injections?
When should we start taking radiographs for child patients?
Is it time to say goodbye to traditional anterior strip crowns and embrace preformed zirconia crowns?
And seriously – how do you get a wiggly, fidgety child to sit still long enough for a solid restoration?! The secret lies in choosing a technique that’s both quick and effective!
In this episode, Dr. Tim Keys unpacks the real challenges of restoring primary teeth, breaking down the pros and cons of popular approaches like the Hall Crown technique, Pediatric Zirconia crowns, and conventional stainless steel crowns (SSCs).
Tune in for practical insights to make pediatric crown work less stressful and more successful – helping you find the best fit for your little patients.
https://youtu.be/VJm4TFKLXEA
Dr. Keys is also involved in dental education and offers courses through his platform, Kids Dental Tips. One of his upcoming courses is titled “Restorative Paediatric Dentistry,” a two-day event scheduled to be held in Brisbane.
Protrusive Dental Pearl: One of our best ever Protrusive Infographics! This week’s Pearl is a handy downloadable PDF infographic summarising the key points from this episode on Children’s Crowns Techniques. Grab your copy here!
Need to Read it? Check out the Full Episode Transcript below!
Key Takeaways:
The Hall crown technique is a non-invasive approach to treating pediatric teeth.
Radiographs are essential for accurate diagnosis and treatment planning in children.
Case selection is crucial for the success of pediatric dental treatments.
Zirconia crowns have superior aesthetics over stainless steel crowns.
The success rate of intra-coronal fillings in primary molars is lower compared to crowns.
Zirconia crowns rarely fracture compared to strip crowns.
Mild supra-occlusion is acceptable in pediatric dentistry.
Hands-on experience is crucial for mastering crown techniques.
Highlights of this episode:
00:00 Introduction
01:32 The Protrusive Dental Pearl
04:19 Dr. Tim Keys
06:26 Work-life balance & parenting
12:05 Hall crowns Vs Zirconia crowns
13:12 Pediatric crowns and caries management
15:40 Failure rates and clinical implications
17:51 Stainless steel crowns: conventional vs Hall technique
21:03 Case selection and radiographs
25:31 Radiographic criteria
27:04 The Hall Technique
29:59 Technique tips
38:00 Zirconia crowns vs strip crowns
46:55 Education, resources, and further learning
51:02 Outro
Key Article mentioned in this episode: Effectiveness, Costs and Patient Acceptance of a Conventional and a Biological Treatment Approach for Carious Primary Teeth in Children | Caries Research | Karger Publishers
#PDPMainEpisodes #BreadandButterDentistry
If you enjoyed this episode, you should check out PDP159 – How to Manage Children in Dental Pain.
This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.
This episode meets GDC Outcomes A and C.
AGD Subject Code: 430 Pediatric Dentistry.
In this episode, Jaz and Dr. Tim Keys explore practical approaches to restoring pediatric teeth, focusing on the selection, preparation, and placement of direct restorations. They discuss material choices, clinical tips, and how to tailor techniques to improve outcomes and cooperation in young patients.
Dentists will be able to:
Understand the clinical indications and benefits of various crown techniques used in the restoration of pediatric teeth
Recognise the importance of selecting appropriate cementation materials and techniques for different types of direct restorations in children
Appreciate the key clinical considerations involved in the preparation and placement of a range of direct restorative techniques in pediatric dentistry
https://media.blubrry.com/protrusive/content.blubrry.com/protrusive/PDP227.mp3
Click below for full episode transcript:
Teaser: The success rate at 10 years sits between 97% and 99%.
Teaser:This is the traditional conventional approach. Yeah.
Conventional crowd. Yeah. And I would argue that is more successful than what you would be doing in an adult tooth. A name of restorative material in adult tooth that you know is got a 97% to 99% success rate at 10 years.
It’s incredible. So there’s nothing like this. So if you’ve got a patient who’s got a clinical issue, I would encourage all your listeners, please do not do anything without x-rays. And if you can’t get x-rays on that patient because of compliance issues, you really need to reconsider your ability.
The strongest way to get that crown to sit down as the kid ’cause their jaws a lot stronger than my thumb. And so I put a cotton roll in it. I get the kid to bite down really hard and you get a floss with a knot in it, and then you put it on and then you get your DA to put dental assist to put their thumb over the top of the crown. You floss down and then pull it out and then go to the other side. Floss down, pull it out.
I haven’t done a strip crown on a primary interior tooth in five years. And I’m so bloody happy I don’t do them anymore. Keep in mind, each x-ray is the equivalent of around six bananas. Six bananas got radiation in right? So the radiation test is insignificant, really. And I think I need your listeners to really understand that we don’t treat children differently because they’re children.
You know, we wouldn’t treat an adult and extract a tooth on an adult without an x-ray. You wouldn’t do a filling on an adult without an x-ray. You wouldn’t do a nerve based treatment on an adult without an x-ray. So please stop doing it on children because there is no defense for it. It’s completely wrong.
Jaz’s Introduction:This episode is such a wonderful resource and refresher on the whole crown technique. If you listen to the end of this episode with the wonderful Tim Keys. He’s like the Aussie, you know, Aussie man reviews those hilarious videos with a funny Australian accent comedy like Tim has that voice where he should just do dental videos and a funny commentary.
He’d be like, Aussie man dental reviews. And Tim spoke so well, so passionately and so clearly about this topic so that by the end of this episode, you will know the difference between the conventional stainless steel crown technique versus the more contemporary hall crown technique.
When should you use? Which one and all about this newcomer, the zirconia children’s crowns, and how the technique actually is really different and how to prepare the tooth accordingly for a zirconia crown, which is relevant both for anterior and posterior teeth, from knowing which cements to use and whether or not you should use local anesthetic on a child.
And something that Tim’s very passionate about. Should we be taking radiographs on children and at what age? What are the clinical and radiographic science look for, to make sure that a tooth is suitable for this type of treatment, i.e. the whole crown treatment.
Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Like I said, Tim, honestly just absolutely smashed this episode, and I’m so excited for you to learn from him. As you know Protrusive, we have guests from all around the world, but I have to say there’s something. I have a soft spot for my Aussie guests. I dunno what it is. They just come on and they put on a show every time. So sending love to all the Aussie Protruserati. You guys have been supporting me for over the years, but we’re gonna win the ashes. I just had to put that in there.
Dental PearlEvery PDP episode I give you a Protrusive Dental Pearl, and today’s pearl is just the most wonderful summary of this entire episode. It is one of our famous Protrusive Infographics. There are two ways to get this for free. One is if you’re viewing this episode on the Protrusive Guidance app, then thank you for being a member of the nicest and geekiest community of dentists in the world. Just scroll down and you’ll see the PDF there, and please comment if you’d like it. Number two is, if you’re not on our community, then head over to protrusive.co.uk/kidsteeth. That’s kids teeth.
And when you enter your first name and your email address, I’ll email it to you personally with the PDF in your inbox. Our infographics are pretty famous, the ones that we have on deep margin elevation to which ceramic to use, which type of zirconia to use. We work really hard, especially the oral medicines one.
Again, that was actually another Aussie guest we had on as well. So once again, hat tip to all the Aussie guests I’ve had on the show. But yeah, you’re gonna love this infographic, so please do download it. And if you’re not on the Protrusive Guidance community, what are you waiting for? Honestly, it’s so, so nice to learn from everyone and to share my special snippets.
And actually, there’s a part of this episode that is gonna be only on Protrusive Guidance, and this might actually sway me in a different direction, but. You know at the point of recording this in February, I know it’s gonna come out much later in the year, but I’m recording this in February, 2025 and we’ve got 30,000 YouTube followers and I’m so grateful, honestly, like thank you so much.
But there is a percentage of these subscribers that are members of the public. They are non-dental. They are patients of dentists, they’re the public. And I feel a little bit uneasy about that because we need our little safe space. This is dentist talk like you’re a patient. I understand that you are seeking information and it’s good to be informed, but this is dentist speak like this is not the best place for you to get information.
And so what I worry about is some pieces of information that is like just dentist talk, getting through the wrong is. And so what I’m gonna suggest is, if you want the full experience of this episode, please check it on Protrusive Guidance, even the free subscription on Protrusive Guidance. It’ll be there, the full video without any interruptions on YouTube, you’re gonna get a little bit of an interruption where I probably censor about five minutes, and the reason for the sensor is a really appropriate and a really good recommendation that Tim makes and is totally appropriate, and I love him for what he says.
But if patients hear this, then I worry about them taking it to their dentist and it’s just not the right environment. So this is very much secret dentist talk that patients shouldn’t hear. It’s a fact of life. And what we do on Protrusive Guidance is that we have a systems in place that we will email you for proof.
So I know that Protrusive Guidance is a safe space because it’s not easy to get accepted. We ask you for proof that you are a dental professional. So if you’re watching on YouTube and you have access to our app, just switch over now so you don’t miss any of it. If you’re watching YouTube, still love you.
Thanks so much. You’re just gonna miss out a few important minutes, which make a very clear clinical recommendation that you should be doing, and me and Tim feel very passionately about that. But yeah, we’ll not go into it anymore. Enjoy the episode and I’ll catch you in the outro.
Main Episode:Dr. Tim Keys so nice to meet you on here. Welcome to the Protrusive Dental Podcast. Your kids are asleep. It’s a great time. It’s morning here. It’s evening where you are in Australia. So tell me, my friend, whereabouts in Australia are you and are you a general dentist? Are you a pediatric dentist? I wanna learn more about you sir.
[Tim]Mate, I live in a state called Queensland, which is a very sunny place, one of the more sunny places in the world. And I live on a location called the Sunshine Coast, which is a nice, a beach area, very well known and it’s a beautiful, beautiful place. Absolutely. I’m a pediatric dentist, have been now for several years and obviously prior to that was a general dentist. And I love my pediatric dental job. I enjoy it and I love teaching too.
[Jaz]Would you call yourself a big kid? Would you refer yourself like you’re a big kid yourself?
[Tim]The best part of the job of working with kids is that you can have a lot of fun. You’ve got an important job to do, but you get to do fun things and you get to talk about all sorts of crap that you can’t talk about to adults, so you can have a joking time. They converse the worst part of our jobs, dealing with parents, which sucks.
[Jaz]And you live in the Sunshine Coast. There’s a book by the “The Almanack of Naval Ravikant” and great book. And then this really clever guy, he says that in life, we don’t spend enough time thinking about where we want to spend our lives, where we want to live.
So what I wanna know from you is, were you just born into there and then you just stayed in your Sunshine Coast? Or did you make a conscious decision to design your life so that you live in a beautiful place?
[Tim]Conscious decision, Jaz. Conscious decision. I live 800 meters from the beach, very close to little canal system. It’s beautiful here. Good surf. Good weather. And I’ve got my commute one kilometer to work. I go through two sets of traffic lights. So if it’s a bad day, it might take me five minutes to get to work.
[Jaz]That’s amazing. I’ve experienced that joy before. That has its downside as well. Like, you know, I know you’ve got kids and we’ll talk about that, but I’ve got two young boys and so when I used to work literally right next to the clinic and I’d be like home in like four minutes.
I never had time to read because I was always serving my children or whatever. And so therefore now I’ve gotta commute back. I’ve got like a 45 to maybe an hour commute now. And so now my audible credits are getting used up, which is great. So, you gotta take the ups of the downs. How old are your kids?
[Tim]I got a 4-year-old, a 3-year-old, and a 1-year-old.
[Jaz]How would you do it, man?
[Tim]Alcohol helps few bees, mate. Absolutely.
[Jaz]Lovely. Why paeds why did you go into paeds?
[Tim]I feel like it’s the last real remaining specialty where you can actually do a lot and try to still refine your skills within that. So by that I mean, it’s not just doing fissure sealants and crowns and fillings and extractions on kids.
You can do surgical extractions, exposures, and bonds of canines and teeth. You can do some pretty gnarly sort of auto transplants. You can do endodontic treatment as well. So there’s a whole scope of things where you can still focus on certain stuff. I quite enjoy dealing with children. I thoroughly enjoy the job.
It does get fatiguing, like I think three to four days of clinical peds, like in the clinic dealing with kids and anxious kids can get quite emotionally draining. So therefore it’s really nice to have that one day a week or a fortnight, under general anesthetic where I could just somebody else’s behavior managing ketamine and profile.
[Jaz]Really fascinating. It reminds me of people I speak to whose spouse happens to be a chef. And so, when they’re cooking all day long. They don’t cook at home ’cause they’re just done with it. So how do you, right, this must be the toughest gig. Like that week we got like anxious children all day long and then you come after, you have to come home to your own kids. How do you make sure that the dad mode is on?
[Tim]Mate, it’s hard. Like I leave home and I have screaming children from 6:00 AM. I go to work and I’ve generally got screaming children for eight hours, and then I go home at nighttime and I’ve got screaming kids until seven. So I have 13 consistent hours of screaming children.
And you’re right. Look, it does get a bit sad sometimes that I can use up all this patience on other people’s kids. And you go home and you think, ah. But yeah, what do you do? Right? But I’ve gotta say, everybody that’s got older kids and Jaz, I don’t know how old your kids are-
[Jaz]Five and two.
[Tim]Five and two. So you would hear the same advice. Anyone that tells you, they say, you’re a bit in the trenches now, but these are actually such magical years. You got these little humans who all they wanna do is spend time with you. And sometimes you get a bit over that, but that’s all they wanna do. They just wanna spend time with you and I really do.
I don’t work weekends. I don’t work late nights other than doing podcasts after the kids are asleep. I think for all of us with kids, it’s just that really valuable special time, which you just, that’s that 20% you gotta think about while you get through the 80% grind of just screaming battles, right?
[Jaz]It’s an absolute joy ever. I totally agree on the book I’m listening to the moment is “Hold On to Your Kids” by Gabor Maté and Gordon Neufeld. Have you heard of this book?
[Tim]I haven’t, no.
[Jaz]Okay. So I’m early into it, but I love it because it’s talking about the culture we have brewed as a society, we have created this culture of sending our children, encouraging them to have attachment with their peers.
And then children, it is like you can’t serve two masters. And so what happens is that because now they are attached more to their peers than to their parents, then this is why they don’t wanna hang out with their parents anymore. This is why they’re sort of moody at home. And we think this is a phase, but what the book argues is that actually this is a new phenomenon and we need to make sure that we hold onto our kids.
Their primary attachment and guidance in life should come from their parents, not from their peers, because otherwise the blind leading the blind. So that’s a really fascinating book. I thought it’d be nice to mention it in the pediatric. There’s lots of parents listening. The other one I’m listening to, thanks for a recommendation from someone in the community is the anxious generation.
How the newer generation and screen time is really messing up our kids’ brains. We know this already, but like it goes deep into the science. Any guidelines you follow at home just as parent to parent on screen use.
[Tim]Mate, we are very limited, but I’m fortunate that our kids are young. So we’ve got the point now where we can, to some degree, control them. Yes, there’ll be a big screaming fight and argument, but we’re pretty rare. Like we might do, there’ll be multiple days in the week where they get no tv, and then if so, they might get short periods, 15 minutes, like after they’ve cleaned up the playroom and things like that. So it’s used just as a reward basis.
Don’t get me wrong. Occasionally when it’s like five o’clock and you’re late for dinner. And you’ve got three screaming kids and it’s chaos. You’re like, we’ve gotta crack this. But we actually found about a year or two ago, we were finding that we were resorting to it too much. And I’m the same as you.
I just feel like, particularly where I live, like our winters at worst are like 12 degrees to 25 degrees. That’s how cold winter. So that’s excuse.
[Jaz]Excuse for those Americans out there. It is pretty good.
[Tim]Yeah, absolutely. So we’ve got no excuse where I leave not to be outside and playing. And we’ve got a fenced house so they can have a good time. But yeah, I agree. Absolutely. I think there’s a few things, there’s a lot of ultra processed foods and that sort of stuff. A lot of sugar, a lot of tv, and I’m so happy that Jaz, you look similar sort of age to me that we grew up prior to social media.
[Jaz]Big time. And so the book argues, and I’m glad you mentioned this because I remember growing up and I would be away from the home. Like I’d be like nine, 10, and I’d be like, in a distance park, maybe 500 meters, maybe in a kilometer away from the home, and I’d be in the park, no phones, no contact, and I would just come home six hours later or something.
Okay. And parents were accepting of that. Nowadays we can’t bear to not know where our children are at such a young age and for them to just go and walk off. And so this is what the book argues is a real one. The biggest tragedies of our time. So it’s interesting to talk about this.
[Tim]Absolutely. I agree. Yeah. I mean, to be honest with you, but I think I would struggle to let my kid, I did the same. I used to go for a bike ride, 15 K away, but I’ve still got young kids, but I struggle to feel like I would let them do that. It’d be emotionally tough for me, but I don’t know. We’ll see what happens when we get there.
[Jaz]Yes, exactly. So it’s society, but I enjoyed that pre-check. Thank you so much, Tim. I’d like to learn about why someone goes into this particular specialty and learn a little bit more about the individual. And I know it’s nice to learn about you and your family and just parenting advice is nice to talk about as well as books.
But the main crux of today is hall crowns or rather formally, we used to call them stainless steel crown technique versus hall crowns. But now the new player zirconia. And I was saying to you before we hit record, actually my wife, she did a MSC at Eastman in pediatric dentist. And her thesis, a master’s thesis was on zirconia hall crowns versus stainless steel hall crowns, basically. So, very interesting. I believe the only supply, and you correct me wrong, is it new view or new smile that zirconia-
[Tim]New smile. So there is another company called Sprig, which came later to the game, but the predominant market in the world is a company called New Smile. So they’ve made the zirconia crowns, which I think those particular crowns are not suitable for a hall crown, and we can go and discussing that why. But they’ve created another crown, which is like a resin base, is acrylic crown called BioFlex, which they’re trying to say is a bit more like a hall crown.
But I think what we should do Jaz is let’s go through the pros and cons and things of stainless crowns and zirconia, and we’ll talk about the pros, cons, limitations in how we can do it. But I’d be very fascinated to read this. This thesis.
[Jaz]Yeah, I’ll send it to you. I thought I just mentioned that as a little background, but yeah. Where I want to start this podcast is for our younger colleagues, and actually, you know what, for our older colleagues, because they probably qualified at a time where the technique wasn’t being used so much, or not in the way that the whole crown suggests they were still prepping perhaps. And so let’s talk a little bit about the history of using stainless steel crowns from pediatric molar teeth and how that’s evolved and where, when, and why the whole technique and what it is.
[Tim]Yeah, so Jaz, essentially the way we have managed decay, as many of us are aware, has changed, right? And the reason is we are moving away from this infected and affected dentine and things. So dental caries, the outcome is a cavity. Okay? Once you’ve got a cavity, you can’t tend to remineralize it without plaque control it will continue to progress.
And that’s our justification for putting fillings in, right? Restoring form, function, and aesthetic. So for pediatric teeth, there’s significant limitations to putting intracoronal restorations in teeth. So my thesis was a part of a series of surveys of dental protection is nation, so nations wide, so internationally, and so for us practitioners in Australia, what do they use to treat kids’ teeth?
And the dominant material used for primary teeth was GIC followed by composite resin and then some RM GICs and some stainless steel crowns. And you’d find the variability was significant. You’d have 25, 30% of people using this, 30% using this, 20% using this. Well, if you asked for permanent teeth, it was 85% composite resin, right?
So why is there so much variability for primary teeth? And I think the reason comes is that there’s not a great deal of research on this. And essentially everyone’s just having a crack at it. My supervisor’s using fuji and, but a fewer GICs, and that works really well. The issue that we’ve got primary teeth takes six months to form, not three years.
The enamel that’s present is much thinner. It has a much lower mineral content. Now we use predominantly resin based or a chemical adhesion. Yes, GIC has that ion bond, but the vast majority of our resin restorations. They’re just glued in and we don’t have, even, despite trying to go for that, still, our best bond we can form is with enamel.
And so you can imagine if a primary tooth begins its life with less enamel. And the enamel that says, got less mineral content, it’s much more difficult to glue a intracoronal restoration into the tooth. Our main drawback with GIC based materials is that they’re structurally weak and children, because they’ve got their flat occlusal plane, can actually have higher bite forces on their marginal ridge than weak can as adults.
So, but why therefore do we use a inferior strength material to restore primary teeth? And so the failure rate for tooth surface intracoronal restoration at three years sits at about 35 to 40%. That’s what our evidence shows us. So that means if you’ve got a child in your clinic-
[Jaz]And that’s any restoration that’s GIC or comp, any direct restoration? Yeah?
[Tim]Much higher failure rates of GIC. Like if you look at the American Academy of Pediatric Dentistry and other guidelines, a lot of them are recommending, once you get past a single surface for GIC. It’s really not indicated. It’s contraindicated, it’s a temporary restoration-
[Jaz]But while RMGICs does that make a big difference? ‘Cause you know they are two different materials. RMGICs, you know, far mechanically superior.
[Tim]Yeah. But it still can’t put up with the years. If you’ve got a 5-year-old and you’re putting a DO in there first primary molar, you got six years of occlusal forces on that. I guess the question Jaz to you is would you expect six years to survive in an adult tooth with an R-M-G-I-C as a tooth surface restoration?
[Jaz]Put it this, say it’s not predictable treatment. You wouldn’t say to a patient, ah, it should be fine for many, many years to come. Whereas with a composite, you definitely could say that, yes, I expect this to last long, whereas your reducing the predictability for sure.
[Tim]Correct. And so the same thing applies to kids and so therefore, composite resin has a higher success rate when it’s small. The moment you move past the contact point, so it gets wider and extends onto the buccal or lingual surfaces, you’re actually now moving into a three surface intracoronal restoration and it is a contraindication of placing in intracoronal restoration and that for longevity. Why else? If you wanna put an R-M-G-I-C in what’s in it, what makes it stronger?
[Jaz]So it’s the silica.
[Tim]Well resin, right? It’s a resin modified glass, ominous cement. Is resin moisture resistant?
[Jaz]No, it’s not. But there’s the same issue with the composite.
[Tim]Correct. So if you want to do an intracoronal restoration that you want to survive, you need local ’cause you’ve gotta drill. And you need rubber dam on ’cause without rubber dam your failure rate increases by 200%. And then even then, even if you’ve got a tooth surface resin put in those areas, your composite failure rate can still approach about one in five. So if you’ve got a kid, you put four fillings in, you would expect at three years at, to be getting close to one of them failing at least.
Keep in mind that’s an average place under rubber dam with local anesthetic. Can’t be hard to do, so therefore we move to stainless steel crowns. So a stainless steel crown on a primary tooth was traditionally, as you said, the conventional technique, and it was reserved for those teeth that were heavily compromised.
Large multi-service areas, decay or pulpotomy based teeth where people were scared to put a filling. The success rate at 10 years sits between 97 and 99%. I would add-
[Jaz]The traditional conventional approach, yeah?
[Tim]Conventional crown. And I would argue that is more successful than what you would be doing in an adult tooth. A name of restorative material in adult tooth that you know is got a 97 to 99% success rate at 10 years. It’s incredible. So there’s nothing like this. So in the UK there was a particular dentist who was audited because she was claiming a lot of NHS think it is, a lot of the rebates but she was doing so many stainless steel crowns.
It was just like this can’t be right. This girl’s lady’s doing too many and they went and ordered her records and found out she was putting them on non-invasively. So this goes back to that decay scenario. If we can deprive the bacteria of a food source, they’ll die. But it has to be well sealed and that’s where standards of chronic overcomes that.
As long as you have sealed the decay. So they ordered her and actually found out her success rates were brilliant, and this is what became the hall technique. Now, pediatric dentists were actually one of the more resistant groups to adopting this technique. So they said, this can’t be right. We’ve gotta sit down and drill it and put a conventional crown on.
Otherwise it’s gonna be too uncomfortable. It’s not gonna work. They were two, there’s actually a studies done, and there was two comparison postgraduate pediatric groups in the UK that did this. They treated 836 teeth and had a 77 month follow up. One group did conventional crowns and one group did hall crowns.
[Jaz]Before we talk about the success rates there, because I just wanna just clarify to our audience, what actually does a conventional technique entail and what makes a difference to a hall technique?
[Tim]So a hall technique is no preparation. So you put two separators between the tooth. So you’re leave there for a couple days, then you come back and take the rubber bands out, and so now you’ve got a little bit of room to fitch ground.
Then you just size up. The best size you can and the more you do, the more comfortable you get it. Doing the size, you still gotta crimp and adjust the crown. So crimps like bending the crown to make it tight. Then you fill it full of glue and this is probably the best place to use. GIC in kits is within a stainless steel C crown and you squish it on over the top.
Okay, now it’s heavily reliant on your diagnosis. And investigations prior, which I think we’ll cover, but in comparison to a conventional crown. And a conventional crown is where we used to just, you’d numb a kid up and you’d take about a mill and a half off the top. Then you get a bur, like a stiletto, or what’s called a flame bur sometimes, and you just sort of open the contacts up and round it all around a little bit.
Then you get a crown, try it on several times, bend it, adjust it, fill it full of glue, and stick it on. Okay? So they’re your differences. Now, you still need to do conventional crowns in circumstances where hall crowns are contraindicated or following a pulpotomy. Okay? So you still need to know that skill set.
But going back to this study, the hall crowns are non-invasive, filling full of glue, squishing on when it met the guidelines, which we’ll go through in a second. The success rate for that was 95. 0.8% for the hall success rate. Hall crown success rate for conventional crowns was 95.3% statistically insignificant.
So that converted us. So you got, yeah, that’s a lot of kids. That’s 400 kids. And that’s like, okay, this technique works. So in my clinic alone, I think we probably pace about 1200 hall crowns per annum. So a reasonable number. And your failure rates are not significant if you place ’em in the appropriate situation.
And just to be honest with that, we’re beginning to see a much larger number of failures is where they’re probably placed on teeth that weren’t suitable for this technique.
[Jaz]So like in everything in dentistry, right? Case selection is so, so important to actually doing the technique well and correctly and to get the success rates.
[Tim]Yeah, spot on. So, to know how to treat kids, you’ve gotta have done a comprehensive clinical examination. And arguably, even more importantly, you’re gonna have x-rays. So it is medic legally indefensible to do a restorative procedure on a child without an x-ray. I mean, we wouldn’t do it on an adult. We see a lot of people doing it on kids ’cause it’s hard to take x-rays on kids.
[Jaz]But have you seen a big friction here, Tim? On social media perhaps with dentists where I’ve seen dentists openly say that, listen, I don’t radiograph children until they’re 12. Like, and they’re very adamant about that, right?
And so whereas I was taught by Professor Helen Rodd in Sheffield, and so when I saw children, I would take radiographs at the soonest opportunity. Maybe age four if they’re looking like they’re gonna be high risk if I can do it. But definitely age five and beyond. What guidelines do you suggest in terms of, okay, when should you start? Basically, I just want you to encourage the listener to remember that actually it’s okay. We should be taking graphs for children.
[Tim]Absolutely. But these people that are saying they don’t take x-rays on kids to 12 should probably cease practicing on children. To be realistically, ’cause they’re causing more harm than good.
When you should take radiographs on children, let’s say you’ve got a child who’s got no clinical issues, you’ve done a clean exam, it looks good, but you’ve got closed contacts. It should be taken 18 months after closed contacts. So Jaz, well done. Four years of age, that’s about when we should start taking them.
It’s hard. There’s lots of variations you can do to the technique to still achieve it. Keep in mind, each x-ray is the equivalent of around six bananas. ‘Cause six bananas got radiation in right? So the radiation test is insignificant, really. Now, if you’ve got a patient who’s got clinical issue, I would encourage all your listeners.
Please do not do anything without x-rays. And if you can’t get x-rays on that patient because of compliance issues, you really need to reconsider your ability to treat them. ‘Cause if you can’t get an x-ray on them, how do you expect them to sit through an extraction or a restoration or even a bit of putting a bit of Fuji2 over the top of it, right over RMGIC.
So you need to get x-rays and sometimes you gotta vary the technique. So you might do like instead of getting a set of bite wings, you might get, like, you might capture like a quadrant with a little crocodile. So you get your little sensory, your plate in the crocodile, get the parent to hold it, just angle it up, try and get the contact points.
And the benefit of doing that early is that you can also do prevention such as silver diamine fluoride and things like that to prevent lesions from developing. But then you’ve got a firm diagnosis, and I think I need your listeners to really understand that we don’t treat children differently because they’re children.
We wouldn’t treat an adult and extract a tooth on an adult without an x-ray. You wouldn’t do a filling on an adult without an x-ray. You wouldn’t do a nerve based treatment on an adult without an x-ray. So please stop doing it on children because there is no defense for it. It, it’s completely wrong.
[Jaz]I mean, what got me from memory, and I appreciate you saying that. And I think we need people just sometimes to say how it is. And I wholly agree with you, except, what I see on social media is reluctance of dentists. So I’m glad you’ve really been very clear about that and I appreciate that.
It can be challenging, but we must do it. And the piece of research that always stuck with me in final year dental school and now, I dunno, it’s been like many, many years since then, but it was like, you are likely to diagnose eight times more caries when you have radiographs. So if you think you’ve got two lesions or two areas of caries, it’s probably a lot, lot more than that basically. And so you’re missing a lot of diagnosis.
[Tim]Correct. So, Jaz, if you can see a cavity in a primary tooth, let’s say the five, the upper right. First primary model, what we would call five four. What environment is the six four sitting in? Same environment. Where’s the seven, four, and eight, four sitting?
Same environment. Maybe they’ve got a tongue, a bit more saliva, so maybe less, less effective. What’s happening to the five five? By the time you can clinically see a cavity in the mouth, it’s been there for a long 12 months. How close is it to the pulp? I can guarantee you if you just go put a food, just bog up that little five full, A) it’s not gonna last. B) the kid’s gonna come back for probably an extraction of that tooth. And C, you’ve probably missed the three or four other holes that are there.
[Jaz]Totally. I’m glad that’s nice and clear. So the message here is, let’s start taking radiographs in children. And then it’s imperative, I mean, to any treatment modality you do, but in terms of how could this sway you in terms of, okay, is this now suitable for the stainless steel or hall crown approach? Or actually we should be considering another way of treatment.
[Tim]Let’s say you’ve done a beautiful clinical and radiographic examination and you picked up a couple of holes in the mouth. With the hall crown, the main key is at this point, according to the guideline for this, which is once again published UK, you need to be able to have a clear, radiographic band of dentine between the cavity and the pulp.
So you’re looking for about a mil. It shouldn’t be something where you like, ooh, I think I can see it. It should be, yeah, I can see hole and I can see decay. And what we’re thinking there is that you’ve got like a bit of insulation, okay? At that point, hall crown is eminently suitable. You can treat a single surface. Two surface, three surface doesn’t matter as long as you’ve got a radiographic band to-
[Jaz]And if it’s cavitated or non cavitated, does that inform the prognosis? The broken marginal ridge. Okay, good. Good.
[Tim]No, doesn’t change it. So we’ve moved away from that thinking that a marginal ridge involves pulpal involvement, therefore you require pulpotomy. You only need a pulpotomy if radiographically the decay is into the pulp. Or if the symptoms are guiding you to question the health of the pulpal status. But if you’ve just got a standard hole, whether you can see it clinically or not, with on your x-rays and you’ve got that radiographic barrier, and the kids just say, oh, it hurts when I eat.
Happy days hook in. Now, where would you do a hall crown over an intracoronal restoration? I would probably encourage you to do a haw crown in most circumstances. Why? Because you don’t need local, you don’t have to drill it. Your success rate’s higher. And so it’s cheaper, quicker, and easier to place happy days.
What’s your big drawback? Aesthetics. And what is becoming increasingly more important for people these days is aesthetics. And that’s obviously why we’ll talk about the zirconia crans shortly. Now with the hall crowns, you need a vital tooth with decay not involving the pulp. Two other things I want your listeners to look out for because you are not adjusting the occlusal surface.
The ability for the crown to sit down towards the gum level, it can only sit down as much as the crown will go down, right? And when it hits the top of the tooth, it’ll stop. So if you’ve got a really deep hole, not towards the pulp, but down like under the gum, I need you to think. If I put the silver crown, the Staines stainless steel on this without taking anything off the top, will the crown actually seal the cavity?
Because what happens if it doesn’t? Well, the decay continues to tick away, and then you end up getting sent to me. I pulled the tooth out. Okay, so that’s tip number one. If you can see decay, that is about the gum level, I would start thinking my crown is gonna struggle to seal that. Okay? If it’s above gum level, you’re probably gonna be sweet if it’s well below gum level. You’re gonna struggle.
[Jaz]So well below gum level is obviously okay, as long as A is vital and B, it still has that band of dentine, it’s still okay to treat with the whole pan approach. Except what you’re suggesting here is perhaps consider some occlusal reduction?
[Tim]Yeah. The problem is, I don’t know why Jaz, but if I pick a little flame will still let the bur up and go in proximally without local, the kids don’t tend to feel it. ‘Cause there’s reasonable enamel there. The moment you seem to pick a footy up and touch the top, the kids do seem to feel it. So when I’m looking at my x-rays and clinically I’m looking at how deep down towards the gum the decay goes, and if it gets below gum level, despite meeting the other criteria.
So plenty of space to the pulp. Symptoms are sweet. I might say to them, hey, we need to do a conventional crown here because I need to numb ’em up. Take some off the top to get the crown to sit down far enough to seal decay. The second thing I need people to look out for is when you’ve got a clinical cavity that’s present usually on the D, the D blows before the E or for the other people that know that the first primary molar goes before the E.
The second primary molar reason is it’s been there longer and it’s got much thinner enamel on, so it tends to blow first. What can happen is you get a clinical cavity on the first primary molar and then the tooth behind it tips into the hole.
[Jaz]Hate that scenario. ‘Cause it just makes everything so awkward and tight.
[Tim]Correct. And then how do you get a crown? You need to do like an S bend, it’s gotta get like a dog lick to get around the second primary molar to seal it. And that’s once again where you might look at the scenario and say, actually I need to numb the kid up into a conventional crowd. But they’re your two main ones.
They’re the two things. Just for tips for young players, you’re getting started. I would say don’t pick a D, pick an E. So second primary model, they’re easier teeth to manage. Pick obviously a very compliant child. And if you’re a bit concerned and you’re worried, like you’d think, oh, I dunno if I actually sealed that decay.
Take an immediate x-ray. So before the cement sets. So if it has, and you haven’t sealed it, get the crown back off and reassess your plan and maybe you need to numb ’em up and take a bit off the top.
[Jaz]Okay, that’s wonderful. And so the questions I have clinically on the back of that is just some common questions I actually see on forums on this technique is, let’s imagine a scenario where you have a, let’s say 5, 6, 7, 8, and eight.
So lower right D for some of our listeners, it’s clinically cavitated, but it’s equigingival caries, and you have, or, it’s vital. You have that band of dentine, so it’s suitable for a whole crown and you don’t have any space issues per se in that scenario where, because it has got an an obvious cavity, the guideline says, obviously if you can get a seal, you don’t need to remove the caries.
But in that scenario, it’s so tempting to just pick up an excavator and just scoop out some of that the most superficial decay. Is that something that you do because it’s just so easily accessible, just scoop it out in case there’s some bread or cookies stuck in there or something?
[Tim]Oh, absolutely. You gotta get the food out. Yes, please. So definitely give it a clean, but you don’t need to scoop out tooth structure, because once again, that boils back down to the understanding of decay. Decay is not an infection, it is a biofilm related disease. So if we can, so plaque bacteria related, right?
So if you can kill all the germs there because they’re deprived of a food source, don’t worry about it. Don’t pick anything up. Just make your life easier, quicker. Don’t pick a drill up. Just squish it on.
[Jaz]And then just the point there to make is if you see an obvious bit of food there, just get rid of that, cleanse it in that way basically, and get rid of it. And then the other scenario is when you are a bit more experienced, and then I’ve done a fair few hall crowns in my time, don’t see children anymore, but I used to love doing them. And when I did them, sometimes when it’s a bit tight. We need to then, yeah, zip the contacts just to allow it to seat a bit better.
And in that scenario, like you said, I also experienced that, okay, children were okay with that. They didn’t need any LA for that. That was okay. In that scenario, you are able to then seat it, which is great. Now going back to the stainless steel crown, the conventional technique is there sort of like a hybrid technique whereby you are doing the conventional technique, you are zipping off the contacts.
But you are not adjusting the occlusal for whatever reason. And then essentially what you have is kind of like a modified approach because with the whole crown, they’re gonna have super occlusion, their mouth be propped open. And so is there a place to utilize that approach, either to make your treatment quicker, more efficient?
So given the patient LA, you are zipping the contacts, but you’re not then doing the occlusal reduction because it will dahl in or it will settle occlusally anyway. Is that any need to do the occlusal adjustment?
[Tim]No, the short answer is no. I agree with you. There is certain circumstances where I’ve just got a zip between, and I won’t numb them up for that because they really don’t tend to feel it.
I would still, for in my hands, I still sort of call that the hall crown. For me, conventional crown is when I’m picking a needle up and I’m giving LA which is pretty rare on its own. Usually it’s when I’m doing a pulpotomy or I’m doing like back to back things, I’m extracting a tooth and then I’m like, oh, I’ll just put this on at the same time.
But, yeah, vast majority of time. Yeah, absolutely. You can just sort of zip between if you need to. But I’d say to most people, the vast majority of times, 80% of cases, you’re not gonna need to pick a single driller. You’re just gonna need to clean the gunk out. You’ll have seps (separators) in, leave ’em for a couple days, pull ’em out. You’ll have room and on your go.
[Jaz]And at the point of placing just a little technique here, but at the point of placing I placed, and then what’s the most efficient and best way to remove that GIC cement without then removing the crown or pausing discomfort to your child?
[Tim]Yeah. So my usual discussion with the parent or child before we’ve even got to that point is, I describe how we’re gonna do this technique. And I usually describe it in such a way, like you asking before about what, how does it work? My analogy I give to most parents is, imagine if I had a water tank and I put you in it, Jaz, and then I filled it full of concrete. How would you go? Not very well, you’d be dead. Right? And that’s what’s gonna happen to all the germs in here.
Okay. Now I need to put rubber bands between the teeth. Your child’s gonna be most upset by this bit out of the whole procedure. Why? ‘Cause it hurts. It’s like having a big chunk of corn stuck between your teeth. Usually at this point, I say to the kids, hey, you ever eaten corn before you eat meat? You know, we get stuck between your teeth.
It’s really annoying. So what we’re gonna do, I’m just gonna floss this in. It’s gonna be a little bit annoying. Always do the harder contact first. So usually on a D, do between the D and the E first, and then do the D and the C, right? If you’re doing the six, do the most, whichever one looks, the dodgiest do the hardest one first, and then the kids usually get a bit upset because it’s hurting and they wanna pull ’em out.
I always just reassure the kid and the parent that every minute it sits there, it’s gonna get less uncomfortable ’cause we’re making space and that’s the worst part of this whole procedure. So usually when they come back for the hall crown, they’ve got the space. Now there’s a particular set of pliers called Howe Pliers, H-O-W-E.
So there’s two pieces of equipment you need to place the stainless steel Crown. Well, there’s Crimpers, which sort of tighten the the gingival margin and make it sort of click, click on and retain better. And Howe Pliers, they’ve got like flat ends. They’re like little pliers with just flat ends. And what you do is you actually put them on interproximally on the crown and you can squish it a bit meso distally.
So they’re brilliant for those cases where you’re lacking a bit of space. Okay. And then it makes it a bit wide buccolingually, so you gotta crimp that in. That will help with you get those two things with good set of separates, you’re pretty good. Then I clean out the gunk, I’ve sized it up pretty well.
I’ve eyeballed it. Sometimes I sort of nearly put it on, can be a bit uncomfortable. I don’t tend to put topical anesthetic on the gum anymore. I tend to find the kids just got the taste of it half the time and I hated it. So I just pretty much now just load the crown up. With a, like a runny glass ionomer cement such as, like in Australia we call them Fuji 7, would be the type and then-
[Jaz]Or like a Ketac™ Cem or-
[Tim]Ketac™ Cem, perfect GI cement. Yep.
[Jaz]So you shouldn’t use the Fuji 9, for example. It’s too thick.
[Tim]Too thick. Can you get a struggle to seat it down very well. So you wanna runny. Not an RMGIC. Absolutely not. You wanna run GIC bit more like a looting cement? Okay. Yeah, yeah. And then load the crown up and definitely load it up. Good halfway. Keep in mind ’cause you haven’t taken a whole heap off, you don’t need a huge amount. And then just push it on. Okay. And then to clean it up, I usually just get some gauze and just wipe around all the excess initially.
Then the strongest way to get that crown to sit down is the kid, ’cause their jaws a lot stronger than my thumb. And so I put a cotton roll in it. I get the kid to bite down really hard. Okay. And then I get my triplex and I just wash all the cement off and off you go. Then you get a floss with a knot in it, and then you put it on and then you get your DA to put dental assistant to put their thumb over the top of the crown. You floss down, and then pull it out. And then go to the other side, floss down, pull it out.
[Jaz]That can be tricky, right? That can be a little bit tight and annoying. In my experience it has been. Have you found the same as well?
[Tim]Absolutely. But you gotta do it. Yeah. Otherwise you’ll glue the contact.
[Jaz]It’s a stressful part of the procedure where you’re like, okay, quick, quick, quick.
[Tim]Yeah, spot on. But keep in mind, if you get a slower setting one, you’ve got about two to three minutes. And that’s where if you put it on and you look at it, you’re like, it looks like the one surface is sitting in the air.
That’s when you’re thinking that’s not on, like it should be like a mill and a half high. Right? If you’re looking and it’s like, it’s low on the mesial, really high on the distal and that’s where my cavity is. And that’s your time to get it off.
[Jaz]Can be quite fiddly to begin with. But like you said, it’s such an incredible success rate you get, and it’s great to be able to intervene in this way just so I can make sure that for the show notes, everything is correct and my understanding has been correct as well. So I’ll summarize.
You’ve done a wonderful summary here of the hall crown technique, why we do it, why it’s beneficial compared to the conventional technique, but just there are still some scenarios whereby you may use the conventional technique with LA, occlusal reduction, zipping the contacts, and that is. A, when you’re doing pulpotomy B, when the caries is very subgingival, is there any other times where you would veer away from the hall crown technique?
[Tim]When you’ve got that significant space loss? Okay. And then potentially, like if I’m doing a quadrant of dentistry, like the second primary molar is gonna hole in it. The first primary mole’s got a big hole in it and the canines got a hole in it. You can’t hall crown a canine, so I’ve gotta numb ’em up. And then I might just say, I’m just gonna knock out all three in one go. I’m not gonna get ’em, do all these hall crowns come in and numb ’em up. So I might do, potentially a composite on the second primary mole.
If it’s small, if it’s big, I might do back to back crowns, for one needs an extraction, whatever. I’ll probably just move ahead and just, ’cause I can get a, it doesn’t take me long. I just get a quite nicer fit. Yeah. But you nailed it mate. That’s pretty much it. Brilliant.
[Jaz]Thank you so much. And that was all down to your wonderful summaries. So let’s now the last bit. Okay. Zirconia is a newer product in the market for children. It has been around for a little while now, but I haven’t seen it in the UK, been used very widely, but perhaps because the bias of me not looking at what the children’s clinics are doing in the UK at the moment. So tell me, my friend, how far are we in the zirconia being potentially replacing metal? And what have been your experiences with it?
[Tim]So we place quite a lot of them. They probably make up about 40% of the crowns that we place in comparison to hall crowns and conventional crowns. The main reason is obviously aesthetics.
Okay. Success rates are pretty similar between a stainless steel crown and a zirconia crown. If placed well, okay, so why would we put ’em on? It’s just purely aesthetics. That’s it on posterior teeth. So I would usually discuss with the parents and say, hey, look, your kid’s got, let’s just say they got all back eight molars in decay.
I’ll say, hey, look, all back eight molars with decay, whenever I’ve got a cavity in the first primary molar, the success rate of fillings is pretty low. So I usually will say, you got your choice is, are stainless steel crown or zirconia crown for a first primary molar. For a second primary molar, i’m a little bit more comfortable doing restorations on them, intracoronal restorations.
Okay, so let’s say they’ve got that, I’ll be discussing with them and say, hypothetically, let’s say they need eight crowns based on what I’m seeing. They’re all really big holes. I will say to them, oh, we can do eight stainless steel crowns. Your success rate sits in eight, that 95 to 97, your main drawback is you’re not gonna love the way it looks.
They’re gonna look a bit like jaws. So you’re gonna have all these visible eight teeth. So the other option you got is that we can do zirconia crowns. Now the more visible teeth are the first primary moles. So you can do them all in white. All in silver. Or you can do a mix. You can do maybe the front baby teeth in white and the back baby teeth in silver.
And so then when the kids smile for school photos, you’re not really seeing all that metal work. You’re predominantly just seeing a nice aesthetic looking tooth and Jaz that would be our most dominant use. We don’t commonly get that many parents who wanna do like all eight teeth in white because it costs more to do, they do take more time as well.
That can take fair whack a bit more time if you’re doing eight of them. And the reason is it’s a non flexible material. So if we talk about zirconia for a minute, most general practitioners are familiar with zirconia crowns or zirconia is a product for adult. We know it’s not flexible. We know it’s very strong and durable and compressive strengths, excellent once it’s cemented, but it’s not flexible.
So if you sat there with your fingers or got a little interest. Banged on it, it’ll fracture which means that you can’t squish it on like a stainless steel crown for kids where you’re like, oh, my prep’s not perfect, but I’ll just push it and the crown will bend on. And that’s why hall crowns work.
‘Cause it’s a flexible material. So for zirconia, you have to prep the tooth and it’s a bit like an adult crown prep with like no edge, no, no ledge, no feather edge, no shoulder, nothing. So what you do is you take about a mill and a half to two mil off the top, and then you take roughly about a mill everywhere else.
And then, so pretty much you create like a ledge all the way. So usually the way on which I would do it is I’ll take it off the top first ’cause it makes you crown shorter. So you then having to remove less. Then I stay on the same bur, which is usually like a football bur. Then I take some off the buccal and the palatal.
‘Cause you try to remove bur changes. That’s what makes things quick. Then I get a stiletto bur, or flame bur you gotta go below the gum. You’re about a mill below the gum, and then you buzz all the way around, get all your edges away, clear in proximals. And then for the new smile, you get a try in crown, which is excellent compared to that other brand called Sprig.
The reason is you use the try in Crown, which will get contaminated by blood products and things, and you try to fit it on, and there’s a classic size and there’s a narrow, the narrow is obviously designed for where you got space loss and you try it on so it passively fits, so you’re not forcing it. If you force it, you break it so you don’t want it rocking.
You want it passively fitting on with still contact points established. Once you go onto that, you then go and get your white crown, the one you’re gonna cement. You get good hemostasis of the gingiva. So sometimes they’re, I’ll use local ’cause it’s got adrenaline, so I’ve already had the patient numb, so whenever I numb a patient up for any procedure, I always numb through the interproximal gingival to the palatal lingual.
Every case I do more so for zirconia. And then otherwise you can use like hemostatic pace like 3M makes a hemostatic pace. ‘Cause you would need much better hemostasis than you do for stainless steel crowns. And then fill it full of the same you want. Now you want a runny R-M-G-I-C potentially. Okay, so you take too long for you if you just go use just a thin, like Ketac™ Cem, you want something you can cure with a light.
Okay? But you still want it thin. You don’t want like a food. You can cement with Fuji too. But for posterior teeth it’s a bit thin. Thick and sometimes you can’t get the crown out ’cause the cement can’t escape. So we use a 3M based product, which comes into syringe called RelyX. It’s really nice material and then you load your crown up, you put it on, and then I don’t touch anything.
I just set it. And so there’s excess cement everywhere, but it’s sets really quite tacky. So it’s a bit like a tack cure, but you’ll set for 40 or 60 seconds and then I just clean all the extra cement up. If you use Fujii2, it sets like bloody, like sets like rock, and it’s really difficult to get out in approximately, and then you’re done.
That’s it. Nice and easy. How long would it take? Look, I can probably do a stainless steel crown, conventional stainless crowned tooth in about three to four minutes. Okay. While zirconia might take me closer to 10-
[Jaz]This is because the zirconia involves that buccal and lingual additional prep, and essentially you are removing the belly of the tooth, right? You’re just removing the undercuts.
[Tim]Spot on. You just sort of, I mean the listeners, they can’t see. But for those who are watching on YouTube, I am going to describe something. So Jaz, I’m sorry for your listeners, they won’t be able to see this, but I’m going to describe it. For those watching on YouTube, you’d be able to see this.
So this is an anterior case, but I’ll show you posterior. So with it, you’ve gotta make them quite sort of peg, like see, there’s nice hemostasis there. I’ve got stainless steel crowns on the first primary molars, and on the anteriors I’ve reduced the anterior is down to look a bit like a conventional crown preparation, and then I’ve cemented four zirconia crowns there. The gums look a bit like minced meat. They get a bit traumatized here, but they always heal up really quite nicely. Now I’m gonna show a photo of a posterior.
[Jaz]Yeah. I’m gonna say it looks a bit like a vertiprep in a way that you just went round. You got rid of all the undercuts and it is not much of a margin.
[Tim]No. No, you don’t want a margin. You don’t want a ledge. So on the posterior tooth, I’m now showing, you can see that I’ve actually created a ledge. That’s what I was talking about before. So you create a ledge, it just gives you an indication of where to reduce. Then you cut that entire ledge away, which you can see there goes under the gum. Then you try the crown.
[Jaz]This is the shoulder that Verti prep. Lovely.
[Tim]And then that’s your crown cemented. So the crown’s cemented on sits quite nicely. You want it roughly the same occlusal height as everything else, and you want it sitting under that gum quite nicely. As I said, the gum will be a bit traumatized, but it will be okay.
[Jaz]Now here’s an interesting question then, because you’ve just raised a really good point that you want it the same occlusal level in this scenario whereby you are off a bit, then you’re kind of like in the whole crown scenario, you are leaving it in supraocclusion. Are you okay with that because you’re used to doing it anyway in children and they adapt really well? Or are you a little bit more fastidious that you’re gonna start adjusting to equilibrate the bite?
[Tim]No, I’m okay with it. I do try to get it a bit more even, but just for comfort and particularly, let’s say if I’m under anesthetic and I’m doing a whole quadrant. I don’t want, just like I’m only chewing on a couple of teeth, it’s just a bit uncomfortable.
So if I can, I’ll try to get it as close as I can. It won’t be perfect. But we do know for the whole crown, it can sit proud and it’ll settle in quite well. So they’re really good. The other place where they are so much better, which I actually personally feel they should replace entirely, is strip crowns so anteriorly, right?
So for a strip crown, it’s the same sort of principle you gotta do like that vertiprep, get rid of the decay. The issue is strip crowns. Success rate’s not great ’cause it’s resonant just chips. Kids go put bloody carrots in there and they bite grizzly bars and all sorts of things. And you just, in any pediatric dental program, when you’re a a first year, you spend all your time dealing with fractured strip crowns from the third years of the guys who graduated.
And so you benefit of your zirconia crowns is they very rarely fracture. You need a really solid trauma to break it, which would’ve broken the tooth anyway. So your main drawback is they might to bond. There’s not much retention on ’em. So that’s where we do cement them with Fuji 2. So we are at thicker R-M-G-I-C in the anteriors, but they are such a better aesthetic result.
You don’t get discoloration . They work very well for pulpotomies. You can successfully pulpotomy and anterior tooth, they can mask. If you’ve put silver diamine fluoride on and it’s black, they so they look a lot better. They last a lot better, so they’re much more superior material. Your main drawback is if you’ve got a kid with heaps of crowding, it can be a bit difficult to try to get ’em to fit all together.
So just tip for young players on that one. That’s where strip counts can help. But mate, well I haven’t done a strip crown on a primary interior tooth in five years and I’m so bloody happy I don’t do them anymore.
[Jaz]And for those you know who are listening, I would encourage you just reference back to this video, make a little handout ’cause this is Tim, this has been absolutely amazing. We make a little handout. Do you have permission to use those images in that handout for our Protruserati?
[Tim]Yep.
[Jaz]Okay, amazing. So I’ll put those images so you can easily download because they were wonderful. It really shines. The benefits of this approach. And it’s nice to know that, a very significant percentage of time actually you are using this. And also to learn about how you’ve no longer pretty much using strip counts anymore. That was amazing. You’ve answered pretty much all my questions in terms of the technique itself. Now I know you do some teaching in Australia and maybe more as well.
Before we get to that, I wanna say, give you, pay you a compliment, Tim, if I had your accent right, which I love, by the way, if I had your accent, I would do the dental version of Aussie Man reviews. Right. I would just think it’d be so funny and good to see these dental procedures happening, and then you just like, honestly, I really enjoyed listening to you today.
The hour went by really quickly. The audience would’ve loved you as well, the Protruserati. Please tell us how can we learn more from you? I know you are active in the education circuit, and I think for everyone. Like it’s nice for them to be inspired by what we discussed today, but I think it’s very fiddly and to just secure the protocols and so much more to it to get hands on experience. How can they learn that from you?
[Tim]Yeah, absolutely. So we have a like free dental website could kidsdentaltips.com and you can describe, there’s a whole heap of articles on there. How to manage permanent traumas, do pulpotomies, how to extract primary teeth prevention techniques, fluoride, toothpaste, or anything you can think of for peds.
That’s pretty much on there. It’s free access. There’s not a great deal of videos yet. Jaz, I haven’t quite got to that point yet. There’s some free lectures on there as well that you can view. Otherwise, we do do hands-on programs in Australia with which I’m actually doing one, I’m doing a four day one coming up on Thursday, the next few days, we haven’t done any internationally, but Jaz if you think there’s a place for it in the UK, I’d be very happy to come across for a nice trip to the sunny UK. Do some courses there, but, otherwise, if you are interested in doing something like a zirconia crown. You can find in videos of like how to on the Nu Smile.
So N-U-S-M-I-L-E, the Nu Smile website will have like how to videos and they do tend to run international events as well. I just dunno if they’ve gone into the UK ’cause I know that you market is quite different in regards to nHS and private. So for example, in Australia, there’s really no very limited public funding dentistry where it’s all private, which has got its own problems.
If you don’t have money, you can’t pay for it. It’s bit like America. Conversely, in the NHS, I know you’ve got a lot of restrictions on time and how much you really encouraged to get through things quickly. So, and perhaps that’s why that they haven’t targeted that market previously.
Look, if you listen this, there’s good demand out there. So I’m very happy to come across and run a course on hall crowns, zirconia crowns, restorative materials, local anesthetics and stuff.
[Jaz]Yeah, I think that’d be wonderful. So I think if there’s enough comments below, we’ll reach out and see. But I think what you’ve talked about today was absolutely fantastic. In one hour we actually managed to to cover a lot. So I would encourage you, I’m gonna put the website, just say the URL again for my benefit.
[Tim]It’s kidsdentaltips.com.
[Jaz]Lovely. I’ve seen the website, that’s how I managed to reach out to you guys. If you wanna learn more about Pediatric Dentistry, check out Tim’s website and check the articles out there as well. And if you are in Australia, there’s a good whack of Protruserati in Australia. Please check out Tim’s courses and maybe coming soon to a nation near you. And Tim, I wish you all the best.
‘Cause I really love your education style. I just love people that you are so direct and honest and just full of little nuggets and tips. And I know for a fact that Protruserati would’ve loved today’s episode, so we’re gonna make a little handout for them as well. So, Tim, thank you so much my friend. I put all the links in the show notes. Are you active on social media?
[Tim]Not too much. I am in Facebook and I do a few posts and things like that as well. But not, I just time poor Jaz, with three young kids.
[Jaz]Oh, I can relate. I can totally relate my friend, but no, it was so nice to connect you on Facebook and thanks for applying to me and being so wonderful on here. I really appreciate it, Tim. Thank you.
[Tim]My pleasure. Thanks for having me. I think you do a great job as an interviewer mate. You’re very engaging as well, so thanks very much for having me.
[Jaz]Amazing. Thank you.
Jaz’s Outro:Well, there we have it, guys. Thanks you so much for listening all the way to the end. If you’d like CPD or CE credit, scroll down, answer the quiz and get your CPD. You’ve done the hard work, like how many times do you have to sit through boring webinars to get your CPD?
Well, you’ve just enjoyed Tim’s fantastic commentary and explanation of this awesome technique. And now to validate your learning to be able to reflect and get a certificate, you can just answer the quiz on Protrusive Guidance if you are on one of our paid plans, which I think is the best value educational resource on the planet, but of course I’m biased.
It’s fully tax deductible as you know, and it helps team Protrusive to grow and to make better content. So if you’re not already on there, head over to protrusive.co.uk/ultimate and that unlocks Verti Preps for Plonkers or Sectioning School, all the various other master classes we have on there.
Especially, and of course, the community of the nicest and geekiest dentists in the world. The infographic is also there. We also have a secret space called Protrusive Vault, which has got all the downloads from over the years. And lastly, like Tim is such a cool guy to learn from. I know he does his courses on Australia, so next one is in November.
So if you scroll down, I’ll put a link to his course in Australia in November. Predominantly for the Aussie and Kiwi audience. But you know, if you’re in Asia or sometimes you wanna make a tax deductible trip to Australia, then this is a great reason to go. Tim is absolutely brilliant, and of course I’ll put a link to his website.
And with that, I will say thank you so much guys, honestly, for listening to the end. If you enjoy this episode, please send it to a colleague. This is how we grow. All the best. I’ll catch you same time, same place next week. Bye for now.

Jun 5, 2025 • 1h 2min
5 Airway Patients In Your Dental Practice Right Now with Dr Liz Turner – PDP226
How can dentists help kids breathe, sleep, and grow better—even if the problem isn’t the teeth?
When should you refer, and what tools can you use right now in your practice?
In this AES special episode, Jaz Gulati is joined by Dr. Liz Turner and Dr. Meggie Graham—general dentists who have evolved their practice with a deep passion for airway and whole-child health.
They walk us through five real patients, including Jaz’s own son, to show what airway dentistry looks like in the real world. From growth appliances and myofunctional therapy to inflammation control and ENT collaboration, this episode connects the dots between breathing and behavior, development, and even dental crowding.
https://youtu.be/Y6EfufPd98E
Watch PDP226 on Youtube
Protrusive Dental Pearl: “Don’t stay stagnant—keep learning, keep growing, and reinvent yourself every 5–10 years.” Think of your dental career in seasons—explore new areas, refine your interests, and let go of what no longer brings you joy. This keeps your passion for dentistry alive and evolving.
Need to Read it? Check out the Full Episode Transcript below!
Key Takeaways
Airway dentistry is a growing field that emphasizes prevention.
Understanding airway issues can lead to better health outcomes.
Dentists can play a crucial role in optimizing health through airway management.
Health optimization is a key focus in modern dentistry.
Interdisciplinary collaboration is essential for effective patient care.
Functional dentistry addresses the root causes of dental issues.
Children’s airway health can significantly impact their development.
Dentists should feel empowered to make positive changes in their patients’ lives. Facial aesthetics can significantly impact self-esteem and health.
Nasal breathing is crucial for overall health and well-being.
Quality of life can be improved through better patient care.
Breastfeeding plays a vital role in a child’s development.
Addressing sleep issues in children is essential for their growth.
Understanding the connection between breathing and systemic health is vital.
Highlights of this episode:
02:04 Protrusive Dental Pearl
04:08 Interview with Dr. Liz Turner
06:18 Interview with Dr. Meggie Graham
07:43 Personal Journeys into Airway Dentistry
16:26 ENT Referrals
21:55 Understanding Airway Symptoms and Treatment
26:10 Patient Case Studies and Treatment Approaches
36:46 The Importance of Nasal Breathing
45:30 Pediatric Airway Concerns and Solutions
55:09 Educational Resources and Final Thoughts
🎓 Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES).
🗓️ 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.”
🎓 Learn more about airway and breathing issues with Dr. Liz and Dr. Meggie on The Untethered Airway — and stay tuned for their first course, launching soon! – Waitlist for course and email list
Enjoyed this episode? You will also enjoy exploring the world of OSA with Prof. Ama Johal in PDP033: “Airway – Dentistry’s Elephant in the Room.”
#PDPMainEpisodes #CareerDevelopment #BreadandButterDentistry
This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.
This episode meets GDC Outcomes A, B and C.
AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Sleep medicine)
Aim: To enhance the general dentist’s ability to recognize, evaluate, and initiate management of patients with airway-related dysfunctions across all age groups.
Dentists will be able to –
1. Identify common dental signs of airway-related disorders in infants, children, and adults.
2. Understand the systemic impact of airway dysfunction, including its behavioral, developmental, and physiological consequences.
3. Describe the role of early intervention, including tongue-tie releases and palatal expansion.
Click below for full episode transcript:
Teaser: Have you ever been on an airplane and you hit turbulence and the whole plane goes like, nobody can say no to that. It's the same thing with breathing. We need our breathing to be passive and not turbulent.
Teaser: We as dentists shouldn’t be feeling like we’re putting out fires all the time. We should be patting ourselves on the back for being quarterbacks of not just the oral cavity, but of full body health as well. If you’re looking at things with an airway positive spin.
This is an ENT issue. This is a dental issue, but the body has no idea what you’ve studied. It has no idea what your specialty is. It’s just functioning or dysfunctioning the way it is.
Jaz’s Introduction:In this episode, I’m joined by two dentists, Dr. Liz Turner and Dr. Meggie Graham, who started as general dentists, but then they have later niched or pivoted more into airway and health. They still do dentistry, but they’re very much an airway focused passion. I think passion, is the best word, and let me tell you guys, you’re gonna absolutely love the different themes and facets we explore.
The thing I love the most about this episode, which I know you will too, is how it made airway tangible. For example, when I ask my patients, what do you do? They will say something like, oh, I’m in logistics, or I am a project manager, or I am a business consultant. Honestly, I could not even shut my eyes and imagine what they actually do.
Like I wanna know what people do day in, day out. I dunno if it’s just me, but I genuinely cannot imagine what a typical day in their life looks like and how they actually operate. So similarly, when someone says, oh, I’m a dentist, but I have an airway focused practice. I actually didn’t know what that actually looks like day to day.
So one of the questions I asked them is, okay, what does a typical day look like? What interventions do you use? What different tools do you have in your toolbox to help your patient? And I think they both did a wonderful job to explain that. And you’ll see these five patients discussed like five typical patients that they see that we see day in, day out.
These are five real patients, the fifth one being my second son, Sihaan, that we actually discussed who we can help as dentists. But their primary issue is an airway issue, so I love how we made it tangible. Now, this episode is part of the AES takeover. We are shining a big light on the AES conference in Chicago.
That’s in February 2026. The website will all be below, and this is where the creme de la creme come together in occlusion, TMD and Airway. Me and Mahmoud will be speaking at the conference, but honestly, the lineup is insane. I definitely want every single person to click on that link to AES. I’ve got my show notes and have a look.
Does this tickle your fancy? Have you never been to Chicago before? Lemme tell you. It’s an amazing place, great culture, great food, but just comfort the education alone is gonna be mind blowing.
Dental PearlHello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite Dental Podcast. Every PDP episode I give you a Protrusive Dental Pearl, and this one was inspired by my conversation with Liz and Meggie.
Before we actually hit the record button, I was talking about one of the missions. This podcast has is to help dentists fall in love with dentistry again, and we need to remember that the kind of themes we’re talking about, the discipline of dentistry, which is airway that we talk about is growing and is growing for good reason and reminded me of how not only our life, but our career also comes in seasons.
And we need to appreciate that dentistry is a wonderful profession in the sense that we can redefine ourselves or be reborn like every 10 years. Think of it like that, like every 10 years, there could be like a season of your career. For example, for the first 10 years, you could be focused on general dentistry.
The next 10 years you could be general dentistry and facial aesthetics. And maybe in the 10 years into that, it could be just facial aesthetics, for example, should you wish for that. I’m giving quite extreme examples on purpose. For someone else it might be single tooth dense for the first 10 years, then it could be for the next 10 years, full mouth dentistry.
And for the last 10 years it could be periodontally focused alongside full-mouth dentistry. And of course, you can think of every possible combination. You can bring in implants at 10 years, or you can start doing more ortho. The most important thing here, guys, the lesson I’m really trying to share here is don’t stay stagnant.
You’ll get bored. Keep learning, keep growing. Keep pivoting, keep niching. Get rid of the elements of dentistry that you don’t like and do more of what you do like. And give everything a chance though, like sometimes we’re too quick to give things up just ’cause you’re not good at it. Maybe not good at it because you were never taught well.
And so maybe you wanna go on that education to be a good generalist first, and then niche in to the areas that you love. So think of your career as coming in seasons of. Five years or 10 years, however you want to play, and don’t stay stagnant. Keep learning, keep growing. And with that, let’s listen to what Liz and Meggie have to say. I catch you in the outro.
Main Episode:Dr. Liz Turner and Dr. Meggie Graham, thank you so much for making time on this really important episode for so many reasons, because we get to discuss career and passion and changes in our professional lives and the different facets of dentistry that often we can explore more and more.
And really, I wanna just shine a light on airway in a big way, and I’m so glad you’re here to do this. So Liz, we’ll start with you. Where are you speaking to us from? And tell us about yourself.
[Liz]So I’m in Denver, Colorado. I am a general restorative dentist. I have a huge focus on pediatric growth and development because I just think that’s where we can make so much change.
We work with so, so many adults, but at the same time, a lot of what we’re doing at that point is symptom management, and to get across the finish line is just a little more challenging, where if we could just be preventative in our mindset, we can reduce so much hardship that people experience in their health journeys.
So I am just so excited that our paths have crossed, and that’s mainly through AES. So I am just really excited for anybody that’s listening, that is considering coming over across the pond, as you guys call it, to Chicago in February. Our meeting is gonna be awesome, and I’m just so excited to have Jaz and Mahmoud on our lineup.
[Jaz]It’s an absolute honor. I tell you, it’s crazy when I think about it. I’m very, very excited for that. Liz question, like, do you treat just young people or do you still treat adults, and then do you do any restorative at all?
[Liz]Yes, so I have two practices. I have this airway focus practice untethered, which Meggie and I share from Denver and Milwaukee, and hopefully we’ll see that grow in the best way possible. I also have a general restorative practice where I focus heavily on functional restorative, airway focused dentistry, so I am able to utilize my clinical skills on the daily with an airway positive approach. And we’re able to plant the seeds in our hygiene chair and really work hard in educating our patient population who’s just asking for more.
And it’s not uncommon for me to hear, you know what? I asked my dentist about that 10 years ago, and they said I didn’t need to do anything. Or somebody pointed that out to me. I just didn’t think it was a big deal and neither did they. So we’re really running into this time where patients are coming in so much more informed and they’re asking for more of us as clinicians, not just to do the best anterior restorations possible, but why can’t we can’t improve upon the foundation as we’re doing? So it’s just a really, really fun time to be in dentistry and I am just so grateful that, like my personal path has taken me that way. And I think Meggie feels the same.
[Jaz]Well, we’ll be discussing the journey, but Meggie, please tell us where you are talking from today and your experience in. Are you like only seeing children now? Do you do any restorative?
[Meggie]Hi, I’m Meggie Graham. I’m in Milwaukee, Wisconsin. Also across the pond. Like Liz, I have two practices. One is a restorative practice. Where you come and you have your hygiene visits, you come in for restorative dentistry. But we do have that mindset of getting to the root cause and focusing on functional restorative smile design.
And then we also have the specialty clinic, which is untethered, where everyone that comes to untethered has a dental home where they go and see their hygienist and their general dentist, but they’re coming to us to take out answers to their questions about sleep and breathing and facial development and growth. So we have very parallel situations where there’s a restorative practice and the specialty practice.
[Jaz]What I love about everything we’re talking about and everything we will be talking about is it’s a way of putting the mouth and density back into medicine overall. Right? Back into the body, which is such a huge thing.
Like way early on in my sleep journey and airway journey, I have been sleep testing for just two years, but the difference I’ve been able to make already on my adult patients, I don’t see children anymore. I’m especially eager to learn from you both about how you manage your day in, day out, the kind of questions you get from patients, how you’re able to influence and impact and help all your patients.
But I just wanna start from the journey, right? I just wanna spend a couple minutes on the journey because one of the purposes and the missions of this podcast is to help dentists fall in love with dentistry again, and dentistry just doesn’t have to be class twos and crowns, right? The most beautiful thing about our profession is we can pivot and we can niche into a million different ways.
So I would love to hear your niche stories. Something I talk about on the podcast is niche kebab. For every one thing that you wanna add, you remove something and eventually you end up with a little niche kebab of that just defines you. So Liz, tell us about your journey. How did you fall into this scope of dentistry?
[Liz]So I had some facial trauma when I was a kid and I ended up in the dental chair a lot. And we didn’t talk about prevention. Like I just thought you got cavities. It was not a thing to have my parents, no offense guys, if you’re listening to this, managing my dental hygiene, it was like, you’re 12, you brush your teeth.
I was like, heck yeah, I did. Yeah, right. Did I? No. And in terms of diet and prevention, it just wasn’t a conversation in our household and really like amongst the population. So ended up in the dental chair a lot, had some facial trauma and I’m still managing all of that because the foundation was never appropriate to start.
And so ended up being, having a dentist, I was a distance runner, I guess still am retired, recovering. But I always appreciated the full body approach to health. And so I’m eight years into my career I think to myself, well, okay, another root canal. Another extraction, another crown. But it was single tooth dentistry, like there had never been.
I went to Tufts Dental and I had a great education, but it was basic. It wasn’t heavy on occlusion. And the general consensus was that the occlusion guys were crazy. And really it was the big picture that we needed to look better at and really emphasized to our students. So finally, I think I’m in the wrong space.
I should have been a physical therapist. I should have been a chiropractor. So I’ll admit I was doing well, but I was pretty unhappy with the way that my journey was shaping. And then I had my son and stuff started to shift because I didn’t know much about babies, but he just seemed different. Like he just seemed franky and fussy and uncomfortable, but he was healthy, so nobody really cared.
And I started asking questions about tongue ties to a provider that I knew outta school who had posted some things about a laser. And she goes, I can’t diagnose from a picture. But that baby’s got a pretty significant tongue tie, and I’ve been told in the hospital it was mild. We’ll see if it affects his speech.
He’s gaining weight, don’t have pain. So it was just so dismissed and there was so much gaslighting behind it then. And there still is now. So fast forward a month, I have him treated three days later, my father-in-law has a heart attack due to years of undiagnosed sleep apnea and eventual A-Fib (atrial fibrillation) that he developed.
And months later, I start putting the pieces together and he’s got a bilateral posterior crossbite. He had a speech impediment that still affects him today at the age of he survived miraculously after being put in a medically induced coma. He still got his speech impediment at 80 and it bothered him when he was a kid.
And maybe if we just looked at his growth and development, we could have improved his breathing and ultimately the way the story ends. So we don’t have a crystal ball to say what’s gonna happen for everybody. But as I’ve seen my career evolve, I’ve realized that if we can help children breathe, we can help adults breathe better too.
So it’s been just a really fun progression and a lot of it, Meggie and I self-admittedly that’s how we met, is like we had to figure a lot of it out on our own. And it’s been really fun to develop our own way and our own nuances and share those with ourselves. And now we’re just really excited to share ’em with everyone else.
[Jaz]The two words I wrote there was health optimization. You are in the health optimization space, which is amazing. And Meggie, your own personal journey, we always love to hear them. So Liz, thanks so much for sharing that. Some personal details really appreciate you sharing that and everything aligned and pointed you, the universe was sending you that sign. Meggie, how does your story go?
[Meggie]I mean, so, so many overlaps, so many parallels, and I think a lot of people in this space, in quote unquote airway dentistry have similar, at least some overlap on a venn diagram of similar journeys. But mine started very similarly as a new general dentist. My dad was a dentist and I remember very profoundly, this is one of those memories that stands out.
I was on a walk with him shortly after graduation and I just said, dad, I think I made a huge mistake. I was like this, I cannot imagine doing this for the rest of my career. It is so unfulfilling. It is so high stress. It is, people don’t like to come to see me. I’m causing pain. I’m just, I feel like I’m putting out fires constantly and there’s no real satisfaction.
I was a single tooth dentist and I just kinda sat there for a while in regret and doom and gloom, like you said. I love that phrase. And I just leaned heavily into starting to ask the question why so many patients would come in. And we were taught in dental school, or at least my takeaway from dental school was home care and diet.
Those are the things that patients can control and that’s what causes all of the problems. And that didn’t add up to what I was seeing in my clinical practice, where some of my most fastidious patients coming in on their prescribed recare, every time I saw them, they had another broken tooth or they had another set of caries and something wasn’t adding up.
And so I kept on adding, asking why, and that led me to my CE journey, which really reinvigorated my passion, which is lifelong learning, and that led me to occlusion. And I really laid heavily into learning and understanding the function of occlusion. And then it still didn’t quite add up, like there still was something missing.
And that led me to our mentor and friend Jeff Rouse, who really connected the dots that there is a component to this that is systemic. The mouth is not annexed from the rest of the body. It is related to breathing and sleep. And so then that just kind of kept me going. And my friends thought, maybe they still think I’m crazy, right?
Like the amount of time, energy, and money I was spending on collecting CE for the first decade of my career was insane. I was dragging babies with me and just I couldn’t consume it enough. But like Liz said, there wasn’t a clear cut path for us of how do we take all of this knowledge and then go home and implement it.
And so that’s kind of how I fell into it. And then of course, personal stories, my nephew, myself, I realized I was the airway patient, my own children. And then once something becomes really personal, you can’t help but just grow your passion to figure it out. And then I started to see that in my patients.
And so my shift in focus went very heavily into sleep and breathing and airway, and I let go of the restorative dentistry to the detriment of my practice, to the detriment of my staff. I lost patients. They’re like, I mean, I just want a cleaning. And so I had to kind of find that middle ground where we can create curiosity and ask questions and plant seeds in my patients, because I had consumed all this information, didn’t mean that everyone else had this.
And so really figuring out how can I take all of this and get it to people so I can actually help and not scare them away was that next phase of my journey. And then as I continue to change my focus, I’ve figured out how to kind of marry the two in our own way. And she and I, Liz and I have done so many things in parallel that we finally were like, what if we started doing this together? What if we took your path and my path? We married them and made a bigger impact and also learned from each other and did this faster.
[Liz]We just started sharing so much information because we needed to almost teach each other like, oh, I figured this out. Can you teach me how to do this? So even from an administrative standpoint and what type of forms and how do you work with insurance?
And I know you guys are different system, but like that’s one of the biggest questions we get asked by dentist in the US is how do you manage billing? How do you manage this administrative portion? So it’s challenging to know all the things in dentistry, and like you said, Meggie, it can be challenging to not be fulfilled when you’re always putting out fires.
[Jaz]I mean very much what we are doing with airway is the exact opposite of single tooth dentistry. It is bringing everything together, which is why I love. Now, to explore that common theme that you both have discussed so you know how it’s affected you and your close family members. I love my restorative dentistry, right?
I also get a lot of referrals for TMD and the last few years I’ve implemented airway testing, like sleep tests and I’m looking more and more into this. Very fascinated, my now 6-year-old, when he was about two, three, I noticed that he was not breathing at night. He was holding his breath while he was sleeping.
I was observing him holding his breath and I was like, this something isn’t right here. And went to the doctors and they’re like, yeah, he is growing. He seemed fine. And I was very insistent that look, is there no diagnostic test you can do? And they reluctantly did a sleep test and lo and behold, they found that yes, there is an issue.
He had his adenoids removed and he’s a different boy. And my 2-year-old. He’s now two. But when he was one, he also had the sleep test. He actually got even higher scale, moderate sleep apnea for at that point he was age one and he snorting, he’s disturbed sleeping. Sometimes I have to wake up six times a night to get milk ’cause that was the only thing that would pacify him.
I was like, something’s not right here. He’s like nine months old. Why am I having to go get milk? This is after he stopped breastfeeding at age one and then now he’s being monitored and when he is healthy enough again going down the same path of adenoid removal, potentially tonsils. So I’ve taken a great interest to this, but what this ties into is when I see the dentist Facebook groups and classically they mention about, oh, I have a child patient and the parents are concerned about X, Y, Z.
And then often there’ll be bruxism and then you have a whole 20 different opinions, many of which are okay, ENT, there’s nothing to do ENT. And one of the things I’d love to discuss with you, ’cause you guys are experienced in this, you guys are developing this fantastic niche is at the point of the GDP, we’re very often we’re like, okay, it’s at ENT or a sleep specialist. The misconception is there’s not really much the dentist can do, so please explain about, is this a misconception and then develop that more for me.
[Meggie]Can I go?
[Liz]Yeah.
[Meggie]One of the things we’ve noticed, Jaz, is that we’re both so excited and we’re both so overlapped, like we’re both ready to jump in and talk over each other. So we’ve learned to be like, be very careful at answering questions. Can I take this one? So you know it’s yes, both, right? Like and all of them. It’s not, and I think we’ve done such a disservice to humans and patients to compartmentalize the body and say, this is an ENT issue. This is a dental issue. But the body has no idea what you’ve studied.
It has no idea what your specialty is. It’s just functioning or dysfunctioning the way it is. And so you have to have a really full comprehensive understanding of the whole system, even if you’re not gonna treat all of that. And what I think has made untethered really special is we are really good at quarterbacking or stepping back and seeing the whole picture.
And yes, we offer services to help our patients and we also recognize that sometimes it’s not our services that are needed first. So when I first jumped in, and I mentioned a minute ago that everyone was an airway sleep patient, and I did the detriment of my practice. You know, I was sleep test, I was airway testing, sleep testing, everybody.
And I realized I don’t do that as much anymore. I still do sleep screenings and sleep studies, but now I recognize if we can optimize function, which in an infant or a child might be breastfeeding, speaking, eating. We can optimize breathing, we’re gonna optimize growth. And so if you can just optimize function and the foundational structural components, TMD symptoms fall away, breathing symptoms fall away, bruxism falls away, and then the sequelae, like dental breakdown falls away.
And all the systemic things that come from poor breathing and sleep fall away. So a really long-winded answer to your question is, yes, ENTs are appropriate if the ENT can look at the big picture, because so often if they go and see the ENT and they’re told no, they don’t know where to go next. And that’s where I think we really wanna get providers to is how can you go to 12 different providers across different specialties and get the same information, right? Like the full body understanding.
[Liz]I think that’s the hardest thing. And Meggie, what you’re basically saying is you can still just do the dentistry. Like you can still just do dentistry and make positive change because really a lot of this, these systemic problems have dental manifestations or what came first?
Did the dental manifestations cause the systemic problems? So what came first, the chicken or egg, it doesn’t matter because you’re right, the body doesn’t know the difference. So if there’s not space, make space, if the teeth are worn and we’ve lost vertical and we realize there’s an etiology of sleep apnea, doing that full mouth rehab is beneficial to the patient from a health standpoint as well as aesthetics.
So like we as dentists shouldn’t be feeling like we’re putting out fires all the time. We should be patting ourselves on the back for being quarterbacks of not just the oral cavity, but of full body health as well. If you’re looking at things with an airway positive spin. So it’s a challenging time because you’re right, there’s so much disconnect.
And even for me, my most favorite and most understanding of development, craniofacial wise, ENT, I’m finding out now is requiring a sleep test on everyone. And I can’t get people sleep tests for five months and five months if that was my kid, that’s too long for my child to suffer. It’s within, at least in the US, it’s within our ENTs guidelines.
If there’s an alteration, if the adenoids and tonsils are causing an alteration to craniofacial growth in their guidelines, to look more closely at just the structure and not the data on the sleep test ’cause also the data on the sleep test the cognitive effect of if you have an apnea score of 10 or one in a child, the cognitive effect is exactly the same.
The severity doesn’t relate to the fact that negative change is occurring in that little brain. So that’s where I just get a little irritated with medicine in general. But there’s my soapbox.
[Meggie]Well, taking it back to your question, Jaz, about your own kiddo and this like these Facebook posts of understanding that there are ways to jump in and do even without a positive sleep test or without an ENT, so like we get a lot of people that are searching for solutions and giving parents the power to know that they can make a ton of little changes. And all of those things can add up while you’re seeking out the more structural, bigger picture things.
You know, looking at function, looking at how they’re chewing, looking at their diet, looking at the quality of the air that they’re breathing. All of those things can impact them very positively while you’re seeking out a provider in your area that has that whole body understanding, whether it’s an ear, nose and throat doctor, an airway focused dentist. But yeah, really starting to understand that it’s just not a yes or no answer.
[Jaz]About taking what I’m gathered from that is being more proactive and yeah, the bigger picture and being part of a multidisciplinary team where you can call the shots a bit. Well, again, actually this patient will benefit from an opinion, but working on this together and we’ll talk more about which other specialties are involved.
I’m gonna explain the next two questions ’cause then we’ll revert back to the first question, which is I want to actually know what you actually do. And what I mean by that is it reminds me of patients, right? Like in my mind, I can shut my eyes and imagine what they do, what a typical day looks like.
When a patient tells me, oh, I work in logistics, or I’m a consultant business, whatever, I can’t even close my eyes. And like, what do they actually do? And so the reason I ask that is I would love to know, like if I say restorative dentist. Okay. But I would love to know in a typical day, how do you actually structure your day?
What are you actually doing? What are the different interventions, diagnostic tools, that kind of stuff. I’d love to know, but that is a follow up question to first we need to understand what the signs are, what the symptoms are that you get, parents tell you that children tell you what we actually looking for, which will then help to explain, okay, what then is your role? What tools do you have at your disposal to actually help these patients?
[Liz]Do you wanna go with the symptoms? And I’ll go with what a day looks like?
[Meggie]Sure. I think that’s great. Well, even in the name, you asked what our journey was before and even in the name of my practice was my practice is now our practice. It started out as untethered tongue tie center, hence the name untethered to untethered tethered tissues. But then realize that is one positive sign of many possible things that we could be dealing with or seeing. So tethered oral tissues is a big one, and it’s going to impact how our muscles function, which is going to impact how we do everyday things like chewing, speaking, swallowing, and that’s going to impact the way our structure grows.
And then that’s gonna lead down to everything else that we deal with. So, tethered oral tissues, we’re looking at facial development, the shape of the face, the position of the jaws. Intraorally, we’re looking for, some of the complaints we might get from patients are TMD pain, facial pain, continually breaking teeth from bruxism or clenching, uncontrolled caries, narrow vaulted pallets that are more-
[Jaz]Can you explain uncontrolled caries? Just so, because younger colleagues may be listening to this like, wait, how caries is plaque and sugar? Why is it that an airway patient will be more successful to caries?
[Meggie]Yes. Great. Great question. Yeah, and it took me actually some time to get there too, is so, like in my journey in school, it was home care and diet. You brush your teeth and you have a clean diet and you avoid sugar, you’re gonna have a healthy mouth. And that is very true. Home care and diet are essential, and they’re very important. I don’t want to say that that’s not the case. And if you don’t optimally breathe through your nose, if you are somebody that has restricted nasal breathing, you’re gonna have an airway that’s more collapsible, and that creates a vacuum pressure.
And that vacuum pressure brings up acid. And that acid is not like gastro acid where we feel heartburn or feel discomfort. It’s a mist and it’s asymptomatic, it’s laryngeal pharyngeal acid, and that creates a constant acidic environment in our mouth, which is what cavities or decay thrive in. It also produces a signal to our body that we have an acidic environment and we start to brux our teeth, and that bruxism is to produce saliva to buffer the acid.
So now we’re bruxing in an acidic environment and that’s causing significant erosion and attrition in the mouth. So uncontrolled caries is that there’s a breakdown despite the effort going in by the patient’s own accord.
[Jaz]How about the fact that mouth breathing, like the sliva quality would be less dry mouth? Is that part of the-
[Meggie]Totally. So that’s one part. So like let’s say, ’cause some people are like, oh, I don’t mouth breathe. I breathe through my nose, and yet they’re still showing signs of acid and erosion. Those are still airway patients. Then there’s more overt patient that is mouth breathing. They’re bypassing their nasal system.
They’re not filtering their air, they’re making their saliva a different quality. They’re drawing out the mouth, they’re creating an an acidic environment that also increases the cavity risk as well. So it’s coming at it from two different mechanisms.
[Jaz]And you are listing all these symptoms. I’ll let you finished for any more, but then I would love to for you to tell our listeners and watchers which ones are perhaps specific for younger patients, children, and which ones are more specific to adults.
[Meggie]So as we grow and as we age, and as we mature, we adapt and the symptoms can change. And so the common thing that Liz will talk much more articulately about than I can is many providers, myself included years ago, would say, oh, they’ll grow out of it. Don’t worry. It’s not a grow out of it, it’s a symptom adaptation and a dysfunctional change, and the compensations change.
So we can see increased caries or decay in children and adult. We can see erosion and attrition in adults and children. So that doesn’t really line up with age specifically to those types of symptoms. In a child, though, we’re more like somebody that is a child that can’t breathe and therefore can’t sleep very well, is more likely to show signs of hyperactivity and behavioral issues.
Because when they’re underslept, that’s how that manifests. Whereas an adult, it’s more common to see, not always, but more common in an adult than a child to see profound fatigue, excessive daytime sleepiness, just this wrecked, crushed fatigue. So those symptoms do show differently between adults and kids. And then like you experienced with your own son in a baby, it’s cranky. It’s fussy. It’s in a hyperactive fight or flight state all the time.
[Jaz]Absolutely. So Liz.
[Liz]So I’m gonna give you four patients because I think when you look at the patients, you can look at the treatment options and also understand the symptoms a little bit more and kind of how a day operates.
And think about it like this, Meggie and I both started our practices untethered was within the dental practice, and that’s no longer, but this stuff is possible in a dental setting. But what I would encourage you if you’re listening, is to start to compartmentalize your brain a little bit of you don’t, and like Meggie said, losing patients, losing friends.
You don’t have to go all in all the time. Like we can plant seeds in our hygiene operatories, and that’ll be patient four for us today. But you can actually do this well within the walls of your own practice without having to have two facilities and a whole separate team and all these things. So, okay, so baby number one.
Referred over by a lactation consultant and a chiropractor had been seeking and asking questions about why the baby took so long to feed and why they would fall asleep. The pediatrician says, oh, just flick ’em on the foot or take their blanket off so they’re cold, so they’ll stay awake. Okay, so you got a really, really sleepy baby while they’re feeding at three and a half months-
[Jaz]That was my first born, by the way, my wife tried her best to breastfeed about four to five months. She did it. So well done to her. But then it was like this issue of him falling asleep and not thriving, not doing so long. When my second born was a fantastic breast feeder. We had to force him off to boob ’cause my wife needed to go back to work after a year. So yeah-
[Liz]He’s your one that wanted the milk it a little too late because he’s keeping that tube open with suction. So that’s why breastfeeding slowed down at four or five months. Baby comes to us three and a half months supplies tanked, baby super frustrated at the breasts, were starting to decline and wait and using the bottle is working to keep the weight up, but the baby’s super uncomfortable because they’re taking in so much air.
Moms supply tanked because it switched from hormonally driven to supply and demand, vacuum driven. And since the vacuum wasn’t good because the oral cavity wasn’t working, maybe there’s a tongue tie or lack of tongue tone. The palette’s narrow because genetically we’re going that way. We need to work on infantile suction from the first day.
And we do a disservice to babies and moms because the swallow pattern is what drives growth of the upper and the lower jaw, especially the lower in the first two years of life. We get more jaw growth in the first two years of the mandible than we will at any other time. And anybody that says they can grow a mandible consistently, I don’t know if you got a person, we’re missing a huge growth window if we don’t optimize function.
So baby number one comes to us. We treat them through, they’ve already had a lactation and chiropractor. They’re in a good space to be moving forward with tongue tie treatment, laser phrenectomy. They return a week later. We make sure symptoms and healing is appropriate. So there’s patient one.
Patient two, four and a half years old has seen ENT. The adenoids and the tonsils aren’t big enough to be removed, but hyperactive snoring, lack of sleep that is disrupting the family as they’ve had to lock the child in the room because they’ll come into the parents’ room so much. So they wait for him to start screaming on the camera before they help him because the ENT said there’s nothing they can do.
And they’ve been asking questions about this kid for four and a half years. So what do we do? We’re super narrow. The lower teeth are tipped in. There’s not a visible crossbite because it’s compensatory, but if you look at the maxilla, it’s smaller than the mandible, and we need that hat to be bigger than the mandible.
So we expand them and we can get statistically significant shrinkage of the tonsils in the adenoids with expansion. The question is, is it enough to reduce the need for tonsil and adenoid surgery? They were already told no tonsilil and adenoid surgery. What choice do we have? Let ’em suffer or expand him. Upper palatal expander, improve the nasal breathing.
[Jaz]What age are we talking here, Liz? For patients? What age are we talking?
[Liz]That’s a four and a half year old. In a perfect world, I’d wait closer to six. Typical orthodontics, but I still like the concept of fix before six when I can. But if I’ve got a kid who’s sick, I’m not gonna let them suffer because no one else said they could help them.
I’m gonna inform the family. There’s gonna be some relapse. You’re probably gonna need a second incremental palatal expander at some point, but I want your child breathing and growing and releasing human growth hormone and healing that brain as quickly as humanly possible. So there’s patient number two. Patient number three-
[Jaz]I’m loving this by the way. I’m actually loving this. You’re making it tangible. I’m loving these two patients so far. But then, so this, yeah, the expansion. Okay, so, so this gonna be brilliant. So the first one was actually diagnosis and managing parents and helping a child to feed better and a tongue tie release, right? Did I get that right?
[Liz]Yeah.
[Jaz]Second one was, again, diagnosis and education. And this was, sorry, expansion at the age of four and a half. Brilliant.
[Liz]3D printed expanders go in like a dream. So my boy, tonsil and adenoids weren’t quite big enough. His a HI was a 10. That’s not good. We expanded him. We took his AHI (apnea-hypopnea index) to a 1, so sleep numbers, but then he relapsed ’cause we couldn’t correct the breathing.
So we did some adenoids, tonsils on top of that because I got him breathing better for a little while. But it didn’t solve the whole problem. And that’s kind of where this interdisciplinary care comes in is one thing is not always enough. Sometimes it is, but each little step here is incremental. So that tongue tie release in the baby could have prevented the expansion at four and a half. Maybe we could have started expansion. It’s seven on that second kid.
Okay, so patient number three. You got a 3-year-old female. She complains of migraines. That’s not her chief complaint. Her chief complaint is TMD pain. She’s narrow.
[Jaz]How old, sorry? Did you say how old she was?
[Liz]32.
[Jaz]32, okay, fine.
[Liz]So she’s narrow. She has abfraction recession on her maxillary dentition. She has a thin biotype. She has been clicking since she was in orthodontics and now it’s coming to a head and it’s causing discomfort. Her mandible is locked up. And why is it locked up? Because it never grew to the correct spot and the orthodontist lined everything up and now we’ve got this beautiful smile, but it’s dysfunctional and uncomfortable because she’s got a restricted envelope of function.
[Jaz]Can you explain for our younger colleagues, what does a locked up bite look like?
[Liz]So how many class ones do you see that have TMD issues? Like class one bite. So a normal bite on paper, which should be functional. Yet we’ve got people that are class one that are chipping their anteriors. And you’ll go and you’ll repair an edge.
And then three months later, oh, your bonding failed like right after I left. Like your bonding sucks, is basically what they’re trying to tell you. Like what’s really happening is that path of function is compromised. The path of function does not have enough rotational space because the mandible is likely tucked back, the condyle is posterior displaced and maybe they weren’t dysfunctional and uncomfortable until that mandible, that kind of like tiger in the cage concept that mandible wants out. It’s got nowhere to go. So it’s either breaking teeth or it’s causing myofascial and or internal derangement of the TMJ complex.
[Meggie]Can I throw something in there?
[Liz]Yeah.
[Meggie] Like that’s the patient Jaz that like if you put them in a mandibular advancement device or you put them in an anterior deprogrammer, or those are the patients that are the most at risk for developing a bilateral posterior open bite because finally they’re uncaged. And their jaws like, nah, I’m not going back. Thank you. Like, I don’t wanna go back to that dysfunctional jammed back position. My CR is actually forward.
[Jaz]Yeah. So some schools of some occlusion camps would call this a constricted chewing pattern.
[Meggie]Correct.
[Jaz]A CCP. And so I love these analogies as well. And yeah, uncaged is a great way to put it being re locked. A lack of wiggle room, a trapped mandible by the maxilla. So this is the kind of theme we’re exploring. Please continue with patient three 33-year-old.
[Liz]So you’ll see that in kids too. They’ll posture forward ’cause they’re trying to get outta their tonsils. So tonsils are in the way.
[Jaz]So this my second born and we’ll talk about him a little bit more later ’cause I’m actually genuinely more curious about him and he can be patient five, we’ll come to him.
[Liz]Yeah, sure. Perfect. So I’ll give you my decision tree. So 32, she had ortho, she was in ever since then it’s the jaw’s been clicking. She played soccer, so she got hit in the head a little bit. So the ramus length is a little bit off because she grew not on the disc is what many of us would say. And so what do we do? She’s not breathing well through her nose. So we start some lip taping because she’s able to, she can breathe well through her nose when she’s at rest, but when she goes into sleep, her lips part open.
She realizes her migraines decrease. The symptoms of them with just lip taping and better nasal breathing, but now she wants more, and so I tell her, if the lip taping doesn’t work, come back and see me in two months and let me know how you’re doing. She wants more. She’s asking for more. She’s asking for more treatment.
So what do we do? We go ahead and we refer her to myofunctional therapy to work on that tongue posture and placement. We start considering tongue tie released, release some of the tension in her tongue to better able live where it’s supposed to. And we start thinking about some type of expansion in adult, which is possible.
There is orthognatic surgery, which is patient four, but patient three is a candidate for enlarging the entire craniofacial respiratory complex through maxillary expansion. So we put her in a MARPE, mini implant assisted rapid palatal expander. Really, the current protocols are to go very slow. So there are some people that are calling it a mini implant assisted slow palatal expander, which makes way more sense.
And we expand her and make the hat that sits on top of the mandible larger. We give her that improvement in her ability to function well. And then restoratively, we fix some abfraction lesions that were popping out on her over and over and over again ’cause now they’re not.
[Meggie]The cool thing about that patient too is we get so many oral cavity volume improvement. It’s unlocking that lower jaw. It is increasing the floor of the nose, so it’s decreasing nasal resistance. So by just making that one change, we’re checking multiple boxes of improvement. And yeah, the facial aesthetics is really cool. I was like, I like my cheekbones better now.
[Jaz]It’s amazing to know. Oh wow. You have one on right now.
[Liz]Sure do.
[Meggie]I used to have one. All the cool kids end up getting on.
[Liz]I got a cute little gap here I masked, I can show you.
[Jaz]I mean, very good and I like it that you talk the talk where you walk the walk, like when I’m making occlusal appliances, every single one I’ve done, whether it’s a mandibular advancement or for the bruxism and whatever, for the TMD, I’ve had it on myself as well.
So it’s great that you guys practice what you preach on yourself as well. Now, patient three, like I love that you are talking about lifestyle. I love that you’re talking about oral posture, anatomy function. These are the very basis of of our healthcare. Right? Can I just probe you further on the mechanism?
‘Cause it’s not the first time I’ve heard it. The mechanism behind mouth taping, then allowing you to breathe better nasally, which can then help with migraines. What’s the connection there? What’s the hypothesis on how that works?
[Liz]Have you ever been on an airplane and you hit turbulence and the whole plane goes like, nobody can say no to that. It’s the same thing with breathing. We need our breathing to be passive and not turbulent. And what happens when we nasal breathe is we release nitric oxide from our perinasal sinuses, which is actually a vasodilator. So it gets more oxygen to our tissues. It’s actually a treatment for erectile dysfunction.
‘Cause like breathing, that’s a problem for that too. So this is again, a full body concept. So nitric oxide release is essential to health. The nasal breathing, it filters, it humidifies, it warms the air that we breathe. When we nasal breathe and we get that nitric oxide release, we kind of get that double whammy. If we’re mouth breathing, what also happens is that turbulence of the airflow causes that collapsibility that me was talking about. So it’s twofold. You’re missing the health benefits of the nitric oxide and the filtration and the cleaning of the air, but you’re also getting the turbulence of the airflow that’s sleep disruptive and not supportive.
So many of our patients, especially those upper airway resistance patients are gonna wake up at 2:00 AM 3:00 AM they’re gonna have to go to the bathroom. That’s why they’re getting up. And then they just, the weight of the world is on their shoulders. They got stuff to do, and it’s because their body is in fight or flight mode.
And it has been for years. These are anxious patients. Our depressed patients, our patients who feel like they can never get enough done because there’s so much brain fog. So like the trickle down of the symptoms from not nasal breathing is substantial. It’s not just TA tonsilil and adenoid enlargement in childhood.
When we don’t grow out of it and we grow into it narrow and open mouth posture or class three, we’re not going to be breathing well in adulthood, and that will have a systemic effect. And so mouth breathing will help with getting the oxygenation to an unoxygenated area, the TMJ complex, and it will help the brain heal from-
[Jaz]You said mouth, you meant nasal breathing will help.
[Liz]Nasal breathing. Yeah. And so a lot of people will support and get proof of concept from mouth taping. And it’s kind of fun because it’s become really mainstream now that it’s been on-
[Jaz]Thank you, tikTok.
[Liz]Some of the reality shows. Yeah, TikTok.
[Meggie]Well, I’ll say that the other thing to consider with that too is like I can breathe through my nose. I can sit here and I know I’ve trained myself through myofunctional therapy to feel wrong. If I’m mouth breathing during the day at night, your body’s gonna find the path of least resistance to breathe. And for me with a narrow nasal passageway and nasal valve collapse. I default to mouth breathing without the tape.
And for some of us that have already grown into a suboptimal foundational structure, we need a little bit more support. So in addition to mouth tape for adults, I will also recommend some sort of nice nasal dilator. Like I-
[Jaz]I think she wrote that on here as my next thing, because I saw the ads for it and I was like, this seems pretty cool. And like I tried it myself and obviously your nose goes like really, really wide. And it felt great. I was like, wow, this is what breathing feels right. Is it normal? Should it be feeling like that?
[Meggie]In combination with mouth taping, because you can keep your mouth closed, but if your nasal passageway is still restricted, you’re not gonna get that full effect. So those two things together are really impactful.
[Liz]It’s just one more way to decrease the resistance that’s occurring internally. And like Meggie said, when we go to sleep habitually, we can become mouth breathers ’cause we haven’t for lifespan, but our muscles also go into paralysis. Say for example, that tongue is down and back because it’s always lived there or it’s substantially tied in adulthood.
It doesn’t a have the strength to live up there or the mobility, but it’s also going into this phase of sleep. That’s where a lot of our upper airway patients are REM sleep disrupted. And so the manifestations of that long-term health-wise is, it can be Alzheimer’s, it can be cardiac because we’re working hard to combat a disease that’s been underlying for a lifetime, like-
[Meggie]And we’re not getting a restorative sleep cycles. Yeah.
[Liz]That health stability, I use the phrase I want to bring harmony to your system. I want your system to function in harmony because right now something is working harder. Your neck, shoulders, your nasal passages are working harder than they need to be. They’re not working the way they were designed. So does that answer your question?
[Jaz]Emphatically. And I just wanna say just a theme. Something I learned from one of my mentors is at dental school we get taught that, oh yeah, if you find an oral cancer that’s a one time, you can save your patient’s life. And then you say, oh, actually if you find a Barrett’s esophagus, you might be able to help save your patient’s life.
Well, actually what you are talking about, not only are we helping save lives, actually helping to extend quality years to someone’s lives, right? So, 10 years, why often here, you are adding 10 quality years and if you are intervening with children at the right time, then yes. I mean, the reach of that could be much greater.
[Meggie]And to circle back to dentistry, right? Like we’re talking now about erectile dysfunction, quality of life, sleep, quality, rest, and systemic health, which is obviously so important. But as dentists, we’re also helping get, give our patients the opportunity to be on a trajectory that requires less intervention.
So much restorative dentistry is avoidable if we get them on a more optimal health journey. So even as dentists, we’re changing their quality of life. Yes. And we get all the warm fuzzies of increasing their life quality and maybe longevity, but we’re also helping them not have to put out fires and suffer through unnecessary dental work as well.
[Liz]So let me give you patient four.
[Meggie]Oh yeah.
[Liz]Patient four is Bob. Bob’s your patient in your practice. He’s been there for years. He was there when you bought your practice and you don’t know if he’s ever really liked you. ’cause he’s kind of cranky, can’t really get a read on him. He’s just like, he’s a bit older, he’s bigger, he’s kind of crotchety. And you’re like, I like this. This guy like me. Is he gonna leave my practice?
[Jaz]What does crotchety mean? I just wanna just, what does crotchety, that’s the first time in my life I, I’ve heard that.
[Liz]Oh man. I mean he is cranky. Like cranky. Cranky. Yeah. So you like think he’s gonna leave your practice and you kind of don’t mind if he does because you’ve been saying, Bob, you need a full mouth rehab.
You got acid reflux. And he is like, I’m on my reflux medication. I don’t want my teeth fixed. ’cause he doesn’t feel good and he doesn’t feel good in himself. So what do you do? You start saying, well Bob, I know you’re on the reflux medication but it’s still there. Like clearly ’cause you just choked up a bunch of phlegm sitting here and you just complained about your heart pain.
I think you should get a sleep test and you say it every six months. Like, I don’t wanna give you a solu- this is what John Coy says, and I love it. I don’t wanna give you a solution to a problem you don’t have. But I am seeing some signs that could be related to sleep disorder breathing. So like, talk to your primary care, like he doesn’t wanna hear it from you and he doesn’t need to.
He finally goes to his primary care and then all of a sudden you have this book “Breath” in your lobby from James Nestor, which is great because it’s written by a journalist who’s amazing and funny and he swears in his book and people like reading it. And so you have it in your lobby. And one day Bob comes in and he points to the book and he goes, I have sleep apnea.
And you go, well, Bob, oh shit, I’ve been telling you that for a long time. But he goes, have you read this book? I go, well, Bob, it’s in my lobby. Like of course I’ve read it. But so Bob is finally ready to talk about it because you know what? He had that sleep test and he goes, I didn’t ask the question until I knew you’d been talking about this.
But my physician said, Bob, I’m worried you’re gonna have a heart attack. And sometimes that has to do with sleep apnea. And he goes, my dentist thinks I have sleep apnea. And now you got two people coming together for the common good of Bob to help him where he’s never really felt helped. And now Bob, he has a sleep test and I say, great.
He goes, how can you help me? I say, I think you need your sleep test. And I think there’s a chance you’re gonna need CPAP and that’s okay. And because he gets his CPAP, the next time he comes in, he’s happy as a clam. He’s lost 25 pounds, he’s got a new girlfriend and he wants his teeth fixed. So now you have a full mouth rehab and you saved somebody’s life.
And in turn, not to do, only prolong their life, you made a really cranky man really happy. So you improve the quality of their life as well. So the first three patients either self-referred or referred over, but these patients are in your chair every single day and they’re asking for help, like they’re coming to you for a reason.
Bob didn’t leave because he knew there was something else, even though I don’t think he liked me very much. But I mean, I think there’s just a lot of opportunity for us to do better for our patients. We see our patients more than they see their doctors. And you can take a blood pressure and you can see that it’s high and then you can ask why, especially if they’re on medication. But sometimes it’s sleep related breathing disorders. So, I dunno. That’s my little soap box, my 2 cents. You wanna talk about patient five?
[Jaz]I’d love to, I mean, firstly, I just wanna emphasize again how much I’m enjoying this chat with both of you and how we’re making it tangible. One of the taglines of this podcast is making dentistry tangible and this space within dentistry is putting the mouth back in the body.
And it’s so exciting to talk about, but there’s much more I need you on the podcast to talk about it. So, formally these are some themes that we’ve never touched on a podcast for. So I’m very grateful for that. And so, yeah, patient five, right? His name is Sihaan. He’s now two and he was exclusively breastfed up till age one.
Okay. So that’s fantastic. I think. So well done to my wife, but I’m always very careful when I talk about this because I’m very mindful of the fact that there are some women who are unable to because of life circumstances or whatever, but those, if you’re able to, and you can breastfeed your child, I mean, what a great start to life you give a child, and I’m sure there’s something that you talk about and helping to work as a team with their lactation consultant, what they’re called. And so I was really proud. Did you know, you probably know the stat, only 1% of women are breastfeeding at month six in the UK? Only 1%.
[Liz]And you know what’s wild? The world guidelines, not to put even more stress on families, they want us exclusively breastfeeding until age two, I believe is the-
[Jaz]I think it was age two as well.
[Liz]Yeah, because the US just changed their guidelines as well. And like we have a epidemic of maternal stress and postpartum anxiety and postpartum depression. And a lot of it is on feeding and the stress associated with it and the metrics and what does my app say? Did my baby get enough to eat? It’s maddening. You’re right. This can be a very sensitive topic, but women should be able to be given the choice and the assistance to breastfeed if they’re able-
[Meggie]And can I add one thing to that too? Like, and so yes, we always go into breastfeeding kind of like you just did Jaz. Like if you’re able to, if you can, ’cause we don’t wanna add more pressure to one of the hardest chapters of life, which is postpartum, especially when you don’t get enough maternity leave or you have a baby that has other issues. So maybe that is the path of least resistance to choose to bottle feed or you’re unable to breastfeed. But knowing the importance of breastfeeding, even for families that don’t breastfeed, can still be a superpower because now you know your child is at risk for not having optimal development. So great. Roll up your sleeves and add in other things that can help counteract that, rather than be like, oh, well now that my baby’s on that growth.
[Jaz]Yeah, you haven’t missed a boat. There are still things like we were discussing, so.
[Meggie]Exactly. So great. If you can, and if you can’t, okay, well, you at least are aware of why you should or would optimally be able to, so let’s see what else we can add in so that there isn’t such a huge deficit.
[Jaz]He had one year of breastfeeding, but then now like why has he got crowding? He’s got deciduous teeth, right? And you should not have crowding deciduous teeth. Am I right? Would you agree with that?
[Meggie]You should have positive spacing.
[Jaz]Spacing.
[Meggie]If there’s just teeth are touching in the deciduous dentition that is crowding.
[Jaz]And so not only he’s got teeth touching, but his centrals are slightly imbricated, like his As. And so he’s had that since they’ve come through. I’m like, how does this work? But then of course he had moderate sleep apnea. Now at the time when he was diagnosed, I think they said it because in a publicly funded system we have in the UK, they probably don’t test very many one year olds.
I was a very adamant parent ’cause I’ve been through my first child and now I saw the benefits of an airway intervention had on him. And I was like, I knew something wasn’t right with Sihaan because of how much he was waking up his snorting, his stopping, breathing, all these factors, right? And so I pushed for it and yes, his sleep score was even worse than my firstborns.
So breastfeeding, great big tick. But he still has crowding. And I love what you said, Liz, you said earlier, right? Posturing your mandible forward. And he smiles like that sometimes. He loves to go in that position. I always joke, that’s his purple minion position. You know, purple minions, right? So that’s his purple minion position.
So, you probably see children like this all the time. As a parent who has real concern. That’s how I’ve always been pushing and real interest in helping him thrive. What should I do?
[Meggie]How stressful to know that there’s a problem and then not know what to do.
[Liz]So breastfeeding was good for a year. There’s a chance that even on the first day of life, there was some compromise to the latch that didn’t lead to the terminate clearing, because that’s what happens with first latch is as first latch is appropriate, there will be a distraction breath that occurs because babies are born with congested turbinates.
There’ll be a distraction that occurs as they take that first breath while latched, that clears the nasal cavity. ‘Cause there’s like the whole thing with the birth crawl and there’s a whole timing that’s supposed to be physiologically appropriate and that’s often interrupted with modern day intervention to make sure a kid’s healthy.
Maybe there was medication on board, maybe there was C-section. So everybody’s birth journey is different. At the end of the day, at least we got a healthy kid. But there’s a chance that many of our children, that latch was disrupted. The nose was blocked from the get go, increase the resistance, and led to even in the presence of breastfeeding some type of acid reflux that was continuing to block the nasal cavity.
[Meggie]One thing it took me a while to learn was that the acid reflux causes more inflammation, causes more congestion. So it’s not just detrimental to the teeth in an infant that doesn’t have teeth, it’s causing more swelling, more stuff, and decreasing that negative airspace.
[Liz]And depending on who you talk to, everybody’s gonna have varying opinions on why adenoids and tonsils get enlarged. There’s going to be many reasons adenoids and tonsils get enlarged, but in part, that acid and that presence of inflammation can have a huge impact on that tissue that’s trying to fight a battle of harmony for the system. So for a child of that age, there’s a pretty good chance that the adenoids and potentially the tonsils are quite enlarged.
The other thing, and this probably isn’t you guys, but when we talk about environmental stuff, there can be nutritional impacts. Especially I hear a lot of gluten and dairy sensitivities, especially here in the US. We have mold in our homes. We have different viruses-
[Jaz]Just to add on the diet, Liz, if you don’t mind, I recently bought this like home blood test, which tells you all your sensitivities and whatnot. I bought it for myself, but actually I have a very good system and I knew my wife needed it more than me. I kind of said, Sim, you need to do this. Okay. And lo and behold, severe dairy allergy, severe allergy to case in the protein in dairy, mushrooms, cashews. So many things that she enjoys and so they’re everywhere, right? And so it is our duty to get tested and that could be part of it as well. I mean, maybe my son has it.
[Liz]And so that’s the thing is like you can’t go back in time and say, well, if we’d eliminated dairy, we wouldn’t be having these issues. All we can do is look at what’s sitting in front of us. And work for better.
And so for a kid like that, there’s a pretty good chance that adenoids and tonsils are significantly enlarged. Maybe it’s as simple as putting them through a nutritional panel to see where we can make changes to reduce that inflammation, putting them on some type of naturopathic path. And again, I don’t do that.
I guide that through other naturopaths. Many of the families we look at are minimal intervention. They don’t want surgery. And nor do I want that for your child. But I also tell people that noise that you were hearing earlier, in my background, that’s my dryer vent. If a dryer vent is closed and clogged up with gunk, it needs to be cleaned out.
And that’s kind of the way I describe this. Adenoids are clogging the two. They either need to be reduced in size naturally, or they need to be surgically intervened on so that a child can breathe, but at that age it’s gonna be difficult to say, well, let’s expand ’em. There are a couple of dentists who’ve expanded or increased the oral volume of the oral cavity with aligners at that age.
Is it something that you would always recommend to a patient? No. Is it something that you could do on your kid? Potentially, but I would always talk to the ENT first with that age group. Yeah, because at the end of the day, depending on the age of the child, the lack of breathing that’s occurring can have a different implication.
It can have an IQ impact, it can have a behavioral impact, and that can be really like systematically broken up by age. So that’s where I want that kid breathing as quick as I can for patients.
[Meggie]And Jaz, like you’re seeing, it’s already causing a growth change, right? He’s got crowding who’s posture his lower jaw forward. So you know, Liz is spot on working with an ear, nose, and throat doctor. I would add in there, if you have access to a, in our country it’s SLP, Speech Language Pathologist that has functional feeding therapy to start to optimize the muscles so that he can start to grow that really reactive bone by having his tongue posture in the correct position whenever he can.
Using a growth guidance appliance of that age to help chew and develop muscles is really important. And then other things outside of the things that we’ve already mentioned, have a HEPA air filter in the bedroom introduce in a really non-threatening way, saline rinses or nasal rinses. In my family and growing up, we would use nasal sprays or neti pots when we were sick.
And so it was this thing that we dreaded because we were sick. We didn’t feel that we didn’t want anything up our nose. But in an ideal world, that’s part of normal hygiene. You brush your floss and you rinse your nose. And so while he might have inflammation that’s causing congestion because of diet, because of environment, because he missed that first latch, who knows?
What can we do? What do we have access to to make positive change where we are right now? Maybe we don’t have an ear, nose and throat doctor that’s on board because of his age. Maybe we can’t do expansion because of his age. Well, what can you do? And I would just say, throw spaghetti at the wall and see what sticks.
But I will say from my own personal journey, don’t hold your kid down and put saline up their nose, because then it’s a really long battle back to making that fun. So give him like a misting aerosol bottle in the bathtub, something that he can control. And I think the kids are smart, even if they don’t understand everything that we’re talking about right now. I think that there is this intuition that, hey, I breathe better, I feel better, I sleep better.
[Jaz]Well, just to celebrate with you ladies, that since he turned two, like 15 days ago, for some reason, miraculously he’s actually sleeping through the night for the first time in two years. So this is huge for our family. So for two years we’ve struggled a lot. I’m just like, wow. Liz, sorry, did you wanna add something?
[Liz]No, because I’m talking about like the extremes, right? Surgery and expansion. Meggie’s talking about all the day-to-day stuff that we do, and kids are smart, they’re intuitive. When mine are in trouble, they’ll come up and they’ll stand next to me and they’ll go. Because they’re trying to show off at their nasal breathing so they’re not in trouble anymore like you guys are. Oh man. Little manipulators.
[Jaz]Wow. I just wanna say this was absolutely amazing. I’m so glad we connected and we shall meet at AES. But I really want you to just talk about your education that you guys provide, because whether you have docs from the US or docs from the UK who’s gonna make that trip over, which I would love for them to do, and I myself am thinking I need to learn more about this as well. How can we learn more? What are the channels that you provide? Where are the websites which, where we can follow you to learn more about this wonderful thing that you’re talking about?
[Meggie]Well, you talked early on about our journey, right? Like our evangelism, our educational like resources is a journey and we are constantly adding and changing things. So right now, I would suggest going to our website because we have a resource page that has one of the questions we get all the time is, where’s the research? We’ve compiled a lot of research and we have access to that on our website.
[Liz]Hundreds of articles. It’s amazing.
[Jaz]Yeah. Good ’cause one question actually I wasn’t gonna ask is the evidence based? You know, there’s a lot of controversy, especially around orthodontics and airway, right? There’s a lot of controversy, let’s face it. And so is it like in the world of occlusion, a lot of what we follow and what we teach is not evidence-based because you can’t get the study, you can’t get a randomized control tile when everyone’s got different height of ramuses, different tooth time contact, different facial structures, different dietary habits.
How can you disprove anything? And so where are we at with with airway? I mean, it’s great when we’re talking about that on the wheel website, it’ll be a great place. I’ll put that in big letters for everyone to click onto because everyone needs to do their own research and homework and make sure that there is a good scientific basis and foundation.
[Meggie]We said this at the beginning, we didn’t have a really clear path forward. There are unbelievable resources out there for education, and because we’re at a time where science is catching up and there is more research to support what we’ve been seeing and have seen clinically for decades, it’s easier now to jump in than it was maybe 10 years ago when we jumped in.
So we’re trying to make the journey easier. So while there’s so many different platforms out there for education, we wanna create what’s worked for us. So we have compiled our research. We have an email that goes out daily to drip information, like, how nice is it to be spoon fed, easily accessible information without having to commit to hours at an end.
And we’re also super excited because we have recorded our first course, which is gonna be on demand, and it’s gonna be a really big overview of kind of this podcast, but a little bit more in depth on each section within a course library that has how we do things in our office. And then we’re gonna offer monthly one-on-one office hours with us so that we can talk real time about individual cases. Case number six through a hundred, right?
[Liz]Because a lot of it’s the decision tree and just knowing where to go next. And it’s not hard when you wrap your head around it, but that’s what I’m really platform the untethered way. It’s just gonna be such a great space for people who are really trying to dive into this.
And Meggie’s always talked about the concept of babes, littles, and bigs. So babies, children, and adults. And we kind of have it segmented out into that to make things a little bit like in this, it’s like a mind dump, right, in this podcast, but we can really start to compartmentalize all the age groups based on what we’re seeing, and then know how to control the controllables from there.
And that’s what I think our course will do a good job of. So definitely check it out, sign up for the email list. It’s gonna be amazing. And then AES like, we have two, it’s AES American Collaboration Society. It’s in February and Chicago, Jaz and Mahmoud are gonna be there. It’s gonna be awesome, but it’s very occlusion and joint heavy and the conversation of airway hasn’t always been at the forefront of it.
But I’m super excited. We have Tracy Nguyen and Jeff Rouse on our stage this year. I’ll be there ’cause I’m helping organize it. But we would just love to have everybody join us in person because in the first time I was there, someone was fighting about how the maxilla causes the problem and someone else was fighting about how the mandible causes the problem. And when you have two incredible world class speakers like going toe to toe on a stage, it’s fun dialogue that you can have.
[Jaz]The panel discussions a great highlight when I attended two years ago now and I’m excited to listen again and share a little bit. But honestly the lineup you guys have brought me and Mahmoud aside, I mean if you look at the actual names you got, you got Rocabado, you’ve got Lassmann.
You’ve got Jeff Rouse, you got some amazing names. So I’ll put the links to all that but also to Untethered for the email list. Also resources and the on-demand course. So ladies, you have your day to start now. After this, it can only get easier from here. You guys did a wonderful job on this podcast and I really enjoyed, I was learning. Thanks for patient number five. It was like a free consultation for me. So thank you so much.
[Meggie]So much fun. Thank you for having us and letting us spout our excitement.
[Liz]Yes. We really appreciate you.
[Jaz]For those who listening on Spotify didn’t actually get to see it. For those who watch it on YouTube and stuff and gotta see it, you could see that at a point Liz was jumping to like, I loved it very much. Thank you so much.
Jaz’s Outro:Well, there we have it guys. Thank you so much for listening all the way to the end. Didn’t I tell you? That’d be interesting. Listen, Protrusive Education is a paste approved provider. You can get your CE credits or CPD, this episode’s, one hour CE credit, or one hour CPD, depending on where you are in the world.
If you want to collect your CE, you have to answer a quiz and get 80% at least. Go to protrusive.app, or for those of you who are already on the Protrusive Guidance app, scroll down, answer the questions, and get your certificate. You’ve done the hard work, you’ve listened to the episode. Now’s your chance to consolidate your learning, and don’t forget to download your premium notes.
Every episode we do, we create these premium notes. We also have a transcript of every episode, and our premium members can download all of this. Don’t forget to check out Liz and Meggie’s website, and I’ll put that on there as well, so you can check out their resources and education they have. More power to these fantastic women for sharing everything they know, for sharing their journey so selflessly and so compassionately.
I had a lot of fun on this episode. I hope you guys did as well. And if you did like it, please do hit that subscribe button. It helps us a lot. And with that, I just want to say, one last thank you to my team. Without Team Protrusive, there will be no podcast. I would be totally burnt to toast, completely burnt out, and it’s only through the team looking after the video editing and helping with the premium notes and quality controlling that I can continue to hopefully sound as infused as I was on day one.
So thank you Erika, Gian, Krissel, Mari, Julia, Nav, Hannah, Xyra. As you can see, the team is growing every few months and of course the podcast is growing. Thanks to you and all the supporters of Protrusive, appreciate you very much so again, catch you same time, same place next week.
Bye for now.

May 29, 2025 • 1h 15min
Occlusion Myths and Red Flags with Lukasz Lassmann – PDP225
Are you still using long-term provisionals just to test OVD?
Is an occlusal splint really the best way to assess vertical dimension?
Could raising the OVD actually harm your patient?
Dr. Lukasz Lassmann joins Jaz and Mahmoud Ibrahim this AES special episode to challenge conventional thinking around occlusion, vertical dimension, and full mouth rehab. Lukasz shares his unique perspective as a clinician, educator, and researcher, bringing clarity to a topic that often feels murky and divided.
They explore real-world questions like managing asymptomatic clicks before ortho, why occlusion alone won’t “cure” bruxism, and the number one reason not to raise the vertical without proper understanding.
Plus, Lukasz drops an incredible airway assessment tip at the end of the episode!
Protrusive Dental Pearl: Use a comprehensive TMD history-taking form to effectively triage patients into urgent (red), moderate (amber), or low-risk (green) categories—this allows you to prioritize care appropriately and build rapport by focusing on examination rather than data collection during the appointment.
https://youtu.be/ZhIoUxdMMsg
Watch PDP225 on Youtube
Download the form: protrusive.co.uk/tmdhistory
Download the Patient History Evaluation Form
Need to Read it? Check out the Full Episode Transcript below!
Takeaways
Understanding red flags in TMD patients is essential.
Patient history is vital for effective treatment.
Phonetics can be unpredictable in dental rehabilitation.
Diet and sleep significantly affect TMD management.
Gut health is linked to chronic pain conditions.
Communication with patients is key to successful outcomes. Bruxism may not be solely caused by occlusion issues.
Palpating the lateral pterygoid is often ineffective and painful.
Equilibration and centric relation are controversial topics in dentistry.
Increasing vertical dimension can exacerbate sleep apnea.
Holistic approaches are essential in diagnosing and treating TMD.
Not all patients with TMD have malocclusion or attrition.
Sleep apnea is increasingly common in younger, slimmer patients.
Polygraphy is a useful diagnostic tool for sleep apnea.
DISE (drug-induced sleep endoscopy) is a valuable diagnostic procedure.
Highlights of this episode:
02:48 Protrusive Dental Pearl
04:37 Lukasz Lassman’s Journey and Philosophy
08:11 Debunking Myths About Vertical Dimension
12:10 Patients in the Red Zone
23:15 The Role of Diet and Lifestyle in Facial Pain
31:38 Adapting to New Restorative Methods
34:41 Phonetic Challenges in Dentistry
39:02 The Role of Occlusion in Bruxism
41:18 Palpating Lateral Pterygoid Muscle
43:27 Centric Relation vs. Equilibration Debate
50:07 OVD Red Flag: Airway
01:03:27 Conclusion and Future Events
Studies Mentioned:Gut Bless Your Pain—Roles of the Gut Microbiota, Sleep, and Melatonin in Chronic Orofacial Pain and Depression
Randomised controlled trial on testing an increased vertical dimension of occlusion prior to restorative treatment of tooth wear
📅 Upcoming Talks & Courses
AES Annual Meeting 2026: The Evolution of Oral Physician – February 18-19, 2026
Lassmann Education: SummerCamp 2025
If you loved this episode, be sure to watch Myth Busting Occlusion and TMJ – PDP022
#PDPMainEpisodes #OcclusionTMDandSplints
This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.
This episode meets GDC Outcomes B and C.
AGD Subject Code: 180 OCCLUSION (Occlusal therapy)
Aim: To enhance clinical understanding of occlusal principles, vertical dimension management, and red flag indicators that impact prosthodontic and TMD treatment, based on current best evidence and insights from Dr. Lukasz Lassmann.
Dentists will be able to –
1. Identify common myths and misconceptions about vertical dimension increase and temporization.
2. Recognize red flag patient presentations that are not suitable for prosthodontic treatment.
3. Understand the airway implications of increasing vertical dimension and how mandibular rotation impacts it.
Click below for full episode transcript:
Teaser: This is insane. You know, I was always asking, what do you mean progressively you want to increase first like two millimeters and then you want to check if it's all right. If there is no joint pain or- I never start doing prostho or ortho when my patient has pain. I first want to turn my patient to be asymptomatic and then we go ahead.
Teaser:On the first appointment, you are explaining on the second one you are justifying. We don’t want to tell our patients that this is because of the systemic disorders or some psychiatric disorders because we, ourself, we consider it is like showing the white flag that we just confessed that we don’t know the answer we do. If your patient has a problem with the bladder, you as a dentist, you’re not treating the bladder, but you just refer the patient to the proper doctor. Right?
Jaz’s Introduction:Stop placing your patients on long-term provisionals, or even worse, giving them an occlusal appliance. If the sole reason you’re doing it is to test the OVD.
Hello, Protruserati. I’m Jaz Gulati. Welcome back to your favorite dental podcast with an absolute superstar, Lukasz Lassmann. I remember meeting him in 2019 in Dubai on a course, and he just blew my mind. His cases are spectacular, and honestly, I have no idea how this guy does it. You guys say Jaz, how do you do it?
I look at Lukasz and think, how do you juggle everything, PhD, three kids, everything he’s doing in progressing education and occlusion. Absolutely inspiring guy. And yes, of course, we asked him how does he do it? This episode is one of the AES special episodes to shine a light on the AES 2026 conference where Lukasz Lassmann himself will be doing the closing act.
Me and Mahmoud, we got the paracetamol on day 2, AM but don’t worry, me and Mahmoud will try and keep you awake. But Lukasz is the main act and deservedly so. And this episode will give you an insight into his thinking, the work he does, the kind of patient he sees, including at the very end, he will just blow your mind.
It’s a way of checking your patient’s actual airway while they’re laying down in your dental chair, this video at the end, he shares it’s absolutely golden. For those audio listeners, that part lasts for 10 minutes, is on video only because I didn’t want you guys to feel alienated. But for those video watches you are in for a treat at the end.
So my friends, me and Mahmoud on this episode, we asked Lukasz so many questions. It was quite a broad overview and some were quite basic things and some were quite advanced things. And I’ll kind of like chime in now and again just to make a few things tangible because when we talk about occlusion, things can get a little bit saucy, a little bit too excited sometimes.
So we’ll just bring it back down a few pegs now and again with a little interject, which I hope will be helpful. And if it is, please comment below and let us know if it is we discuss real world things like if your patient has a click, does that mean we need to intervene before they have orthodontics, or is it okay for them to have a asymptomatic click?
You’ll also find out how many patients bruxism, me, Mahmoud, and Lukasz have cured from doing a full mouth rehab or an equillibration. Okay, tell you what. I’ll give you the answer. It’s zero. So find out why we believe that in our experience so far, that perfecting someone’s occlusion will not necessarily stop their bruxing.
And I know some of my dear friends and mentors are, are probably about to throw a brick at the screen here or smash their headphones. Let’s try and stay friends, everyone. I know everyone’s got different mixed views when it comes to occlusion, but everyone just take a breath. woosah-woosah. Take a breath. It’s gonna be okay.
Just hear us out. And of course, we’re gonna give you the number one reason not to raise a patient’s vertical dimension. Why by raising their vertical dimension, you might actually be killing your patient a slow and miserable death. All that, and much more to come in this episode.
Dental PearlNow every PDP episode I give you a Protrusive Dental Pearl. This one is kind of influenced by some of the things that Lukasz said in this episode. Like when he has these TMD patients that come from all over the world to see him in Poland, he needs a good way to categorize these patients. Who are the red urgent patients? Who are the amber patients and who are the kind of like the green patients, which are lower risk queries, which can be dealt with easier and they don’t need as much time?
And the way to do this is with a really good data collection or a history taking form, when you ask the right questions and you get a very detailed history, you are much more likely to be able to identify those patients that need to see you, ASAP, think of it like an evulsion, right? When a patient avulsed their tooth, they need to get to the office, ASAP.
So who are your TMD EVULSION patients? And who are the, oh, I’ve chipped a bit of enamel here. Can you please take a look? Kind of patient equivalent of TMD. Now, those of you who are watching this on Protrusive Guidance, our network, the history form that I use is ready for you to download below. That’s my gift to you.
But for the wider audience, I’ll put the link. But essentially it’s protrusive.co.uk/tmdhistory. That’s protrusive.co.uk/tmdhistory. And my team will email you the PDF that we use. It’s quite exhaustive and for good reason, so feel free to cut things out if you need to. But honestly, like when it comes to history taking and TMD, you can’t have too much information.
Some of the great physios I work with, they’re all about, again, the right information before they even come to the office. So you can focus on the examination and actually rapport building, which is so important when we look after our TMD patients. Once again, that’s protrusive.co.uk/tmdhistory.
But if you’re on the app already, scroll down below and you can download it. So now full circle to the very first thing I said at the start of this episode, which is why you shouldn’t be doing long-term provisionals and definitely not do a splint just to test that OVD. You’ll find out in great detail why that’s the case. Hope you enjoy a catch you in the outro.
Main Episode:Lukasz Lassman. Wow. I mean, absolute rockstar and dentistry. We have rock stars like Pascal Magne, we have rock stars like Markus Blatz and Buddy, my friend. Let me tell you, you are right up there, man. You are right up there, Lukasz. And me and Mahmoud literally went offline for like one minute to set your screen share permissions and we were just like, holy crap.
How does this guy do it? Right? And so the whole world is just in awe of this superhuman that you are. So that’s a whole another topic to debate. But Lukasz, for those few people living under some sort of rock that haven’t come across your amazing cases or content and whatnot, please tell us about you. What drives you, Lukasz? What is your driver in life?
[Lukasz]Yeah. First of all, thanks for having me. I think it’s like comparing me to Markus or to Pascal is like, it makes me embarrassed because I truly believe that I’m on a good direction, but I think it’ll take years and years to get where those giants really are.
So what drives me is a progress. If I do not see the progress I’m burning out. It happens with my clinic, it happens with my courses. When I have to repeat the same course twice at the second time, it’s like, I don’t think I wanna do this again. So this is how I change all the lectures. This is how I split the courses, like step one, step two.
And you know, without changing even a single slide, I would never, ever be able to repeat the same lecture. That would be much easier to have the same lecture, to repeat the same for 10 years. I would’ve saved a lot of time doing this way, but my brain couldn’t handle it. So yeah, the progress is something that drives me.
I know that there is a very thin line between the passion and workaholism and I’m sure that I have crossed this thin line many times in my life and I’m really trying to maintain this so-called work-life balance. Right? This is very important. The most important thing is not to regret anything at the end of your life, and this is how I try to live my life.
[Jaz]I remember being at your lecture in 2019 in Dubai and obviously you just, even since then, you’ve just gone strength to strength and strength. I dunno if you remember this, I dunno if you still do this on your presentations, but you ended with like a really like human emotional bit. It was really, really nice and you pretty much summarized it beautifully just now about striving to better, let’s not compare to one another and the problems that social media brings about looking at yourself and wanting to be better and you’ve just described that beautifully.
Mahmoud, just wanna bring you in my friend. How are you doing, my friend? You’re at the clinic, you’re just finishing up some cases and you are as excited as I am to be sat here with Lukasz. They’re one of the biggest geeks in occlusion we know right now.
[Mahmoud]Oh, absolutely. Super, super excited Lukasz to be able to chat to you actually, sort of one-on-one, well, two on one I guess. Pick your brain a little bit. I absolutely love the content you’ve been putting out on Instagram through, Lukasz. So last minute education, which is the sort of the newer one and the stuff on there is amazing, so digestible. So yeah, which one are sort of try and get a few more, as we call it, sort of tangible bits. But yeah, I’m really excited to be here. I have no work-life balance at the moment, but you know, it’s hit the ground rocking.
[Lukasz]My last year wasn’t also the work-life balance, it was the toughest year in my life. Finishing PhD, finishing the book, finishing the clinic, having three kids and doing the courses and treating patients.
It was clearly too much. But finally I’m here and I would say that everything went right, but the level of the cortisol in my brain was very high this year. But I don’t not regret.
[Jaz]That’s the way to be.
[Mahmoud]There’s no point in regretting it, right.
[Jaz]Exactly. Well, today’s geeky topic, my friends, will be something that Lukasz talks a lot about in social media. Lukasz teaches a lot about in his courses stuff, which is the myths surrounding vertical dimension. And there are many myths. There has been some great papers published over time about this. I also want to touch on joint position, ’cause this could easily be like a fire hour debate, right on joint position.
So we’ll try and keep it brief. We’ll try and make everything relatable and tangible for our younger colleagues, right? Because let’s just pay homage to the AES which has brought us together, guys, AES February, 2026. I’ll put the link in. Lukasz, we’re all basically warming the stage for you. You are the last act, right and you are lecture title is Smile and Space Concept in Vertical Dimension of Occlusion.
So very much tying in with some of the small things we’re talking about, but it’s just a huge topic and one of the reasons I compared you to Markus Blatz what you both do so brilliantly is the dissemination of information. So that the masses of dentists can really resonate and collect ideas and understand.
And so a couple of the posts that you did on red flags are just so beautifully put together that it’d be an absolutely travesty if you don’t shine a light on those posts. And so together that will formulate the content. So really sometimes when I ask my guest these questions, sometimes you have to take a step back ’cause it’s such a big topic.
So if I ask you, Lukasz. What are the common myths that as young colleagues we’re learning about occlusion? What are some of the myths that you’ve ever come across when it comes to the vertical dimension or changing vertical dimension? Shall we pick one or two that you really want to highlight?
[Lukasz]Yeah. The one that people very often ask me about the progressive, increasing vertical dimension of occlusion. This is insane. I was always asking, what do you mean progressively? You want to increase first, like two millimeters? Then you want to check if it’s all right. If there is no joint pain or there is no bruxism because of these two millimeters, and then if this is all right, you increase another two millimeters and then another two millimeters.
You do three set of wax ups, occlusal compass on every single tooth, three sets of condylography. Do you do the same when you do the full dentures? You also do three sets of full dentures, or you just use some basic rules and you put it in your patient’s mouth so that it looks good, it functions well, and your patient is happy, and you don’t wait for some deprogrammation in their brain because you know that if the form is good, if the function is good, if the appearance is good, it’ll be okay.
Some people just need a little bit more time. Some people need just a little bit less time, but they will all adapt. I will talk today about the red flags and some conditions where probably the adaptation could take a little bit more time than usual, but even in those scenarios, using prolonged temporization isn’t necessary thing, and we haven’t had any science for decades to support using temporaries for longer.
Now we got one paper which is a good paper, which says something totally against using the spleens or some kind of temporaries to let the patient adapt. I’m not saying that the temporaries are a bad thing. I’m not saying that we shouldn’t test mockup. I’m not saying that. I’m not saying also that if you have a patient that struggles with phonetics, for example, we shouldn’t use prolonged temporization because this is the condition where I would use it, definitely.
And if we want to shape the soft tissues with a soft tissue management, I get vertical preparation all over on every single tooth. We use the PMMA. We want to shape the soft. We’re gonna use this, but for checking the vertical dimension of occlusion, if only we obey the rules, the basic rules, and we screen the patients perfectly at the beginning of the treatment.
So I’m categorizing the patient for that red zone, yellow zone, and the orange zone. So if the patient is in a red zone, this is a patient that we don’t even start doing the prostho. We have to convert this patient first to be in the green zone and then you move ahead and then a treatment is easy.
[Jaz]Can you give a couple examples of red for our younger colleagues? What are a couple of examples that constitute someone has red?
[Lukasz]Especially the acute arthritis in the joint or any chronic exacerbated TMDs, centrally mediated myalgia. If you have a patient with the neuropathic pain, I mean, some people really believe that with the good occlusion we can get rid of neuropathic pain, which is totally against the science. So I never start doing prostho or ortho when my patient has pain. I first want to turn my patient to be asymptomatic. And then we go ahead.
[Mahmoud]Just to clarify again, for the younger listeners. When we’re talking about asymptomatic, we’re talking about pain, we’re talking about inability to function. However, things like maybe a click that’s been there for 10 years has never changed, hasn’t caused any pain. They can chew, they can eat, they can speak. That doesn’t constitute symptomatic, correct.
[Lukasz]Click is not a problem at all, but, function that when there is a big limitation in opening. Yeah, I would say that this may be the big problem because it may be because of the disc, acute, this displacement without reduction.
It may be because of the muscle trismus. And the other question is why there is a muscle trismus, probably because of some inflammatory reasons. It may be the elongation of the coronary process, which I have seen few times in my life. Those people got the deprogramation to let them open more. They got the physiotherapy to stretch the muscles while there was just coronoid process that was hitting the zygomatic.
[Jaz]Mechanical obstruction.
[Lukasz]Yeah. That was a mechanical obstruction.
Interjection:Hey guys, it’s Jaz, interjecting to just explain how hyperplasia or an enlarged coronoid process can cause this mechanical obstruction. If you have a look at a normal size coronary process, and you look at the difference between that and an enlarged coronoid, for those of you whose anatomy is a little bit weak now is like, you know where the condyle of the mandible?
Well, it’s that fin shaped process, the top of the mandible. So the mandibles kind of like bifid if you’d like, right? It’s got the condyle, it’s got the coronoid, and the coronary process is like a little extension. It’s like a fin shaped extension on both sides. Now, when you have an enlarged coronoid or hyperplasia, what happens is that the coronoid gets stuck behind the zygomatic arch and the patient cannot open very big.
So it’s like a more rare thing. And there’s like articles online and case studies. It’s something to bear in mind. I think it’s always just nice to apply anatomy to our patients and anatomy is one of those things where we don’t wanna just memorize.
It actually helps you to get a deeper understanding of the human body. So I was worth just exploring this issue about coronoid process, hyperplasia and how exactly that causes a mechanical restriction. Back to the episode.
End of Interjection –
[Lukasz]If you try to do it too much, you could have broken this, the coronary process. Yeah. So, if you have those conditions, you should get rid of this problem pretty early. Also, when people have a hypermobility, you should also-
[Jaz]Very common, very common, in your TMD patients. I imagine Lukasz, like my TMD patients, a huge percentage. Obviously women, and then huge percentage of those are hypermobile. Is that what you found in your questionnaire and discussion as well?
[Lukasz]Yeah, but you always have to take a look at the side of the hypermobility because very often, the hypermobile side is hypermobile because the other side, the contralateral side is hypermobile. So this one is trying to compensate. So when you get the restriction over here, so in time, probably this will regenerate, but this one will try to catch up. We’ll try to compensate.
Interjection:Okay. It’s Jaz again, just interjecting on hypermobility, right? So many of our TMD patients are hypermobile. They’re just built differently. We know about the correlation, if you remember from a few episodes ago, between TMD and how so many TMD patients have an undiagnosed connective tissue disorder.
Think of things like Ehlers–Danlos syndrome. We call them “bendy”. Someone asked me, Jaz, are you bendy? When I had my pneumothorax and yes, I am bendy. I’ve been told when my physio, I’m hypermobile. I’ve got quite stretchy skin and all those things. But to just drive the point home clinically, right?
It’s wanting to appreciate how hypermobility specifically of the TMJ may manifest in your patients. It’s those patients who, when they open, they sometimes get locked, open a bit, right? And then they just have to wiggle their jaw and then they fix it. So they kind of locked open. Typically like when they’re yawning, they yawn and then they get like stuck open for like a few seconds and then they wiggle their jaw and they are able to close again.
It feels a bit tender when they do that. And so these patients know not to open too much or just be careful when they’re yawning. And that’s called a subluxation. If someone subluxes their TMJs, they’re probably hypermobile. And the extreme end of that is that they kind of sublux and then they don’t go back to normal, in which case that’s a true dislocation and that’s more rare.
That’s like you have to go through the emergency department or dentist who knows what they’re doing, try and get the condyle back under the articular eminence again, and back into the glenoid fossa. So top tip to patients who sublux a lot and they kind of get stuck for a few seconds is tell them they should not be opening their mouth more than three fingers.
There should be no reason to open more than three fingers and tell them, just be careful when they’re yawning, right? So when they’re yawning, I get my patients to put their hand underneath their chin. And lastly, sometimes you hear a click. So as they open and as the condyle gets over the articular eminence, just like when they’re about to sublux, that can sometimes make a click sound, right?
And that’s called an eminence click. So don’t think that’s like a click of the disc. That clunk. It’s more like a clunk actually. And that’s called an eminence click. Anyway, just trying to shower this episode with as many real world nuggets as possible and arm you with knowledge that you can actually apply day to day and help your patients with.
End of Interjection –
[Lukasz]And then you got a patient, you know what? You’re gonna see, you do the CBCT or something and you see the arthritic joint over here, and you are almost sure that this is the one that is painful, but your patient’s telling you, no, no, no, doctor, I got my pain over here in here nothing is clicking, in here is clicking.
But then you realize that it’s not even this clicking, it’s just jump over the eminence. It’s the sublux joint and those cases are pretty tough for dentists if they don’t recognize it because those patients will tell you that they struggle to keep their mouth open with prolonged dental appointments.
And we think this is about the muscles. Yeah, it may be because of the muscles, but because of the protective mechanism, try to imagine that you do the endo in your lower third molar, the worst scenario, and you ask a patient to open as much as they can and you do endo for one hour. And if this is a normal patient, the condyle should stop on the lowest level of damage, right?
With a hypermobile patient, it’ll jump over here and would stay here for one hour. And this is where the protective co-contraction starts. This is why they start feeling the pain. So the solution for those people is always to, first of all, to put the support between the teeth to bite on it. But do not let the patient bite on it when the condyle is displaced.
So let them open only when they feel that it is not displaced. And you can, as a dentist, you can also feel it pretty easily because we can feel it under the skin. So you tell them only to open up, up here and then you give them the piece of plastic to support and then-
[Jaz]The mouth prop.
[Lukasz]Yeah. How you call it?
[Jaz]We call it the mouth prop.
[Lukasz]Okay. Mouth prop. Okay. Alright. So then you leave it for one hour and you would be surprised that just a small difference, five millimeters less opening and it makes a huge difference for the symptoms for the patient.
[Jaz]I always say, ’cause sometimes patients find it like quite often it’s the first time they’ve ever had it when I’ve offered it to them, right? And so I always say to the patient, it’s a bit like me holding my elbow out for like an hour like this, whereas me leaning against something and then patients get it and I say, look, the first 90 seconds it’ll feel strange to swallow, but then you get used to it. And I found, I tell them, don’t bite hard into it, relax into it.
And I’ve found that, it’s made my dentistry easier, it’s made our patients comfort levels easier. And I’m hugely a big fan of mouth props. But some clinicians have been a little bit reserved or worried about using them. Anything you wanna add to that Lukasz, in terms of communication or your use of it?
[Lukasz]You mean why do you worried about it? Because they worry-
[Jaz]Dentist-
[Lukasz]The person will swallow it or what?
[Jaz]I don’t know what it is, about it, but usually they see it as something that you did in hospital, but then you don’t do, like, they associate it with like patients under general anesthetic and they feel as though most clinics I speak to, they don’t even have it in their clinic, operatory in general dentistry.
So I’m like, this is such a simple and good thing to use. Whereas in dentistry, because they don’t see it so much on social media, they don’t see other dentists using it. They feel as though maybe it’s frowned upon. And I’m always saying, no, it’s okay to use, especially on this acceptable patient.
[Lukasz]I feel like I have to record a video with this one and show it on my Instagram. When you spoke about Markus Blatz, I must admit that he was the biggest inspiration for me to open my Instagram channel with educational content because I only then realized that Instagram is not only show off, it’s not only showing before and after pictures. On Facebook, I could have used 100 slides and put tons of knowledge over there.
And now on Instagram we can use 20 slides. But back then when I started, it’s like more than one year ago, I think I opened it like three years ago now. But then we had only 10 slides. So deciding what is important and what is not is was very tough, not putting too much words on the slides, not to distract attention.
We have to realize how the young brain works. I mean, like we are also young, right? But people that are watching us are 10 years or 20 years younger. So this generation, what I see, they don’t really like to read books. They like shortcuts. They need algorithms. They say, don’t tell me why, just tell me what to do.
And this is scary. This is very scary. But, at the same time, only the people who can adapt will survive. And if you’re gonna be stubborn and you’re say no, I will not even try to explain it with 10 slides because this is oversimplification. Nobody will listen to you. So we have to balance between putting things in a very simple way, not too comprehensive, because if you’re gonna be too comprehensive, nobody will read it anyway.
But also, if you have a big message, why don’t you split it in three posts with big picture and main message? Big picture and main message. This is what I’ve seen for the first time in Markus Blatz Instagram. And this really inspired me to do so.
[Jaz]Well, you definitely maintained that. You’ve recreated it for occlusion and more power too, man.
[Lukasz]Yeah. To occlusion, to temporomandibular joint, it was like, I’m doing form of reconstruction almost every day when I do not do fu of reconstruction. I’m doing TMD patients. So like yesterday we had 25 TMD patients one day, and those were-
[Mahmoud]I’ve got a headache speaking about that. Oh my God.
[Jaz]And these patients are traveling a long way to see you.
[Lukasz]Oh yeah. They are traveling. I had patients from Switzerland and so on, but how did we do this that we had 25 patients? It wasn’t like every single patient for 10 minutes. I’m collecting the questionnaires that I have done this year for the purpose of the book. I’m very proud of those questionnaires.
This is one of the things that I’m proudest of with this book, that I’m sending all those questionnaire to my patients. I’ve got a huge list of patients, like 700 patients waiting with TMD, with the pain, this is sick. You know? How can people wait two years for an appointment with pain?
So at certain point, I realized that within those several hundred people, there are people with this really severe pain and there are people that are waiting two years because orthodontists said, if Dr. Lukasz doesn’t see your clicking joint, I will not put the braces on your teeth. And after two years they’re coming and I’m saying, oh, we don’t care about it. Just leave it like it is.
Well, the way to resolve this huge line of patient was sending all those people, all those questionnaires. So I’m like once a month I’m getting the package of 70 questionnaires and then I know who is my patient. Is this a patient with myofascial pain or neuropathic pain or some central intimidated myalgia, neuropathic pain. So yesterday, and I’m tagging all those patients. So yesterday I had a whole day with red, red, red, patient.
[Jaz]Urgent.
[Lukasz]Only neuropathic pains, neuralgia and all those. It’s like terrible stories. I was very exhausted. At the end of the day, they-
[Jaz]Mostly drained. These patients, I dunno how you do it, but they drain you.
[Lukasz]Yeah, they do because, and this is very sad because when patient is telling you that they had several suicidal attempts-
[Jaz]Very sad.
[Lukasz]They’re telling your doctor, if you don’t help me, I will commit suicide. This is such a heavy burden. And what I was trying to say, how did we do this, that we had more than 20 people was because I had my postgraduates students after my TMD courses and we had it in four offices. So we all knew the patient before, so it was accelerated and I had the biggest authority in the pain treatment.
The professor from my capital city from Warsaw, she also came, she’s anesthesiologist and she was helping me with all those people. So I was just going from one office to another, to another. And then coming back, they were taking impressions, they were doing the tropical ology injections, some we were prescribing some pills.
We were talking about the lifestyle changes because this is so important. They are so disrupted at so many levels. This is like, this experiment with slowly cooking frog when you put the frog into the water. Yeah. And it increase the temperature.
[Jaz]Just for those who haven’t heard it, just explain it. ‘Cause we’ve had this on podcast before in a pediatric episode actually. But just tell us about the frog because it’s so relatable. It’s like dentists listening to this frog analogy, even in their career, their life, their family. This analogy can apply in anything. So please just share that for us for a moment.
[Lukasz]Yeah, that was in famous experiment. I don’t even know if that was a true experiment or is it just an anecdote. But if you put a frog into the water and you just slowly try to increase the temperature, the frog will not even realize that something bad is happening until it dies. Until it’s just boiled.
And the same happened with people. So we are sleeping very badly, and this is ridiculous because we are doctors and we are not trained how to improve people’s sleep. We sleep for one third of our life. This is the most powerful regeneration in our life, and we only learn how to take the Zolpidem.
We only learn how to take pills to sleep better. But there are so many tools how to improve sleep that I’m also sharing with my patients. We have never learned. I don’t know, I was in the uk, but in Poland, we are not learning about a diet.
[Jaz]Oh no, not at all.
[Lukasz]We learn how to eat pills. And this is crazy because I remember six years ago when I was never an expert in dietician, but at certain point I realized that maybe there is something that we are missing.
So I had a patient and she was a violent player and she came saying that she had pain for eight years and nobody could help her. She had tons of dentistry in her mouth. You should have seen this. The appliances, unbelievable. When she showed me those terrible appliances, I was not surprised that she still had this pain.
But long story short, I asked her, has anybody ever tried to change her diet? And she looked at me like suspicious eyes. I was like, oh my God. Again, shaman will try to treat me with energy, you know? I was like, no, no, no, no, seriously. Has anybody ever tried to eliminate something from your diet? She said, no.
And just because I wasn’t so good about those different forms of diet. We have this kind of a diet in Poland from one pretty famous doctor. This is diet that is based on the fruit and vegetables and mostly the juices made of fruit and vegetables. You eliminated basically everything else. So I told her, go on this Dr. Dąbrowska diet for two weeks and we’ll see what’s gonna happen.
After two weeks, she came to me and she said, doctor, you will not believe. Everything is gone. And I didn’t know, was it because of what she was eating or what she excluded from her diet? Maybe it was just, I dunno, gluten, maybe it was a casein, maybe it was lactose, maybe it was, I don’t know, tomato skin. God knows.
So with my patient, I sometimes do it, like with the kids, when the kid has a green poo, what do we do? We eliminate everything and we start with one ingredient, and another day we add another one and then another one. So at the end of the month, you just have a normal diet. But then you know what made it worse?
The way the diet, the big problem is that we can have a cross allergies. And we can have also delayed onset with the allergy. So sometimes you feel badly two or three days after you eat something. So I will just tell you one private thing. I used to have the geographic tongue and this lesion on my tongue was always appearing on the same right side of my tongue.
I was always Googling, was there any new signs about the geographic tongue? I was checking chat, GPT, research, everything, nothing. I stopped drinking coffee in September. No more geographic tongue at all. This is why I’m drinking now yerba maté. I don’t know what the connection, but there was some immune response to something in the coffee.
Some people tell me, pick up the specialty coffee. It’s called specialty because, I dunno, they have some special grains. They say that this is maybe because of the fungis in the coffee. It may be and maybe I have some like-
[Mahmoud]Preservatives or something.
[Lukasz]Oh yeah, it may be. So what I’m trying to say, many people think that they have a very healthy lifestyle, but just because something is generally healthy doesn’t mean that this is healthy for you. You may have completely different reaction to healthy ingredients. Even vegetables or fruits.
[Jaz]It’s fascinating because my wife, oh, I bought this blood test for myself to see if I’m allergic to anything. There’s food intolerance. And I bought it, but actually, and she won’t mind me saying this, I hope we will find out-
[Mahmoud]You’re allergic to her.
[Jaz]Well, I found out I was allergic to my wife. No, I made my wife do it because God knows she needs it more than me, with her diet and stuff. So she did it. Severe allergy to dairy, severe allergy to casein, which is the main protein in dairy and mushrooms and cashews and like, there’s a whole 20 other things in here.
I’m like, damn. And so I think one of my, just, before we just circle back to the occlusion topics is that everything you’re saying is really relevant, especially in the world of TMD and healthcare in general, because two things that Lukasz mentioned guys is sleep and diet. And my mentors have taught me in TMD as well that you could do everything right, but if the patient is not sleeping well.
Or they’re in systemic upset, then they will not heal the TMD as Lukasz’s story quite rightly pointed out, and that’s really important. Taking it all the way back to that red flag. Patient’s got acute jaw issues. Make them green first before doing anything with their vertical dimension, and then going back again to the whole progressive changes and vertical dimension, right?
Mahmoud, in the UK we have this old school group. I mean, I don’t know if they teach us anymore, but there’s a Eastman philosophy. Put everyone on a Michigan or a Tanner Appliance for six months, 12 months, make sure their head doesn’t explode. Then give them that vertical dimension. The other things that Lukasz actually mentioned in his Instagram posts and agree with so much is the acrylic material or the material that the temporary is made of. It’s not even the same as your ceramic and there’s a whole adaptation that has to happen. Lukasz, tell us about that.
[Lukasz]Yeah, so you have to know that there are at least 10 reasons why does plane work? People think that if patient is getting better because of the appliance, it is because of the occlusion that is different now that there are many, many reasons and you have to know that one of the reason is regression to the mean.
And one of the reason is also placebo effect, which is very powerful, especially for the people with myofascial pain and some mental disorders. And usually within six months, this is what science says, 60% of your patient will recover no matter what kind of crazy appliance we’re gonna use. And so when I hear that in some occlusal schools, they have to use an appliance before prostho, before ortho, like, MAGO appliance, and they are happy that they have a huge success rate.
You know why the Indians were so effective at the rain dance? Because they were dancing until it start raining. So it’s just sometimes to wait enough and the symptoms will just go away. And you can have a patient that just got your appliance and the next day this patient’s going on a Hawaii for vacation and they have a less stress, they got an appliance.
I always tell my patients, even if now is all right, especially those with the chronic pain, you have to know that those symptoms may fluctuate. You can sometimes have a bad weather and there is a big correlation between the bad weather and chronic pain. Not with acute, not with inflammation, but with chronic pain, with oversensitization of the cortex.
Yeah, there is a correlation. Some hormonal disbalance, bad night’s sleep. This is not without the reason why women are four times more frequent patient within the TMD practice. But we have the same bite, right? The same occlusion. But we have completely different lifestyle. And I was trying to connect the dots also when I wrote the paper.
‘Gut Bless Your Pain’, but not the gut, but gut, you know? So it was about the connection between gut microbiota and the chronic orofacial pain and the role of melatonin in sleep and chronic or facial pain. And when I was reading all this, I was shocked that for so many years we didn’t look inside the guts.
I was always hearing that this is our third brain, but for me it was just a saying, it was like, ah, everybody knows that this is true. But actually, for years it was considered to be the pseudoscience. The same as a leaky gut syndrome, you know? There are things in our life when they are considered a pseudoscience until someone finally shows the proof that this is not a pseudoscience.
But I’m not saying that this is a bad way to practice medicine because if we didn’t do this, we will have a lot of shamans, chakras. I dunno, maybe chakras turns out to be truth in the future. We don’t know what we don’t know. In 2018, we found the biggest organ in the human body, and it was published in nature and it was interstitium.
Come on with anatomy. We know everything. Maybe we have to work with the quantum physics, but with anatomy we have already seen everything. We haven’t even seen the different part of the masseter muscle, which we found pretty recently. It was one of the findings.
[Jaz]Even in anatomy, we’re finding new things. So just to highlight that, so basically testing your patients virtual vertical dimension increase purely to see if they will adapt is perhaps not a great idea. However, you mentioned brilliantly that if there are other reasons like soft tissue development, phonetics and stuff, that may be a reason to keep them in temporization for longer.
But purely to test, will my patient adapt to this vertical dimension? And that’s the main reason that perhaps we should go sooner to the definitive or sooner to the more transitional restoration. Like, composite injection molding is quite popular nowadays to get their aesthetics, phonetics and stuff, and then that will be served them well for many, many years.
Before we’re trying to be minimally invasive and stuff. Do you do that kind of treatment, Lukasz, or do you believe more and less go straight to ceramic? ‘Cause that’s longer lasting and better value and better investment for the patient.
[Lukasz]Provided that my patient has no speech issues or doesn’t need any soft tissue management, they got temps for two weeks because this is the time my dental technician needs to make a full mouth ceramics.
So they just got as a teeth protection and they also have those two weeks to get adapted to the new form maybe sometimes with a speech. I will talk about it much deeper with my presentation. But in general, even if you let your patient adapt on the composite and then you try to change it in ceramics, your dental technician, even if they try to do the copy paste, they will never do 100% accurately as it was before.
Even if they do, you can cement your overlays, you can have occlusal seat, your cement will just increase the video on this particular overlay and everything changes. The softness of the material will be different. Softness and hardness, right? So you had the composite, your patient was feeling good with the composite, now they got zirconia, right?
And this is not the same. You use the something mock that is splinted. All the teeth are splinted not separate. And now you put separated teeth. And the perception and the periodontium is completely different. So we very often torture people with few adaptations and they struggle with each one the same.
Instead of giving them the temporaries just for two weeks and explaining. I always say on the first appointment, you are explaining on the second one you are justifying. So if you have a patient that you suspect to have a bigger problem with adaptation, like a patient with mental disorders, I’ll speak about it.
You have to tell this patient that they may require more time. Taking into consideration the drugs they take, their mental history and so on. Don’t talk too much about it because we don’t want to create a nocebo effect, which is the opposite of placebo effect. But yeah, we have to explain those things to our patients for sure.
[Mahmoud]I think one point our listeners need to take away is the amount of information you seem to be able to get out of patients in terms of just history, right? Like you already mentioned that with these questionnaires you’re sending out these patients you’ve never met and yet you’re able to categorize them really, really well.
Just highlights the importance of history taking, like we’re dentists, we want to get our hands on the patient, we wanna get our hands on the teeth and do stuff. But how that history can then possibly inform how adaptable or not adaptable the patient might be. Therefore you can then create a customized temporary phase. But if you go into the phonetic side, what are the common things you see people struggle with and what are your some of the possible solutions to particular problems?
[Lukasz]So the most common is of course, the S sound. But as many studies proved that the speech fanatics is the least predictable thing in our job. And this is also something you have to tell your patient. And what people usually struggle with is the S sound. But with every language we have a different pronunciation. So in Polish language, we say, just, whereas in Spain, they will say [sound like “ith”], right? So they are kind of lisping . In Mexico, they will say [inaudible], right?
And in some languages you would say that they have a phonetic problem, but it’s just a language. So when we and Riaz decided to do the research. Riaz has many cases done with the post and the before and after rehabilitation and with the S sound trying to trace the changes and trying to predict what the changes are, depending on the bite, depending on the incisal relationships.
There is no classification for this, and we are trying now to make this classification, but then I realized that it may be restricted to English language. Not to all the languages around the world, right? But with the S sound, what we always have to know is that this is the closest speaking position. So if your patient struggles to keep this position, the same with the people with the open bite, they’re trying to compensate, putting the tongue between the teeth, right? This is why sometimes you don’t even hear them lisping. This is why the phonetics is so unpredictable.
Interjection:Okay? It’s me interjecting again. And remember, I have asked, I’ll ask you at the end of this episode, how are you finding these interjections? Are they helpful? Are they not? Please guide me guys.
So closest speaking position. How can I make this very clinically relevant to you? I remember when I was early on my career doing my first few DAHL cases, right? When you add composite to worn anterior teeth, but you leave the posteriors to kind of settle occlusally. So dento-alveolar compensation, the anterior is intrude, the posterior extrude, if you like, and that’s how the DAHL technique works.
You’ve got some episodes on that already, but when you add the palatal contours of the upper incisors, imagine a wear case, the palatal incisors, acid erosion. Typically they’re worn and now you want to increase the vertical dimension. You want to add some composite there, but then the patient comes back with a lisp.
Okay? So every time they say S or the S sound, basically what could be happening is that you’ve breached the closest speaking position, right? So everyone has a different way they make the S sound. Some people’s lower incisor comes like just at the cingulum of the uppers, whereas other people’s lower incisal edge comes near the upper incisal edge, right?
So you gotta kind of see how they’re making it. And if you breach this position and the patient is not able to adapt, then the patient will be contacting, right? When they’re making the S sound, the teeth will contact and there’ll be a lisp. So what to check at this point is, I like to get 200 micron paper, right?
So 200 micron, that thick blue paper, yes, it does have a use, right? And I pop it in between the patient’s teeth, between the front teeth specifically, and I get the patient to say 66. 66. 66. And now that they’re saying this, they’re reproducing that closest speaking position. And then where you see blue or wherever you see the ink of the arctic paper, that tells you, okay, this is where the closest speaking position is being breached and probably where you need to adjust.
And this could be palatal of the upper or maybe the lower incisal edge. And there are ramifications of all this. But I just wanted to give you a little trick in case you ever do a buildup of these teeth and you find that you’ve breached the closest speaking position back to the ep.
End of Interjection –
[Lukasz]Because people can adapt between the teeth, between the lips and teeth, between the tongue and teeth. And finally most of them will adapt. But if at the beginning you struggle with S sound phonetics, sometimes it’s because of there is a two big space, but sometimes it is just because there is not enough space. This is when I put the 200 microns paper. And I tell them to say S sound few times. And when they are hitting on the upper incisors, I just know where to take a little bit of the material to create this proper space for speaking.
Sometimes you’ll see people destroying their teeth just because the only position when they can say the S sound properly is when they go, for example, to the left and they find the space between two attrited, worn down, canines. I saw many cases like that. So they keep on destroying their teeth and in those cases.
You’ll have to reeducate them how to speak properly because you don’t want them to destroy the ceramics. Again, this is why in my clinic we have not only dentists, we have speech therapists as well. In Poland, we say logopedas, I dunno how you’ll call those proficiency.
[Mahmoud]Speech therapist.
[Lukasz]Speech therapist, okay. So D sound. D sound is a problem when you have two bulky palatal, wall of the upper incisors. F sound, sound is problematic when you have two long incisors. Yeah, there are many, many sounds that may be disrupted because of the new material in the mouth, but usually it’s very fast to adapt and I see bigger problem with the class two patients rather than class three patients.
I was a little bit surprised because when you think about the edge to edge, worn down dentition, and this is the space which they use to say the S sound. Now when you increase video and you put two completely new incisors and you change the incisal relationships completely, I out of expect that those would be the people who would struggle most with the S sound, they’re not.
What the people that I struggle most are the people with the class two. And when you increase video, you create even bigger distance to say the S sound. So those are the most difficult patient to treat. Increasing video in class three patients is so nice. You improve everything.
[Jaz]Vertical chew is much easier, but that’s a whole another topic. I’m just gonna ask you two quick questions before we go into red flags, right? Because I think you’ve got a lovely presentation that we can just go deeper into maybe a couple of those red flags. Maybe in the interest of time, this is really shining a light on some of your amazing work and some great tips you’ve given already.
But I wanna just really excite everyone for AES, right? So maybe tackle the two most prominent red flags that you think there are. Before we get to that, Lukasz, I have two fun controversial questions for you, right? Which I know you love to talk about and I think it’s gonna be quite fun actually, is how many patients of bruxism have you cured from a full mouth rehab in centric relation?
[Lukasz]Have I cured? You mean it stopped bruxing?
[Jaz]Yes.
[Lukasz]I think maybe zero.
[Jaz]I thought you might say that. So this is such a huge thing, right? People are claiming that bruxism is because the occlusion is not right, and when you get the occlusion right, you’ll fix the bruxism. Now, in my own experience, Lukasz, when I’ve done a bigger case, when I’ve done the full mouth rehab and I either give them a splint, I see where on the splint, or I give them a brux checker and I see that, okay, they’re still moving their jaw.
Obviously I don’t have any polysomnography data, but all the camps who are telling me that the bruxism has stopped, they are not proving it. I’m proving that they’re still bruxing after the full mouth rehab in centric relation, but no one’s proving to me that they stopped bruxing. So what’s your thought process that you wanna explain to dentists about why the occlusion or quote unquote fixing the occlusion may not necessarily stop the bruxing?
[Lukasz]It all started with great dentists, but with a pretty bad science. I think it was in sixties with Mr. Ramfjord who wrote the papers that when they equillibrated the teeth, patient stops grinding. And the methodology was pretty awkward because they asked them if they stopped grinding. Can’t imagine, you know?
Did you grind last night? I think I didn’t. Yeah. All right. So we got a success with equilibration. People think that people are grinding because they are trying to destroy the obstacle, the premature contact to the centric relation. And you see those people with completely worn down dentition, completely flat, no premature contacts at all. They are already-
[Mahmoud]No grinding.
[Lukasz]They’re still grinding. And now they’re asking, Daniele Manfredini was describing pretty nicely, he was just reminding his old professor, his first mentor, that he said that those people have the memory of the obstacle in the past. This is why they-
[Mahmoud]It’s like phantom limb syndrome, but for your premature contact.
[Lukasz]Maybe. Yeah. Phantom, there is something that’s called phantom bite anesthesia, right? Some people say there’s a mental disorder. Some people say there’s too many receptors and the periodontium.
[Jaz]Lukasz, I’m gonna ask you the other, ’cause that was just me being controversial, right? So the second controversial one, I’m gonna ask you now just to set the scene before we then just cover one or two of your favorite red flags in the interest of time is, do you believe that you can palpate the lateral pterygoid in your clinic?
[Lukasz]No, no, it has been disproven. I mean, the science is split. There were papers that described it is possible. There were papers with the EMG that described that it is impossible. When you look at the anatomy, you cannot put your finger so much backwards.
So usually you can palpate the lateral pterygoid muscle indirectly through the medial pterygoid muscle. The question is, what for? Why should we do this if it is almost always painful? So I got a hyper diagnosis, which leads to overtreatment, right? And I always ask myself a question, whenever I put this muscle, it’s always painful.
Why should I even touch it? What should I do with this piece of information, we always have to correlate the history with examination. Because what we should treat is the familiar pain, the pain that replicates the symptoms, not the accidental findings. If you put your finger over here and you ask your patient, Mr. Jones, do you feel the pain? And the patient says, yeah, I do. Do you think it matters?
I always say, if patient has time to think whether he feels pain or not, this pain is completely relevant. When you put your finger here and the patient says, oh, oh, don’t do this, it matters. But usually those people do not come up for veneers and they’ll say, oh, doctor, by the way, yesterday something clicked in my joints a terrible pain and I cannot open my mouth.
No, they’re coming with pain. So you just confirm with examination the symptoms. No reason to do any treatment because of accidental findings. We can test the patient from the head to the feet. It’s like, what for? Are we trying to correct the posture for everybody? Like I think 99% of population has a bad posture. We can be-
[Mahmoud]If you’re over 40, you’ll find something that hurts somewhere.
[Lukasz]Limit of being holistic dentists, you know.
[Jaz]Well said, mahmoud. I’ve got one more controversial question. Have you got any controversial questions for Lukasz before I ask my new one that I have now? ‘Cause I’m quite enjoying these controversial ones.
[Mahmoud]No, you ask yours and I’ll mull it over all.
[Jaz]So here’s my controversy, Lukasz, right? We’re very similar in thinking. Obviously I’ve been to your courses as well, so maybe that’s molded me. Let’s talk about e equilibration and centric relation as a joint position and as a goal, right?
So the beef I have with equilibration and centric relation is this, that if we accept the vast majority, now, whether you believe this is 90%, 93%, 95%, 97% of patients, their conal is not in centric relation in their day-to-day life. Their condyle is not in centric relation, it is probably slightly anterior, and that is, i.e. most people have a slide, and then our goal is, oh, I want to-
[Lukasz]99.5.
[Jaz]There we are almost a hundred percent right? And so, why are we saying that these patients are diseased? Whereas actually the people who are diseased are the ones, the 0.5% who are in centric relation, they’re the ones who are diseased. So I always like, there are some clinicians who I respect, dear friends of mine, who will say that, look, every one of my patients, if I find a slide, I will offer an equilibration because there’s X, Y, and Z benefit.
But I’m thinking just like lateral pterygoid, if a hundred percent of your patients will feel pain, if the vast majority of patients have a slide, then surely they are physiological and normal.
[Lukasz]Of course. So we do not need to be in cr. CR is a technical position. If we want to increase vertical dimension or we want to do the reconstruction of both arches because it is easier for us.
And it is more predictable and more stable for the future. It’s just this, it’s not the vaccine for TMD. Not at all. We can have the best cr, we can have the best occlusion, and if your patients clenching in the joint, there is all the time immobilization. There’s gonna be the adherences, there’s gonna be adhesions, and there’s gonna be clicking and everything.
Interjection:And, okay guys, Jaz again with my final interjection. Remember I do want feedback in the comments in terms of how you found these interjections and so centric relation, right? How can we not tackle this. Now, Lukasz described this as a technical position, and I like to think of it as a practical position, but a great paper by Daniele Manfredini is called Centric Relation, a Biological Perspective of a Technical Concept, and it uses the term maxilla mandibular utility position. The key word here being utility position, i.e. It can be useful to us when we are reorganizing, so we need space. We’re gonna open the vertical dimension. Where should we put the condyles?
Well, why not put the ball in the cup, right? If you liken the TM joint, extremely simplified as a ball and cup. Well, the most orthopedically stable position is having the ball in the cup, i.e., the condyle in the glenoid fossa. And that’s a repeatable and comfortable position. So why don’t we use that to our advantage, specifically the repeatability of it.
Can you imagine doing a full mouth case and the patient keeps changing where they’re biting, but now you can guide them or get them to guide themselves into this repeatable position. And so if you lose your bearings, you know exactly where to go. Think of those complete denture patients, right? So centric relation, the whole thing about sticking your tongue all the way to the back, curl your tongue to the back as a crude way to get this patient in what we used to call retruded contact position.
Well, it helps us, right? It’s a utility position. It helps to guide the patient and we are choosing to use that joint position because it’s gonna be repeatable. And so when a patient no longer has a normal bite anymore, the MIP is not repeatable, it’s not comfortable, and you want to restart. We want to restart the bite.
Then many occlusal camps will use centric relation. Other positions are available, but with the vast majority of occlusal camps, use centric relation and let’s think of it as a utility position and not so much as a vaccine for TMD or a position where all your ailments, your erectile dysfunction goes away and that kind of stuff. It’s useful, man. It’s a useful position for prosdontics. Back to the ep.
End of Interjection –
[Lukasz]You know, most of my patients with TMD, they are women between 20 and 40 with a beautiful bite. They don’t have malocclusion. They don’t have attrition because people with TMD usually do not have attrition. People with TMD usually are clenchers, not grinders, and clenching is not healthy.
Immobilizing any joint in your body is not healthy. This is why having any appliances that immobilize the jaw is very bad thing. And soft appliances that stimulate clenching even more is also not a good appliance.
[Jaz]Mahmoud, have you thought of one before we pick a red flag that Lukasz wants to present? Have you thought of any controversial things that what we can get out of our system today?
[Mahmoud]The thing is that every time Lukasz speaks, like he is talking so much sense. And it’s so interesting. I don’t have time to think of other stuff. I’m just listening. Right. I’m just listening.
[Jaz]Okay, Lukasz.
[Mahmoud]But it is amazing, isn’t it? That you know, ’cause I was on a podcast a couple of weeks ago. I was, and I got asked this question about centric relation and people grinding away their premature contact to get into centric relation. But it’s just, you take the two facts that we know that are, most people are not in centric relation.
That includes the people that are grinding, guess correct. But guess what? They have ground bejesus out of their teeth and yet they’re still grinding. So logic isn’t logic and-
[Lukasz]Yeah- Even opposite because if you look at the data, it turns out that if you incorporate the premature contact intentionally, they’ll brux less, not more. And those are the papers from /inaudible/ and a few others. And this is counterintuitive because I would’ve thought that when you get the two high crown, you will try to smash it to destroy it, to get the good MIP. But it’s not.
[Mahmoud]I wanna disagree with Lukasz.
[Lukasz]The obstacle. Of course there are people-
[Mahmoud]I disagree with Lukasz.
[Lukasz]Yeah, no.
[Mahmoud]‘Cause I don’t think it’s counterintuitive because to me, think about this, if I’m walking around and I put a pebble in my shoe on purpose.
[Lukasz]You’ll avoid it.
[Mahmoud]I’m gonna stop. Yeah. I’m gonna avoid it. I’m not actually gonna try and stomp my foot down to get the feeling to get disappeared.
[Lukasz]There are some people that would do it the other way around. Most of the people will try to avoid it. But people with some specific mental disorders, they will react completely differently and those will be the ones who try to eliminate the obstacle. Right? Those are the nervous people. I’m using aligners now and every week when I change my aligners, I feel like I’m clenching more, but probably because of elasticity of the aligners.
There is some new research that says that the EMG activity is not increased because of aligners. I always say, we are human beings. We are not statistics. So every human being reacts differently. But in general, I could agree that orthodontics has nothing to do with the TMD. The other thing is that mostly those research is done at the universities where the level of orthodontics is a little bit higher in most of the countries.
So I can imagine that very bad ortho can cause TMD. So I’m not the one that will tell you that occlusion is never a reason for TMD. I’m the one who will tell you that it’s so rare that I would always recommend to think about something else at the outset of the treatment and never, ever start with the irreversible treatment at the beginning because equilibration and 24 hour splint therapy is often irreversible treatment.
So if I tried lifestyle changes, maybe nighttime splint therapy, maybe collagen injections, maybe physiotherapy, that is so popular in Poland and we are very happy that we have so many physiotherapies in Poland that deal with the TMJ. I have two in my clinic that do only this.
And if I tried everything, maybe I would consider 24 hours splint therapy. But most cases it is just the diagnosis was wrong initially have to rethink the diagnosis because maybe there is some other problem. Maybe there is some systemic disorder and this is completely new story. And very often people don’t even think about doing blood tests and everything when we have the TMD patients.
We are just grinding teeth because we are trained to do so and we want the teeth to be the reason because if this is the reason, we will be able to help. We don’t want to tell our patients that this is because of the systemic disorders or some psychiatric disorders because we, ourself we consider is like showing the white flag that we just confessed, that we don’t know the answer, we do.
If your patient has a problem with the bladder, you as a dentist, you’re not treating the bladder, but you just refer the patient to the proper doctor, right? And it’s not like showing the white flag. You have to know how to refer the patient to the proper specialist and not to try to do everything with what we know.
[Jaz]Well said. I think it’s-
[Mahmoud]Nail. Everything’s a hammer.
[Jaz]That’s it. You nailed it, Mahmoud, and I think you mentioned this point that we can want a patient to fall into a specific basket, but we should be open to the holistic nature of them. Now, you mentioned about 24/7 splints, and I agree with you, that’s a very serious thing, 24/7 splints.
The longer you wear it, the bigger change it has. And I will only reserve that treatment when you’ve done everything else in the pyramid. But also I try and reserve if patients who already don’t have an occlusion, who already have a messed up occlusion that really you can’t get any worse and sometimes they need just some stability.
Before we get into the deep dark realms of TMD, I would like you Lukasz, just maybe share your screen and share in the interest of time, one red flag that we haven’t discussed that you think general dentists ought to know about when it comes to changing the vertical dimension, which is the most interesting one that you think we haven’t touched on yet that we can discuss now for the last part of this podcast, when it comes to changing the vertical dimension, which is the red flag that you want to discuss.
[Lukasz]If I would pick up only one, I would pick up probably the one that you don’t want me to talk about, because you have the other speaker to talk about it. I mean the airway.
[Jaz]That’s okay. Jeff Rouse is gonna come on. We’re gonna go deep. But what I like then is you’ve now wet everyone’s appetite for Jeff Rouse episode as well, so that’s great. Let’s talk about that.
[Lukasz]So one of the most important red flags, when you consider increasing vertical dimension of occlusion, you have to ask yourself, why do we want to increase video? In most of the cases, we don’t increase it because the patient has lost the vertical dimension. In most of the cases, they do not lose vertical dimension because they have a dento-alveolar compensation, right?
So also the question is if you want to recreate the previous video, how do you know how high was it 20 years ago? Do you have a pictures or what? How do you know that we are recreating some? We do not. So when you have a patient that has a teeth wear and we know that there are some correlations with the sleep apnea.
And the bruxism, in one year, they’re stronger and one year they’re weaker. I believe that the problem and confusion with the data is that we put the whole sleep apnea into one back. We do not separate different reasons for sleep apnea because we can have a central sleep apnea and we can have obstructive sleep apnea.
We can have a obstructive sleep apnea because of the restriction in the nose, the tonsils, larynx, the tongue base, and I believe that the restriction in the larynx would appear much more correlated with the bruxism because if we consider bruxism as a protective mechanism, moving the jaw forward would unlock the airway at the level of the larynx, not at the nasal level, right?
So I think that this may be one of the problems with the methodology. When you see people with sleep apnea, very often they have this special appearance of the neck with the forward head posture because this opens the airway over here. And they have a low hyoid bone with a special kind of neck.
But, in the past it was rather disease of old obese males. Nowadays, it’s not anymore. This is why the STOP-BANG questionnaire is not useful for me anymore because it is mostly for those obese and older guys, and I have very slim young women having the sleep apnea nowadays.
So, whenever I have my patient with bruxism, even if I put an appliance to protect their teeth, my first choice of diagnostics is polygraphy, not polysomnography, the hospital. Polygraphy is the home sleep device. So they can order it via the internet. They just sleep with that for two days and we see what is their Apnea-Hypopnea Index. And only then I would give them the night guard because if they have sleep apnea and I would give them the night guard, something bad can happen.
And we know that increasing vertical dimension of occlusion can exacerbate the sleep apnea. And this may be because as we know, that if you increase video, you get the rotational axis in most of the cases. And if you increase one millimeter at the back, it’ll increase about two millimeters in the front, but at the same time, you’ll have the posterior rotation of the jaw.
It’s not distalisation. It is posterior rotation of the jaw. So your airway at the level of the larynx can restrict even more. Of course, this is generalization that this is the one to two ratio. It could be the one to two ratio with the normal pre-industrial skull. Nowadays we have the epidemic with the modern skulls.
This is called a dis evolution because we have a case that are mouth breathers. They eat very soft diet. So there is a dis-evolution of the skull. And if you look at this high gonial angle, patient probably increasing one millimeter over here would increase at the incisal level about three to four millimeters with the much more pronounced posterior rotation of the mandible.
So we know that when we look at the level of the larynx, increasing video can be harmful. Here I’ve got my click that when we increased video of the leave gauge during the course for her, she said that the bite, she felt comfortable in this position, but not in this position.
[Jaz]So chin up positions those listing like neck extended up.
[Lukasz]It was helpful for her. Ever since she went down with the chin, she couldn’t breathe and look at the neck. This is clearly sleep apnea patient, but during the courses which I do, we trained also on manipulation. So I do it on my participants and they do it on me just to be clear that they do it right.
And once I did it on one of my colleagues and what I’ve seen was pretty astonishing. Take a look. So this is his maximum intercuspation. As far as remember he has been treated by his wife with ortho.
[Jaz]Dangerous.
[Lukasz]So this is his MIP. And now I do the dose and manipulation for him and this is his cr. And now you wonder what should we do?
[Jaz]So just to describe for the audio listeners, Lukasz, is a huge slide. So it looked like everything was like class one, but now he has a huge, no terrible class two and AP slide, basically. Huge Class two. Absolutely.
[Lukasz]Yeah. So for many people going into CR would be going distally, and for some people it would not be just one millimeter. It may be even six millimeters like you saw in here. Now, I would say in most of the cases, centric relation is a very helpful position for doing prostho for increasing video and much the most repeatable, the most stable. But in some cases, I would think twice. What do I want to do? If this was my brother, I would say, bro, if you really want to have it very stable for your lifetime.
Probably would have to do it in cr, but then you would require orthognatic surgery. If you want to do it in MIP, we can go on. You would not have to cut your jaws, but you are at risk of relapse in the future. If somebody ever decide to put you at an appliance, you may end up with this open bite. If you ever get very, now, if you get a lot of anxiety, you’ll get a post-traumatic stress disorder and you’ll be all tensed.
Maybe your muscles will pull your condyles into cr and I’ve seen many cases like that, and this is very common reason for relapse after ortho. If it wasn’t done in cr. I’m not saying that every case must be done in cr, but if you are far away from cr, and let’s imagine that in 20 years somebody would decide to increase his VDO because he has attrition.
They’ll be surprised, right? And they’ll be very confused which bite should they use to increase vertical dimension of occlusion. So for some people, going into CR is not only posterior rotation of the jaw, it’s also distalization of the jaw. And I have checked some papers if anybody has ever talked about digitalization of the jaw while getting into cr.
And there is zero papers. There’s only one paper from 2023, which says that there was no papers. So that was basically the conclusion. There is a theoretical risk, but there are no papers, right? So the thing is that if you look at the normal patient. This is the normal patient with a very wide airway. And this is the patient with the sleep apnea, with the very narrow airway.
So this is even worse if you put the patient in a supine position. And let’s look at this area because in here, we got the attrition and anterior area. And in here you got the airway. So now if we increase vertical dimension, look what gonna happen. So you will restrict the airway. But now let’s say you had a patient with bruxism and this patient also had a sleep apnea.
Your reconstructed teeth with ceramics, it may turn out that you got the patient with a bigger sleep apnea, and if it correlates well with his bruxism, you’ll have a patient with a bigger bruxism. And so now you don’t want your patient to destroy your ceramics, right? What are you gonna use? You will use the night guard, which will increase video even more.
So we went from here up here, right? And there are many papers showing this correlation with adverse effect of the night guard on the sleep apnea. So, very often the solution is to use the mandibular advancement device for those people because then it works like head and shoulders two in one.
You protect the teeth and you protect the airway. But to have this, you have to know that the restriction is over here. This is why after doing polygraphy, we very often do DISE, Drug-Induced Sleep Endoscopy. We put our patient on the propofol and we put the endoscope into the nose to check where is the restriction, because if the restrictions in the nose, this appliance will not help at all.
So if you ask me if there is a patient, that increasing video would exacerbate the sleep apnea, I would tell you that this should be not only one factor, but combination of factors like patient that already has a sleep apnea patient that has significant elevation of video. And what does it mean significant?
I don’t know. It’s like I would say one millimeter increase. Three millimeter increase is not significant. But for this patient that you see on a screen that they very often describe on during the lectures, big case, we increase I think 10 millimeters. So this is significant. If at the same time there is a big shift between the maximum intercuspation and centric occlusion, the risk of increasing sleep apnea is even bigger.
If at the same time this patient already has restriction in the larynx. The risk is even bigger. If the same patient has a high gonial angle, probably the risk is even bigger. So this is like plane crash. They say that it must be at least seven reasons for the plane catastrophe, not a single one.
So this is why for many patients, we just use this appliance and we use DISE at the end. I will just show this a short video to let you know.
[Jaz]That’s because I saw on your Instagram as well, and this is the highest level of diagnostics, man, like you are actually making sure that actually bringing the mandible will actually help your patient. A, not just then putting them through the risks of a bite change and also immobilization. That happens to a degree with these appliances. I mean, kudos, man.
[Lukasz]This is called the precision medicine, right? Because I had so many patients that had the surgery of the soft palate. They have surgery of the nose, they cut off everything, and then it turns out that, oh, it didn’t work.
So let’s try to check if the restriction is not in the larynx, we cannot do those surgical procedures blindly because those are irreversible, right? This is why we do the DISE first. But in this video, you’ll see that we can actually also set the appliance at the proper protrusion using DISE. This is not something I do regularly.
Usually we use just subjective, symptom-based protrusion. So we give this appliance and every day we tell our patient, if you feel very sleep in the morning, if your wife says that you are still snoring, just make two screws more protrude, the jaw half millimeter forward. Some people say very subjective things, so they are asking, how did you decide that you don’t want to go even more forward? And they said, Doctor, I got a morning glory again as a teenager. So, this is not objective data. This is clearly-
[Mahmoud]I think you should write a paper, Lukasz, I think there’s a paper in that somewhere.
[Lukasz]Probably, many patients will not confess. But I think I had at least three guys that said, so. Take a look at a video.
I want to invite you to the operating room where, where we perform very special procedure, diagnostic procedure for the patient that has just received their prosthetic work from me. So the procedure is called DISE, so drug induced sleep endoscopy. So we start with the injection of the propofol so that the patient is sleeping and then my ENT doctor is placing the endoscope into the nose so that he can clearly see the upper airways.
We see the soft palate, we see the the tonsils, we see the larynx, and now what I’m doing, I’m turning the special key that is moving the mandibular advancement device forward. So we are setting this appliance under the control of the endoscope, which is not typical procedure.
Now, the patient stopped snoring, so I do not have to move this device anymore forward. So we have the ideal position, not only for the TMJ, not to overload it, but also for the airways so that the patient will be very happy.
Yeah, so this is it.
[Mahmoud]Very happy.
[Lukasz]Yeah, I had all those other red flags, but I will save it for the other.
[Jaz]To have a conversation with superstar like you, like you have to, you could speak for like 20 days in a row and it’d be like, honestly, the amount of research you’ve done, your PhD, everything is so much of value.
So I just wanna thank you for spending this time with us and really excited to see you again in Chicago next year. But I also wanna just take a moment to just highlight.
[Lukasz]That’s gonna be my first lecture ever in US. So I’ve been lecturing like all over the world and all the continents. This year what we are gonna have. Actually, I’m gonna have many people from UK on our summer camp this year. We do like eight days. But yeah, the event in Chicago will be probably amazing. I’ve never been on the American Equilibration Society, but I’m really-
[Jaz]Dude, it’s amazing, man. But man, the videos of summer camp look absolutely amazing. I would come this year myself, but I know you’re teaching in Malaysia the same group. I’m doing a little bit in August, the same date.
So maybe next year. I mean, your summer camp just looks like a great festival of occlusion, man. Like me and Mahmoud, like when we see the videos, like I messaged him like, dude, man, Lukasz’ summer camp looks so good and you have great speakers like Calita and Riaz and stuff. Amazing man. Honestly, hats off to you for making-
[Lukasz]I feel like, again, like a teenager on the camp, on the high school.
[Jaz]Definitely send that vibe. Lukasz, thank you so much for your time, for your contribution to dentistry and occlusion to temporomandibular disorder. Really excited to see you grow and grow and grow and, and put more stuff out there.
So from us as a profession, thank you. And thank you for geeking out with us. See you in Chicago at AES next year, but hopefully we meet sooner than that as well. To me and Mahmoud are going into Copenhagen next month. There’s Occlusion conference there. Are you going there by any chance?
[Lukasz]No, no, no. I actually, I don’t have any free weekend until the end of the year, so I really have to be busy with the events and usually I’m at the events where I’m speaking, so this is how it-
[Jaz]Exactly. I thought that might be the case, but anyway, it would’ve been nice to you. But we’ll see you next year for sure. Anyway, but we’ll keep in touch my friend. I’ll let you know when this episode’s out.
Well, there we have it guys. Thank you so much for making it all the way to the end with an absolute superstar, Lukasz Lassman, and thanks to my partner in crime, Dr. Mahmoud Ibrahim.
I do wonder if you enjoyed those interjections, like did I annoy you? Please let me know if it was annoying. For me to interject now and again, just to bring things back to basic again, I really would love to know if you find that helpful or not. So please do on protrusive guidance YouTube or wherever you’re catching this, DM me on Instagram @protrusivedental. I really would love that feedback.
As this is an AES special episode, please do join us next year. That’s Wednesday 18th, February and Thursday 19th, February, 2026, in Chicago. The website is aes-tmj.org. That’s aes-tmj.org. If you are in the states, you have no excuse, right? This is plenty of warning. Come and join the most comprehensive organization when it comes to dentistry.
Geek out with us for a few days. It’ll be great to you there and around the world. What a great opportunity to go to a tax deductible trip to the US of A. Let’s try and not focus on Trump and all the bad things happening in the world. Try and focus on the good things, i.e., the dentistry, the education, and it’s no secret that I’m a little bit partial to the US junk food.
Anyway, thanks again for listening. This episode is eligible for CE credits. We are a PACE approved education provider. If you’re on our app, that’s protrusive.app. The website is protrusive.app. On the paid subscription, you can answer our quiz, and my team will send you your CE certificate. Thanks to everyone who supports Protrusive and validates their learning through reflection and certification.
Man, that was a lot of fun I have to say and I enjoy geeking out with the Lukasz today, and I hope you did too. I’ll catch you same time, same place next week. Bye for now.

17 snips
May 22, 2025 • 1h 14min
Basics of 3D Printing, Milling and Digital Dentistry – PDP224
Rustom Moopen is a general dentist with a keen focus on digital dentistry, particularly in 3D printing and milling. He dives into the pros and cons of investing in these technologies, discussing their durability, cost-effectiveness, and long-term ROI. The conversation highlights how milling and printing serve different purposes, with insights on workflow improvements, patient satisfaction, and the importance of mentorship in mastering these methods. Moopen also emphasizes the evolving landscape of dental practices with technology, reshaping how dentists approach patient care.

6 snips
May 17, 2025 • 1h 9min
The Course that Changed Her Career – IC059
“Jaz, I don’t know which course to take?”
“Should I do Aspire Academy, Kois, Chris Orr or Paul Tipton?” (all great courses and legends by the way!)
Of course its confusing – there are now more ‘Level 7 Diplomas’ than Dentists!
There are also lots of biased testimonials – surely they can’t ALL be the ‘best course I ever did?’, right?
So just HOW do you choose the right postgraduate program to elevate your skills?
What mindset helps new grads thrive, especially when they’re feeling stuck?
This episode shares Lakshmi’s decision making as she opted for the RipeGlobal Fellowship.
Lakshmi’s journey is a perfect example of how the right mindset and a strategic approach to education can transform your dental career. Jaz and Lakshmi discuss her experience of choosing the right course, enrolling in the Ripe Global Restorative Fellowship, and the challenges she faced along the way.
They also talk through the importance of ongoing learning, the impact of mentorship, and how Lakshmi’s mindset shift helped her grow as a dentist. Whether you’re a new grad or seasoned dentist looking to upskill, Lakshmi’s story will inspire you to take control of your career growth and make the most of every opportunity.
https://youtu.be/waC_kQJhcio
Watch IC059 on Youtube
Book a free video consultation with the RipeGlobal Team to see if this course is right for you: protrusive.co.uk/RGdiscount
This is an affiliate link that gets you 20% OFF if you enrol – but you first need to discover if it’s the right course for you (it involves treating a manikin in your own clinic!)
Need to Read it? Check out the Full Episode Transcript below!
Key Takeaways:
Hands-on experience is crucial for building confidence in clinical skills.
Finding the right practice is important for professional growth.
Investing in continuing education is vital for skill enhancement.
Mentorship plays a vital role in navigating early career challenges.
A supportive team can significantly impact a dentist’s experience.
Understanding one’s learning style is key to effective training.
Practical learning enhances engagement and application in real scenarios.
Balancing time commitments is essential for managing a demanding course load.
Choosing a course that aligns with one’s career goals is vital for success.
Maintaining a passion for one’s work contributes to success.
It’s important to reflect on personal growth and set achievable goals.
The journey in dentistry is not linear; expect ups and downs.
Highlights for this episode:
02:29 Lakshmi’s Journey and Dental School Experience
06:45 First Year as a Dentist
12:01 Finding the Right Practice
19:49 Considering Advanced Courses
25:36 Choosing RIPE Global Fellowship
29:21 Lakshmi’s Hands-On Experience with Ripe Global
37:40 Challenges and Growth in the Fellowship
42:37 Balancing Life and Professional Growth
52:57 Mentorship and Personal Development
54:41 Future Aspirations and Final Reflections
This is a non-clinical episode without CPD. For CPD or CE credits, visit the Protrusive Guidance app—hundreds of hours and mini-courses await!
Stay up-to-date with Dr. Lakshmi’s valuable content and expert advice! Follow her on Instagram!
If you loved this episode, be sure to check out another epic episode – Non-Clinical Growth for the Busy Dentist (Your Health, Relationships, and Business) – IC023
#InterferenceCast #CareerDevelopment #BreadandButterDentistry
Click below for full episode transcript:
Jaz's Introduction: Hello, Protruserati. I'm Jaz Gulati, and welcome to the introduction of the Introduction, I guess. I think this episode deserved an extra bit right at the beginning to let you know what's in store for you by listening to this episode. Look, the number one question I've been asked for years and years and years is, which course should I do?
Jaz’s Introduction:What’s the best course you went on? What’s the number one course I should be doing right now in my stage of my career and literally daily basis? And it’s a tough one ’cause I need to do some like discovering about you. I cannot answer what’s the best course for you until I learn more about you. So anyway, back to this episode.
A similar interaction happened between me and our guest Lakshmi. And at that time, some years ago, I recommended that she did the Ripe Global fellowship. And so this episode is all about how it went, was my recommendation. Good. And that recommendation was given to her purely based on some of the things that she requested.
Now I’m gonna tell you now that for every single person, that course would look different based on what’s important to you and what kind of learner you are. Some people absolutely smash through online learning, whereas other people really struggle to get the time and to make online learning a priority.
Some people absolutely hate traveling and therefore the online world is well worth it. And believe it or not, there are some colleagues who don’t really need the hands-on so much ’cause their philosophy is, once I understand what I’m doing, once I know what I’m doing, the one or two times you get to do it on hands-on isn’t gonna make a big difference.
‘Cause really practice makes perfect and it’s important I get stuck in with patients and develop that over the next few years, whereas others absolutely need must have loads of hands on. Otherwise they don’t truly grasp the concept of what they’re learning. So everyone’s different and we’re very fortunate that we’ve never had more courses on the planet than today, honestly.
And that number is probably going up and up and up. There are courses everywhere, which actually makes it a bit of a challenge. It confuses us even more about which one to do. Now, I dunno exactly about those in Australia, USA, India or wherever you are in the world, but in the UK we have some brilliant educators.
Like I never did Aspire by Richard Porter and Raheel. I never did Chris Orr’s Continuum, but these are some huge courses that I always hear great things about. Also, Monica Vasan Continuum. So, so much great choice in the UK. Also, shout out to the ACE Academy in London. Look, the list is endless.
There are some great courses out there, but what I want to think about is to decide what’s the best course for you. Figure out what kind of a learner you are. Speak to as many people as you can who’ve done the course. See if it works out with your family life and your logistics and your geography. Try and find out how many people are at the course and what’s like the ratio between educators and learners.
For me, when it gets to more than 12 learners per educator, on some course I’ve been on, like in hotels where there’s been like, 30, 35 delegates and one educator, I haven’t been the biggest fan of that. I also wanna know what is the educator doing? Like how much do they care about your success?
It’s a difference between you being on a course and every opportunity, the educators like somewhere else. Their minds elsewhere, they’re on their phone versus the educator being in your face and really wanting you to grasp every single concept and what are the values and what’s the person like, what is that educator like?
Are they your cup of tea? Can you relate to them? Do they inspire you? Some of the best courses and where I learned the most is when I actually really admired the person. This person inspired me in their personal life and their philosophy and their values, and I often gain more because of that. So please don’t think that just ’cause we’re talking about the Ripe Global Fellowship, that this may be the right one for you.
I want you to do your own research and find out what kind of learner you are. You should know that I have been an educator in Ripe Global before. I’m a shareholder of Ripe Global and I bloody love Lincoln Harris, Michael Frazis, Michael Melker, all these guys behind Ripe Global. And I think it’s an important duty for me to tell you that before we dive into the episode.
And one last thing, just yesterday, I was at my wife’s graduation, right? She got awarded her masters in pediatric dentistry at the Eastman Dental Institute. Very, very proud of my wife. It was no easy feat. It was very tough, with two kids. She was exclusively breastfeeding my second born during her final year, and she came out with a distinction.
So ever so proud of her. And for her, the MSC was a great choice. She liked having that contact time. She was able to do her like online lessons when there wasn’t any contact time. But was there much hands-on? No, it was a lot of reading and research and that kind of stuff. You have to relook at these programs.
Do you actually get to treat patients or not? So there are really pros and cons, but now some of the opportunities she’s getting available to her because of this master’s is very impressive. It’s very good. So there’s no one course that maybe ticks all the boxes and you have to balance it around, your family, the cost of the program, the geography, and all those things.
And I guess we discuss all these things in today’s episode, but if there’s one thing you take from it, it’s about the mindset, right? The mindset of the person or the dentist who’s hungry to learn. I’ve got to a stage in my career now where I was very hungry, early on, I’m still hungry, but now I’m more about quality.
Of courses rather than quantity of courses. And with me having binged so many courses at the start of my career when I go on courses now, it’s these little tiny micro details that mean so much to me, right? I’m not getting tons of information. I’m picking up these few gems that I can implement straight away and they make the course fee entirely worth it. Anyway, I’ll stop blabbing. Enjoy the podcast. I catch you in the main intro and then again, in the outro.
Teaser:Managing life as well as being a dentist and still having to be like everything’s absolutely fine and help everybody else when you might be having like multiple things going on. And it’s not like I’ve been a course junkie.
I’ve definitely like cherry picked, like the ones that I definitely wanted to do. But it was really overwhelming on the front of- In terms of choosing the course, it’s been great. A lot of growth, but there’s not much for work life balance. I think it really helped living at home at that point. ‘Cause I didn’t realize, I think if I wasn’t living at home, I don’t think that that option would’ve been there to just drop that much amount of money towards something. But at the same time, when you look at these MSCs and MClinDents and all of these things, it’s quite a lot less. For your growth.
[Jaz]Over a year ago, a young dentist reached out to me on Instagram and she said to me, Jaz, which course should I do? Now, I get lots of such messages and usually I try and find out what they’re interested in learning and I give them a range of different courses and educators that I respect.
But Lakshmi knew what she wanted. She was looking for something very practical, and she really wanted to learn from the best. And so at the time, I took a risk and I made a recommendation. Now, why is that a risk? It’s risky because even though I’ve recommended some good things to you in the past, like which UV torches to buy to identify your composite or the coffee mug heater, I told you guys about to heat your mirrors, heat your composite.
Thousands of you purchase a Cosori mug from Amazon that even went outta sale several times. But then there was this one time I recommended this caliper. It was a caliper to measure the width of teeth such as urine sizes. And unfortunately, I had some people say, oh, you know what? The calipers, the tips were too fat, Jaz.
The tips were too fat. And I felt bad. I felt sad that I made a recommendation and it wasn’t amazing. And so now the course I was recommending to her was a really sizable investment, but she did listen to me. She booked a call with Ripe Global and she ended up enrolling on their restorative fellowship.
Fast forward a year, and I meet her at the BACD conference, and I finally get to ask her, well, how’s it going? And I’m pleased to say she had some good things to say. She’s very thankful and she’ll share everything about the course and stuff. But beyond the course, it’s not about the Ripe Global course.
Or this course or that course. It’s about the mindset because what I really want you guys to tap into is Lakshmi, a young dentist mindset. I think she’s very mature and I think we can all learn from her, especially if you are in dental school or a new grad, and maybe you are in a tough spot in dentistry. You’re not enjoying what you do because Lakshmi went through that.
She says everything about her journey in this episode. I want you to experience her growth mindset. I also ask her what was going through her mind at the time? Was she considering a Master’s? Why didn’t she do an MSC? Why didn’t she pick any of the other courses? And of course, going deep into what’s good and what’s not so good about the Ripe Global fellowship.
Hello Protruserati. I’m Jazz glarier. Welcome back to your favorite Dental podcast. This episode is with Dr. Lakshmi Ranjan, and I really hope you learn you gain from her journey. This is a non-clinical episode without CPD, but if you want CPD or CE credits, we are a PACE approved provider. There’s hundreds of hours waiting for you on the Protrusive Guidance app.
The website is protrusive.app and you can get CE for the episodes and also my mini short courses and that’s all there as well. As well as the community of the nicest and geekiest dentist in the world. Hope you enjoy it and I’ll catch you in the outro.
Lakshmi Ranjan and welcome to the Protrusive Dental Podcast. Great to have you here. It’s a frosty evening, late night recording. You’ve been telling me how you had like a day off, but it’s never really a day off. It’s been adminy, it’s been video-y, it’s been treatment planning, all that kind of stuff. All the good stuff that we signed up for really. Tell us about your self Lakshmi.
[Lakshmi]Thank you. Thank you for having me on your wonderful platform. Firstly, it’s a round circle, full circle moment, a bit by myself, then. So born and raised in London, essentially. Went through the normal hurdles, you’ll go through to get into dental school. Bit of a different energy with me ’cause I was also quite an avid dancer. At that critical 17, 18 age, so it was either dental school or backup option was literally be a dancer. Got into dental school.
[Jaz]What kind of dance did? We had to talk about it. What kind of dance?
[Lakshmi]So I did South Indian classical dancing and then was like competing and like went on BBC on dancer and then did some stuff on channel four and I was just really into it. So I definitely knew what it was like to have a discipline and be very rigorous in it to get to a semi-professional level, which on that end, on my parents’ end to be, to let me do a competition like that at the age of 18 when you are doing your A levels to like get into dental school is a very critical decision they took there.
But anyways, it all happened in that year, essentially got into Bristol in the end, weren’t there for five years. I was caught in the COVID trap, so graduated 2020 and we’d literally just done our writtens in January. So we just had the last leg to go. It was literally the vivers and we were out. And then COVID hit May, March, May time, I think. So that got really dragged out. That little last leg that you really wanna just get through dental school with.
[Jaz]Everyone says that my year was the year that got affected the most kind of thing, and do you think you were that year or you, do you think the year below you?
[Lakshmi]I would say it was the year below. We just made it out. Luckily, I was quite on it with reaching my totals for whatever our totals were for each. Type of procedure. I wasn’t really a last minute.com gal, so I was actually okay. But I think the year below really did, and onwards probably suffered a lot more on the practical side of things.
[Jaz]I ask all dentists this question by the way who come on all like relatively recent grads. I would love to know like how many root canals did you do? How many crowns do you do, if that’s okay. And just some of the answers we’ve had from American grads that you’d think that if someone’s in US, they’re doing like a million crowns like a day. But they’re really not. And it’s an international problem, not just in the UK. So what were your totals like?
[Lakshmi]Mine were actually okay. I think root canals did suffer. I probably did maybe two incisor root canals and I got as far as orifice opening for the molar endos ’cause we had to like do it stage by stage.
So I’d never actually completed a molar endo and there was no kind of going back and being able to do that because COVID had occurred. But obviously we’d had it done on loads like typodont teeth in the labs and I think they were confident enough in me that I’d done. So I think I’d done like a couple premolars and a couple incisors, but that was about it really.
[Jaz]Crowns?
[Lakshmi]Crowns, I can’t actually remember. Probably like four or five.
[Jaz]Surgical extractions?
[Lakshmi]Surgicals, I honestly, I can’t, I don’t think I’d really done a surgical, no. I hadn’t like actually divided the roots myself and delivered each route. I’d have like a supervisor there who was like telling me what to do, but it’s not like I’d done that as a total, no.
[Jaz]So that’s fairly typical from what I’m hearing. So it definitely is an international issue. It’s not just here. So, you come out, you qualify. Obviously COVID and stuff happened, but already you were qualifying with less experience so that hunger, that desire to improve yourself is there. What was it like for you when you qualified?
[Lakshmi]Rather than hunger and desire as more anxiety, to be honest. I mean, you are kind of struck by COVID. You dunno where you’re gonna be placed and like people are dying left, right, and center. So in terms of where I got placed, luckily I got placed in London so I could come back home.
Thank God. I was like praying like please ensure that I’m near home and it’s not too bad of a commute in. And my trainer was really, really good on the front of being quite hands-on, but I was their first trainee. So they’d never had a trainee there. And you couldn’t go in the room that frequently, so I couldn’t shadow my trainer either.
[Jaz]Oh, sucks.
[Lakshmi]Yeah, it was really tough. But luckily I was in a really good scheme. We sort of got like an integrated DCT sort of style training year instead. So they placed us one day in hospital in a restorative department so you could shadow like the restorative dentist or surgery maxfax, depending, because you couldn’t have that many people in your clinic at that time.
So it was okay. But, I think once things started normalizing again, I was in a really high needs clinic as well, so the endos and the extractions were just running on tap and fast, to be honest. So I’d done a few surgicals by that point, and my trainer was really into extractions as well.
That’s something I’ve learned that I’m not really a big fan of. Like I’ve rather do an endo than an extraction, but essentially it was a bit slow running at the beginning and then it started picking up. But I was quite grateful for that because I still don’t understand how people go from like three hours in university for one person.
To then like 15 minutes and 30 people a day. And there’s no, like, you’re not taught the structure of how you should present an examination or how you should do this or that. Like you are on clinic and you have a supervisor coming and checking now and again. But in terms of the basics of being a dentist, there’s no like handbook on it.
[Jaz]Which is why the year exists. And I think it’s good that in the UK we have that and that most people take, you don’t have to do it, but if you wanna have a performer number be able to work at the interest, then yes, lots of people do it. Most people do it. And I think it’s a nice bridge.
And especially if you have a supportive trainer, it’s good. So it sounds like you got the right type of experiences you did, did eventually hit those high numbers of patients, which, you know what? You kind of have to do your time. You kind of, there’s no shortcut. You have to experience that.
You have to experience the headache that you get at the end of the day. The notes that you have to catch up with. Oh my God, did I just do three extractions, two root canals, and a and a crown prep today kind of thing. Because that’s a quick way to learn.
[Lakshmi]Exactly. And I think a quick way to learn is when you are struggling. I think in that year it wasn’t easy. Like I think because I was their first trainee, like they were also understaffed because of COVID. They didn’t have a DSLR camera at the time. I would have a different nurse every single day. I’d be put in a different room every single day, and then you didn’t have certain piece of equipment available, so there was a lot of just working stuff out on the spot because you had no other choice.
And I think, through struggle that you then appreciate the little things of like, I had to manually do all my referral forms and check that they were sent myself and sealed them in an envelope and put them in the thing rather than ensuring that there is a triaging team on reception to do that.
Or like just the really little things. So it was a really like triumphant year of like clinical growth, but it was also an awakening of like appreciating how much teamwork is involved in the job and how multifaceted you need to be in like having five conversations at the same time. At all times of the day.
[Jaz]Very, very true. I mean, it sounds like most people you got thrown in the deep end, but like you got out of it, you grew and you realize that okay, perhaps the systems that are in place at the practice you’re at when weren’t so efficient. ‘Cause obviously we’re at now, I’m hoping that it’s a bit more digital, it’s a bit more automated, it’s a bit more people do the things so you can focus on the bigger things on the clinical dentistry aspect of it.
Where did it leave you at the end though? What were you craving? Were you looking for an associate position? Were you looking to go back to hospital? Where was your head space at that time?
[Lakshmi]So for me personally, I didn’t really wanna go into hospital because again, I think it’s really good with the specialties or exposed to, and are not bashing anybody who’s there. But I felt like the culture in hospital can be quite, you’ve gotta have quite thick skin sometimes. It can be quite harsh and you are thrown into situations sometimes and then you can be told often for no reason when you’ve just turned up in a particular situation. So I felt that it wasn’t really helping me grow as much as I’d like. So I knew I didn’t wanna go into hospital.
[Jaz]Did you listen to the episode I did with Ameer Allybocus on trials and tribulations of maxfax?
[Lakshmi]I haven’t actually. No.
[Jaz]So if anyone’s listening, just what luxury is saying is so true and some great stories, some experiencing death in a maxfax unit that’s tough. And experiencing that thing where you turn up and you just get a bollock left, right, and center from a consultant. Like all of that is all that good stuff that you can write a book on just that episode I did with Ameer to shout out to Ameer. But you’re right, there are some challenges and a lot of people are grateful for their maxfax year or their DCT year.
So it’s not to say that just ’cause Lakshmi said this doesn’t mean you shouldn’t do it kind of thing. But Lakshmi’s got a great point that it might not be for everyone and you are a smart cookie ’cause you realize it wasn’t for you. So what were you thinking to join the rat race and get, go into the associateship?
[Lakshmi]Yeah, so firstly, I just wanted to leave the practice I was in ’cause I could just see that this wasn’t an area for me to grow. And there was a lot of things I had to do in order to just be at a baseline level associate to get the work done. So my aim was to just be somewhere where things were a bit more organized, just to have a practice manager, someone to just organize stuff and ensure that the team’s running okay.
And I think for me it was practicing what I’d learned. I just didn’t feel confident enough to go into these like, big practices already when I already in the clinical area. I just wanted to be by myself and work things out and have a basic understanding of how the practice should run.
Because I wasn’t really exposed to that. In your training, you’re still doing admissions, you’re reflecting on everything. You’ve still got supervisor to report to. I think that year I just wanted to not sign up to anything, just go free Rodden. Till from the age of like 11 to 23. At that point, you’re just submitting things and doing exams all the time.
So for me, I was like, let’s just have one year of just going with the flow and see how that goes. So yeah, mixed practice was the aim with great good support. Somewhere where a team would be there for you to still get clinical advice on things. Digital scanner, rotary, endo equipment, just the basics.
Like not a major target where the principal’s gonna be pressing on you to do X, Y, Z every month. And thankfully, yeah, they were really supportive on that front and they weren’t pressuring, they were really good with equipment.
[Jaz]How did you find this place, Lakshmi? Because a lot of people say, oh, I dunno where to look for to find my place. So was it luck? Was it forced by you? It was make your own luck. Was it destiny? How was it?
[Lakshmi]It was a combination. So I don’t really have any family in dentistry or really any friends in dentistry other than people from dental school. So it was really through BDJ jobs, where I was just kind of searching every day of like what jobs would come up.
Asking around, like on my scheme as well, if there are any job opportunities like, we had really good educators on the London schemes. So yeah, I would go and ask them like if there are any openings anywhere and they would suggest you should email these people or send your, CV to them was building a portfolio of work with the camera that the practice eventually got those little things.
And yeah, it was just mainly through BDJ jobs to be honest. I wasn’t too fussed like, like on the location and like cohort patients I was seeing and things like that. I was just focused on clinical dentistry and just ensuring that what I’m providing or the care I can provide is a good enough standard in the first place.
[Jaz]And did you feel the DF1 year, which had the study days and all those things, did that now prepare you? Or did you feel as though you now need to supplement some courses at this stage?
[Lakshmi]So at that stage, I didn’t wanna sign up to a course because I was, firstly, you’ve just come out of COVID and we didn’t even get to celebrate final year or go on holiday or like anything to relieve that pressure and stress that you’d built up that entire year.
So for me it was just kind of a release of like finally I can go away like a year and a half later and just go with the flow of life ’cause you’re just on this treadmill the entire time. So, no, I didn’t think, but I definitely knew it was only gonna be one year of trial running this and then see how I feel at the end and what to hop onto and I wasn’t really-
[Jaz]And what did that year teach you then?
[Lakshmi]I think it taught me that like you can de-skill very quickly. I was quite demotivated and you are really run down and exhausted ’cause it’s just like a high turnover of patients every day.
[Jaz]And also how about how quickly you can like pick up bad habits?
[Lakshmi]Yeah, very quickly. ‘Cause again, it’s you by yourself in that room. So luckily I am the type clinician where if I identify that I’m not gonna be very good at doing something for you. Like I’d either stabilize and pass you on or stop at that point and say, look, you might need to consider something else rather than continue with the shortcut idea of doing this filling with an open contact point or something.
Do you know what I mean? So I think I definitely realized by the end that I need to get onto something that covers the bread and butter of dentistry to a high enough like baseline understanding. Does that make sense across all areas? Because I learned from the study days there was like photography was one bit, then you’ve got posterior fillings, and then you’ve got this concept of onlays coming into the equation now when all you’ve been exposed to is crown preps. And then you’ve got smile design and aesthetic work, which was a whole another domain and what I was-
[Jaz]Let alone the communication to actually get patients to that point where they’re open to discuss those things with you and to actually communicate fees and sequencing and how that actually works in amongst all these the busy day that you have and then you have that kind of different type of appointment and nothing prepares you for that.
[Lakshmi]Absolutely not. And you’re not gonna have that understanding in NHS dentistry. Like, it’s just not gonna happen because it’s a completely different line of work. Like it’s still really got its own way of doing dentistry, but you simply just don’t have the time and facilities to advocate to those aesthetic plans.
So I kind of got through that year and then realized all these things and I just was like really demotivated and I wasn’t like enjoying my job as much. Really. I was kind of like going in, seeing how it would be. The other associates were really good doing their own thing, but it’s not like they had that kind of fire for dentistry either.
[Jaz]Did you feel like, actually, if don’t mind asking, did you feel like you were practicing defensive dentistry?
[Lakshmi]It was just a lot of stabilizing really, to be honest.
[Jaz]The area stabilizing the basics just to make sure the active disease is gone. Nothing fancy from there. Mostly single tooth dentistry.
[Lakshmi]Single tooth dentistry, dealing with the problem, referring them to the hygienist for perio most of the time. And then otherwise, yeah, just normal kind of day-to-day dentistry. There really broken tooth at the back. You need a crown. Don’t really do that many crowns anymore, but back then it would be like a zirconia crown or something as the least invasive thing.
So, but I didn’t mind at the time because you’re still kind of getting your clinical skill up, you know? And once I moved practice as well, the rate of endo I was doing really dropped. So I was in two practices. One was very high needs and exempt patients with limited English. So that in itself was just a rollercoaster ride because I was doing a high churn of dentistry, but very exhausted with communicating.
‘Cause I just didn’t really understand what I was trying to say. And then I had another, the other practice was like low to mod in terms of needs. But I was doing a lot more kind of posterior work, composites, crowns, things like that. So I think it was really good for those three years to just really practice all areas of dentistry.
Like one, I was doing loads of extractions at endos at, and the other one I was like doing composites at and realizing that I couldn’t get a contact point and last was dreary. But I was listening to you a lot actually during those years because you’re not really getting any guidance on like what the next step is or where to go and who to turn to when you’re having clinical.
[Jaz]Uncle Jaz was there for you.
[Lakshmi]Uncle Jaz every day. Especially in my foundation year. Yeah, because there wasn’t really a lot of guidance then.
[Jaz]So what changed then?
[Lakshmi]So essentially got to 2023. I was like, the year’s done. Now I’ve realized, we’re de-skilling. I’m not really enjoying this, where to go. But then when exploring these courses, that’s when I messaged you because I was actually considering the Spear courses or the Dawson ones
[Jaz]It’s interesting how you’re considering already like hats off to you ’cause you are already considering going abroad. Whereas most people like, okay, which is the next course I can do that’s within a 20 mile radius of me kind of thing. So what made you think already to the states wide? What did you, here, how did you get this perception that you may need to go away? ‘Cause not many people think that at that stage of their career.
[Lakshmi]Of course. And I think a lot of it fed into my principles at the time. ‘Cause I was asking them like, what do you do? And they were like, why don’t you learn from the people you taught, the people who are doing the courses in the UK. So, I can’t remember who I learned from, but it was one of the like sphere kind of-
[Jaz]Spear, Kois, Dawson, Pankey, some of the good folk in the States.
[Lakshmi]Yeah, one of them. So he was saying, you should go there. But then my thing was, now I’m not really the best traveler and whatever I learn in America, like, how can I apply it in the UK when I’m already struggling to apply in the UK in the first place?
And I just didn’t want to just like focus on one area. And I think the dance background really played into that because when I was training, you didn’t go and see your trainer like every single week. Like I would go to a workshop with the top dancer at that time, they’d teach you whatever the repertoire was.
You’d take away what you needed and go away and apply. And it’s just you practicing in your own time and then just going up the ladder, really. So I already knew, I wanted to go to the best of whatever there is. Sort of baseline bread and butter start to-
[Jaz]I love how you applied that from your dance. I love that you took that as a life lesson. That, okay, you need to learn from the best but then you gotta do the reps. There’s no shortcut. You have to get the reps in just like you used to practice. I imagine late into the evening when you’re doing your dance. Sounds like you got quite serious about it, but now you have to recreate that in the dentistry.
And the only way you could do that is practicing on your patients. So I like that you are already thinking about, okay, if I go here, but how can I actually get those reps in once I’m back and apply it?
[Lakshmi]Exactly. And I tell everybody this, that having a discipline or like a background hobby or something is really, really important because you offer from a young age already, you’ve already developed those innate skills to identify those things.
Like it’s a problem of being a perfectionist. And then there’s the identifying that, this doesn’t just come overnight. Like it’s repetitions of it and it will modify over time anyways, messaged you being like, I was considering this. What do you think? But generally, I think my main prerequisites were hands-on covering generally most grounds of dentistry to a baseline degree and relatively affordable.
‘Cause I was looking at all these courses and they kind of focus on one area for like an entire year and it’s like 10 K for that entire year, but it’s like a couple days every month that you’re just going in for this weekend and then there’s like kind of not much connection in between.
And then some of them you’ve got to do one course first, and then after you’ve done that, you can then sign on to the next one. So I just felt like everything was in pieces and it’s already busy being a dentist and then having to think, how shall I systematically organize which course to do where, and understanding what type of learner you are.
I knew that I’m not like a, let me read this study and then I’ll be able to do the online prep tomorrow. Like, I just knew I was more of a visual, like looking at someone, do something and then see how they rectified whatever problems they had and then apply. So more of a visual learner.
So it was a combination of understanding all these different aspects and then financially I was like i’m going to invest. I’d already made that decision. ‘Cause I think I do find now when I’m talking to people on considering ripe or whatever course, they’re like, yeah, let me think about it. ‘Cause it’s like just a lot. But I’m like, you need to invest in yourselves though.
[Jaz]Did you know that when you qualified that you’d have to spend so much money? Because when I qualified, I remember being like, maybe I was like in fourth or fifth year, I was shadowing who eventually became my principal in a very nice clinic in Richmond.
And I said to Hap like, Hap, any tips you wanna give me? And he gave me some tips like, forget everything they’re teaching at dental school. Like, literally at dental school he tells you forget everything they’re teaching at dental school. And that was a shock to me. And then he was like, be prepared to spend a lot of money.
And even that was like a huge shock to me. He said, spend, you have to, 50 K upwards, he said to me. And I almost fainted. I was like, what? Really? This was all a big surprise to me. Did you have that kind of talk from someone? Did someone anchor that actually you need to spend a lot of money here to be able to break free and acquire the skills to then apply?
Interjection:Hey guys, it’s Jaz and interfering. At the time when I made the recommendation to Lakshmi, I did so because I genuinely believe in the people behind Ripe Global. Not only am I an educator on the Ripe Global website, Lincoln Harris and Michael Melkers have been huge mentors and friends for me, as well as the inspiration of Michael Frazis, who I got to meet recently in London, and so I know they have some great people on board.
I’ve been following the Ripe Global journey for almost 10 years now. I’m a shareholder and I’m really proud to see what Ripe Global was achieving. I think they truly are democratizing education. You no longer need to fly places to learn because of their innovative methods using the mannequin head and world class educators now, Ripe Global, are doing a promotion at the moment to get you 20% off one of their fellowships.
That’s a big amount, and it’s not up to 20% off. It is a guaranteed 20% off. The way you access that is to book a call to make sure you are the right candidate, to make sure it’s gonna fit in your work-life balance and that your learning style is conducive to it. If you would like to take advantage of that discount, just mention my name and they will apply the 20% for you.
You can book the call at protrusive.co.uk/rgdiscount. protrusive.co.uk/rgdiscount, all one word. I’ll also put in the show notes so you can click through. Now, let’s get back to the main episode and dive deeper into Lakshmi’s experiences.
[Lakshmi]No, they didn’t actually, and I didn’t really anticipate dropping. I think it really helped living at home at that point. ‘Cause I didn’t realize, I think if I wasn’t living at home, I don’t think that that option would’ve been there to just drop that much amount of money towards something. But at the same time, when you look at these MSCs and M MClinDents and all of these things, it’s quite a lot less for your growth.
[Jaz]Yeah. MSC is like for a year, MSC, it was 18 grand when my wife did it a few years ago. Now it’s gone up to like 26, 28 grand. Like for an MSC, just, I’m talking about British pounds. British pounds obviously, but all over the world. Ripe Global.
We could talk about it ’cause we could talk about how much you paid because it’s on the website and everything when you were considering it. Obviously it’s important to look at the fees, but it’s also important to look at okay, what you’re getting out of it. So we’re gonna talk about what you were expecting and whether it met your expectations, but how much you have to pay and how do you have to pay it because like you said, if you weren’t living at home, then sometimes we have to defer things for the future when you are a bit more financially stable.
For me personally, I was living at home when I first qualified. Therefore, with my first paycheck, I was able to buy a DSLR, body lens, et cetera, flash and crack on with photography. If I wasn’t living at home, that would’ve gone towards rent. So it’s a massive help and very grateful for anyone who’s had that. And that was obviously part of your journey as well, but how much money was it?
[Lakshmi]Yeah, so comparatively to the other courses, it was actually less per year. So the way it works with them is you can either do it in finance, but it’d be with interest. So you’d be paying a lot more, or you just pay it off in bulk? So if I paid it off in bulk in Australian dollars, at the time I think it was like 20 K. So that in pounds was like 18,800.
[Jaz]Is it 20,000 Aussie dollars? I think it’s two to one. So that’s about 10,000 pounds?
[Lakshmi]No, no, no. It was definitely like in the 18 sort of range for two years. 18.7 to 18.9, or maybe it was like 23, 24, I can’t really remember. But in pounds it translated to like 18.8 k ish.
[Jaz]Okay, so 18,000 pounds. You paid for two years. So it’s about 9,000 pounds a year. Which is okay, fine. Which is pretty competitive-
[Lakshmi]More like, yeah, 19,000. So yeah, which is pretty good for two years. It’s like nine and a half K for the amount that you-
[Jaz]Depends what you’re getting out of it. And so, which is what you’re gonna go into now basically?
[Lakshmi]Exactly. So what I was comparing it to was the equivalent for one year for some of these other restorative courses, which are still really, really good. But you are only going for in, for like two days, like once a month for like a few months for that entire year.
And then that was it really. And I suppose you’d get the study materials per weekend, but between that time there was no like interaction or anything. Whereas here, I think what really stood out to me was that you got four hands ons per module. So that’s like eight.
[Jaz]And how many modules are there?
[Lakshmi]So there’s four modules. Okay. There’s two per year. You’ve gotta do a pre-theory challenge before the actual hands-on. And each hands-on is like eight hours long. So they go from-
[Jaz]And people have no idea about, it’s like when you came to me, you had no idea about Ripe Global. I told you about it and then you were like, oh, what the hell is this kind of thing.
[Lakshmi]Yes.
[Jaz]I knew about it ’cause I was a huge fan of what they were doing, the whole Facebook group initially set up from years ago, obviously a big fan of Lincoln Harris and what he’s taught me. And so I knew that if I was starting my career again, that was a course I would’ve done by the time Ripe Global came out, I had hundreds of courses under my belt already.
But when someone like you, when you came to me and you asked me, and you told me what exactly what you’re looking for, like really practical. And that’s why I said, okay, you know what?
[Lakshmi]Bread and butter really exactly.
[Jaz]And foundational, and I know how much hands-on they do, which is a big part of the ethos because that’s why I recommend it to you and I’m glad is when I recommend something. I’m taking a risk ’cause people then come, oh yeah, Jaz recommended this and I didn’t like, so I take recommendations very seriously. So it is great to see you on the other side and I wanna just talk more about that because for a lot of people, I wanna prepare them for the challenge, the amount of work it is, it’s not like you sign up to a course and you’re gonna get to a five star buffet and chill and drink the sparkling water, which no one seems to drink, but it’s there.
You can drink it. It is a lot of hard work, which perhaps you need to warn people. I don’t want people to go and say, oh, Jaz, Lakshmi came in the podcast, she said some good things about Ripe Global, and then you end up doing it, but you don’t prepare for amount of work involved. So give us a breakdown of how is structured and then how much commitment is required at each stage.
[Lakshmi]Yeah. So once I got off that kind of chat with you. I had a call with them and they kind of talk through how it works and you have to have a DSLR before you start. Now the thing is, when I was starting, I was in the process of moving out.
So like I couldn’t afford to go and buy a DSLR myself at that time ’cause I just paid for this course. And I think I just got a car at that time as well. And I was just about to move out too. So it was all sort of happening at the same time. So I actually borrowed my principal’s 20-year-old DSLR, which he kindly let me borrow for like a few months and then I bought my own like six months later. But you have to have that before you start. ’cause then-
[Jaz]I like that. I like that they enforce that because there’s no point in you coming on and then you don’t have the means to communicate the cases and show the photos. So I think it’s a sign of a good course that you need to have this as a barrier to before you come on.
[Lakshmi]Yeah. And I think what a really beautiful moment was when I messaged you at the time, I felt like another main thing I didn’t mention was the loneliness in the profession. I just felt very anxious, de-skilled, lonely on the front of like, there’s no one who can understand what I’m going through right now.
It’s very defensive in our profession as well. You never like go to a clinician and be like, this went wrong for me. Help. It’s more like, don’t even mention it. But I’m very open book and like, what do I do in this situation? So fast forward. What I loved with the course is that they’ve got mentoring.
They have a lot of checkpoints in checking that you are okay. You are following what the kind of schedule is ’cause it can be really overwhelming. They have different groups for you to message into in their own app for camera problems. If you dunno how to set something up, they will call you and go through that or get one of the educators to go through it with you.
And so it’s not just the clinical. So they talk to you about communication, treatment, planning, how you should even do an examination with all your photographs, the different views and how you should set up your camera. Troubleshooting problems on the actual hands-on, free, hands-on. You’ve got to do all those different views.
So buccal, lingual, palatal, occlusal, pre-op, then post-op and like each of the different stages.
[Jaz]So just make that tangible for me so, you pick a patient, like for example, posterior module. You take some photos of a patient and then you submit that and then you do the dentistry. You submit that. Like just make that clear.
[Lakshmi]So essentially in terms of the actual course, you have your phantom head, so you’re not doing anything on a patient when it comes submissions for the actual course hands ons. So mine was called Jim, Jim G.
[Jaz]Do they name it or do you name it?
[Lakshmi]They name it, yeah. Jim came with a sunglasses in a briefcase that we’ve had a lovely relationship for the last two years, but essentially, yeah, so you do your hands on, on the phantom head in your own time. So another key thing with Ripe is that you have to have a discussion with your principal. That they are happy for you to use the surgery out of hours. Like on a Saturday.
[Jaz]So you’ve gotta have the keys and have that trust and allow you to use the handpieces, use everything. So using the tools in the clinic. How about the nurse or do you have this option?
[Lakshmi]You need the nurse. You just need them to say, okay, you could have the compressor on for that many hours and have the key to the, luckily I was actually doing Saturdays at that time, so it was like fine and every other Saturday. So there were some days where it’d be a 12 hour stretch of just clinical dentistry.
But essentially, yeah, you are on a posterior module. The first one was crown preps, though, you do your one crown prep and you send all your views and you are played it onto this PowerPoint with all the different views that you need to put on. They will then give you a video analysis of that. So when it gets your actual hands on, you have an idea of what you need to improve on.
Then that hands on, you’ve gotta do 16 crown preps, over the course of like six hours. So by the like I think the 16th one. Yeah. You’ve just got muscle memory on what you’re doing. But it was really strenuous. Like I couldn’t lift my head up the next day because I was like bent down for that long.
And again, at each stage you’ve got to take a photo and send it to them. So, occlusal reduction, interproximal, buccal, lingual, you’ve got to-
[Jaz]Is this like synchronized or like you said you had to do 16 preps, but is there someone like from what I’ve seen from the marketing is like you are there like on a Zoom with them or like a web meeting with them, right?
[Lakshmi]Yeah.
[Jaz]WebEx maybe. And so you’re doing those 16 preps, but then as well as that live interaction and they’ve got a little camera watching your prep, right? But then you’ve gotta submit the photos as well. Is that right?
[Lakshmi]So essentially you’ve got your box with the phantom head. You put your laptop on the box and your phantom head is on the chair. So you’re not doing all 16 and one go. You do it like quadrant by quadrant. So essentially the first one is a guided one where they’ll say you need to send us occlusal reduction first and then into proximal and like each step, essentially you’ve gotta send them separately so that they know that you can follow instructions and then you are guided on keeping the preps parallel and how you can do them quickly and efficiently and keep the margins minimal, et cetera.
And then the next one will be timed. So then you get on with it, and then you send them the rough prep and then the polished prep. Then the next ones they just say, just move on and do it in your own time. And then they’ll do one more that is like timed in like five minutes. And it’s really shocking to see where your prep starts and ends in that time.
And I think another thing is because they’ve made you do like, that was a crown prep day, and then it was basically the same thing for class two cavities, but like with different matrix systems. You then had to do that in all four quadrants. So by the time you’ve got to like the end of that module, you’ve rinsed out like everything you could possibly know for posterior teeth in hand with the clinical videos in the library and all of that stuff.
So I think it sounds really strenuous, but genuinely when you are actually doing it with other people and it’s practical, you can also apply it on Monday. So you are automatically kind of engrossed in what you are doing because you’re like, this is gonna help me out anyway.
[Jaz]I love most about it so far, Lakshmi, is the fact that implementation and being able to apply it is at a higher level because yes, you’re not just like prepping on a model in your hand. Yes, there’s a mannequin, which is a level up, but that mannequin is laying in the same chair that on Monday, a patient will be sat in. So it is in your own surgery with your own stuff, with your own handpiece. That’s correct. Right?
[Lakshmi]Yep.
[Jaz]That’s powerful.
[Lakshmi]And the other thing is you’re by yourself. So like there were a number of times when the suction like died and it’s just me at like 7:00 PM and I’m like, I don’t know what to do. Because usually I just look at the nurse like, you sort this out. So I literally had to be on all fours, like trying to work out all this vent plugs in. So like you are really kind of-
[Jaz]You grow as a-
[Lakshmi]Very quickly, and it was really hard, like there were times initially, I’m not gonna lie, where I was like, why am I doing this? ‘Cause I was just feel like I’m still struggling. I am so having to look inward a lot of the time because there isn’t any other clinician there using the DSLR. And it is just me trying to push myself along. And then the pivotal moment for me was actually the fact that I think Dr. Lincoln actually checks in with each delegate like once.
Like that year, ’cause there’s obviously so many of us internationally and he actually came to London for the BACD as a head speaker that year coincidentally. And I’d already done the posterior module by that point and I think we just started the anterior. So I was kind of getting into the flow again, I was invested in the course, but I could be doing more.
‘Cause I was just starting up and so I just dropped him a message saying, oh, I know you’re in town. I just wanted to say thank you to creating such a great platform. Like I feel a lot more motivated and inspired. Just as a general respectful comment. And then essentially had like a one-on-one mentoring meeting with him where I essentially kind of got chiseled into place of like what you need to be doing to see yourself.
I am now essentially like a year on. So he sort of was like a little ignition at the end of that kind of first year of the course to do additional things to grow even quicker because he was asking-
[Jaz]What a lovely thing for him to do, to meet up. And I know we had a chat about when we were at the BACD and he told me about how he probed you and you asked, are you doing this? Are you doing that? Are you doing this? Are you there? No, I’m not. And you’re making notes and what a lovely thing for him to do.
[Lakshmi]And I was really nervous actually. ‘Cause I was like, this is just so out of the blue. I didn’t really plan this in my week. I usually see you virtually on the screen for like every lecture. And he was like, do you have a vision? Can you envision the practice you wanna be in? And I was like, yeah. And he was like, I’ll eat that. And I was like. No. And then I think he asked me, do you treat what percentage of patients you treat that are exactly like you? Like enlisted all my personality traits.
And I was like, none. And then he was like, would you go to the practices you are at currently have your own teeth treated? And I was like, no, actually, like knowing the type of person I am or I wouldn’t. So he was like really kind of got to you in a particular way for you to be like, actually I need to make a lot of changes for me to reposition myself.
I wasn’t on the Instagram. I didn’t want to be actually, because again, from the dancing and being in the forefront and the spotlight and the kind of backlash you got from the performing arts, I was sort of a bit like, I don’t wanna be in the spotlight again. So then he was like, it’s really critical for your professional growth to have a platform.
So, when you said implement, so essentially the next day I just opened it. Just started and yeah. And then he said, you’ve gotta go to these courses, network, ask them how they got there, do what they’ve asked you to do, and then just keep applying and practicing every single day. And then, yeah, it’s just been a following that protocol ever since. And then we moved on to the veneers module on January. And in hand with Ripe, I was also doing other little courses. So do you know Vish and Aaron?
[Jaz]Yes, of course.
[Lakshmi]So they were doing an associate course funded by the NHS earlier this year. And it was like five day kind of course with like Elaine Mo, Mo Bogar. So they kind of had one day on like examinations, another whole day on rubber dam, another day on endo, another day on onlays. And I think the fifth day was on class two. So basically everything.
[Jaz]At this point, hopefully you felt like this was revision or just seeing how other people do it ’cause you already had now some grounding of how to do on Jim and on your patients. ‘Cause I’m hoping that what you were learning on Jim, you were able to then implement on your patients as well.
[Lakshmi]Of course. And I think it was also having the backing of the clinical video library. So again, when I was there, nobody heard of ripe. And they were like, what are you talking about? And how does it work? And things like that. But you can automatically see when even those educators could see that you’ve learned loads of these pearls already, like how have you grasped all this stuff already? But I think there’s an aspect of also taking the time out of hours and sacrificing. A lot of free time towards more of things to do in your profession, like, there was a lot of-
[Jaz]Well, let’s talk about that. You had the weekends to actually do the out of hours to actually have the lessons and stuff. What other commitments, how much more time did demand of you, ’cause obviously you had some pre-reading to do.
I imagine there’s on demand library or videos, lectures you need to watch, but then what was taxing, what was demanding? Because like, my wife was doing a master’s in peds. And there she was like breastfeeding Sihaan and then studying for this and live webinars and all these papers she had to read. It was tough. How challenging, how draining was the actual amount of content you had to go through within your Ripe Global, is it called a diploma? Or is it a-
[Lakshmi]Oh, you don’t actually get, I don’t know, like it’s a fellowship actually. But you don’t get like a diploma or anything. But I think they’re working on getting that once you’ve uploaded all your cases. So I wouldn’t really say it was like mentally draining on the day to day, but you had to sacrifice a lot of Saturdays. On the scheduled hands-on days and then scheduling again another weekday or sometime in your clinical diary to, not in your clinical diary, but again another Saturday or something to come and do the pre-theory challenge for that hands-on. So it wasn’t demanding a lot of time, like you still had your gym time.
[Jaz]You need to factor in some gym time to the hands on to get the hands on, to do the submissions for them to quality control how you’re progressing. Now it makes sense.
[Lakshmi]Exactly, exactly. Okay.
[Jaz]Which kind of people might struggle, basically? Like for example, imagine like some of the people who you’re doing it with. Would you find it more difficult if you’re a practice owner? Would you find it more difficult if you had kids, like some people have kids and they say that, oh yeah, this is challenging because of that. Or various reasons people might say it’s a barrier, but like nothing worth having comes easy.
But what challenges could you expect if you were to do a, a fellowship like this, which is very fascinating remote learning. You don’t have to take flights, you don’t have to go in to anywhere except your practice, which is pretty cool. But you still have to bake that time in.
[Lakshmi]Yeah. I would say to be honest, like even if you have a family and kids and things, I think it’s quite easy to schedule it in. It’s only really two Saturdays a month maybe where you’d have to, and it’s in the afternoon. It’s usually like two to eight or two to nine or something where you’d have to schedule that in. And the pre-theory challenge is really up to you. They’re not ever really pressuring on, you have to do it by this date and like, if you have a valid reason, which is why I was touching upon the mental health and having a connecting point with them where they’re like, you’ve gone off radar a bit.
Is everything okay? Like, are you really busy at the moment? Life kicks in. If you want to take a pause, you can and then resubmit another time. So there is a lot of flexibility with it, which I loved as well. I’m quite the type to just get it done rather than drag it out. But you know, there were moments where I went off radar, like this year it’s just been really full on that I couldn’t really be watching that many clinical videos or being as present as I was last year which they do pick up on me.
I think they probably have an activity radar on each delegate. And I got a message and was like, we wanna have a meeting with you just to see how you’re doing and how we can help you. And which is really nice. Like I didn’t really expect that either. So I wouldn’t say it’s incredibly surprising.
No, like I think it’s not like you have to read loads either. It’s a lot of practical stuff and visual things. So you can be cooking and watching like the clinical video or the lecture in the background in preparation for the course. I didn’t feel like I had to read heaps or anything.
[Jaz]Fine. That’s good to know about yes, there’s reading, which is important, but nowadays people are seeking practical courses. So tell me, like you were considering at one point some of these courses whereby you go in on a couple of Saturdays a month and then you go back to your practice. But then what you’re describing is you still have to give up a couple of Saturdays. What made you think that you made the right choice, or do you think you made the right choice, but what makes you think you made the right choice compared to some of those other courses?
[Lakshmi]I think it was a lot of factors. So firstly, I loved the fact that they went from posterior dentistry right to full mouth rehab and that incremental growth. It wasn’t just being pushed into aesthetic rehabilitation and then we’re suddenly gonna talk about class two cavities and then suddenly gonna talk about class four. It’s like it was very systematic. So by the time I’ve got to the FMR now, like I’ve got a solid understanding of posteriority, anteriority, how you smile design.
They even make you draw the upper three to three manually. So that you actually understand golden proportion. And then the number of times you’ve done composite buildups on anterior teeth to understand. Nines. On Jim. On Jim. On Jim.
[Jaz]Must have a great smile now.
[Lakshmi]Yeah, he’s great. He’s really gone through a lot. He’s really stood by me, actually.
[Jaz]More importantly, have you now been able to find your Jim out in the world and to help them with their dental issues and give them good smiles? Do you feel confident to implement what you’re learning on Jim on real patients?
[Lakshmi]Absolutely. I think that’s the beauty of it, because you don’t feel as nervous doing it on someone because you’ve done it so many times on the phantom head that your hands sort of got muscle memory and you’re able to identify what to do if it’s not gone particularly correctly at that time.
Because they also instill a lot of use what you’ve got. They give you an equipment list, which you also have to invest in, which is really just some matrix bands here and there and some burs, which you then use for the entirety of the course. So they will give you ways in which you can use different things to achieve different things.
So like, for example, diastema closures, I was only really used to using a TorVM band, you know, and using that repeatedly in different ways to do it. But then, you’ve got talk about the modified mylar pull using the Bioclear matrices. You can use a TorVM bands. It’s not like one technique fits all. It depends on that type.
So that already alleviated a lot of anxiety because you’re like, oh, okay, I can maybe try this way and if that way it doesn’t work, it’s all right, I’ve got this this other way, I’ve got plan A to D available. It’s not just plan A or B because on the hands Sunday you’ve got like 15 other people doing it with you. So you are seeing on the DSLR picture, that’s very zoomed in like the different things that go wrong and everyone’s in the same boat as you. It’s not just you struggling-
[Jaz]And you’re learning from the, not mistakes, but learning from some of the practical errors or refinements of other people. Like is, for example, I imagine Lincoln Harris saying, oh, Maria, look at this. What you’ve done here. You’ve created a J margin and are you all watching that kind of feedback live as well?
[Lakshmi]Yeah. And you have an annotating thing to like do that. So yeah, you are tested on photography multiple times. You’re then made to do it each clinical thing multiple times. They have checkpoints with you throughout the year so you don’t feel alone as well. And they also implemented a therapist for all of us this year. Just to look through-
[Jaz]Like a psychological therapist?
[Lakshmi]Yeah, psychological therapist with better help.
[Jaz]Nice. Oh wow. Okay. I’ve heard a better help seen that, seen some of their ads. That’s really cool.
[Lakshmi]Really, really good. Because I think what’s really not spoken about in dentistry is that, you are like managing life as well as being a dentist and still having to be like, everything’s absolutely fine and help everybody else when you might be having like multiple things going on.
[Jaz]Does everyone have to have a session or just like something you opt into?
[Lakshmi]Yeah, you have to. They’ve got it as an option. So they’re like, you can use it to help structure your thoughts and see why you’re struggling.
[Jaz]Have you used it?
[Lakshmi]Yeah, I used it earlier in the year because I felt like, especially this year I was trying to find a new job. I was doing the Vish and Aaron course, I was still in the right course and I had like some-
[Jaz]You were at BACD then I saw you a few weeks later. The event we did, right. Well, you were everywhere actually.
[Lakshmi]Yeah, everywhere this year, honestly, I feel like even this year when I saw some of my course mates, they were like, where have you been? Because you’ve suddenly come onto the scene. But I was just really, and it’s not like I’ve been a course junkie. I’ve definitely like cherry picked, like the ones that I definitely wanted to do, but, it was really overwhelming on the front of in terms of choosing the course, it’s been great, a lot of growth, but there’s not much for work life balance. Because you are basically-
[Jaz]But you get that with masters as well. Like there’s a Eastman Conservative Dentistry Masters, which I considered at one point. They call that the divorce course. Right. And if you do the prosthodontist training, you have to do your own lab work. Nothing worth having comes easy like it, it will sabotage your social life for a little while. And I think everyone has, and it’s good when talking about this ’cause people need to go in knowing what to expect with that.
[Lakshmi]Of course. So I definitely think it was, yeah, it was very full, very rounded. It’s a lot of, you definitely have to take the stairs. There’s no escalators. But I think what additionally made it difficult for me was that I was doing some other things on top of that because I had in mind having had my mentoring session with Dr. Lincoln like last year in November, that I want to be in private practice and I want to be in a new, in a different clinical environment that is going to allow me to enforce what I’ve invested in this course. ‘Cause currently where I am, I’m not able to enforce it and the types of patients I’m seeing.
So in my head as well, they make you also do like an, what do they call it? It was an ECG plan. So it’s like a extraordinary career growth plan. So you write down the steps that you wanna do for you to get to where you wanna be. So that involved going to these courses, asking the clinicians.
If they know any jobs available or what they would do to get those jobs, go and meet really like-minded clinicians and learn from them, which is essentially what I was doing. Applying, making a spreadsheet a way you’ve applied, and then chasing them up and asking them, did you get it? And developing your portfolio at the same time.
So it was definitely an exponential growth of like just nothing and stagnant from like November to May. And it was really, really tiring and you are really kind of wearing yourself thin because you’re just still on this treadmill and trying at your a hundred percent and you just not seeing-
[Jaz]Plus when your few fear Lakshmi, like you, everything’s still new, right? Everything’s still new. You’re constantly doubting your treatment plans, which brings you to a really important question. Like, yes, you’ve done something on Jim, but then now you’ve found someone who you want to apply some anterior resin on, for example, that you’ve learned from your hands-on modules.
But the mentorship aspect, because when you go on courses, where you get stuck is when you actually have the patient, you get stuck because you don’t have anyone to ask. Because the course organizers, it is not like you have easy open, a hundred percent access to them to be able to get that information.
So it’s difficult, which is why I’m setting up this thing called Intaglio. It’s like literally like the Uber for mentorship. Like you find a mentor, you pay them, but then you have that one-to-one zoom thing. So that’s coming soon, but was that already baked in to what you have there? So what mentorship channels are possible when you have that case that you think, Hmm, should I, should I not, who can I check this with?
[Lakshmi]There’s too, probably too many mentors actually on Ripe, to be honest. First you need to take the pictures. So for any of my cases, I have always kind of asked one of the educators from the hands-on day. So mine was Dr. Natasha actually for my anterior composite bonding case. Yeah, I just took some photos, sent her the kind of pre polish initial appointment pictures and was like, I don’t know, this lateral looks a bit strange, but I dunno why.
And then she was like, drawing where I should modify the line angle a little bit. So there’s quite a lot of mentors. Yeah. As long as you have your photo, you just upload it on the WebEx, there’s a community group and then you’ve got your separate sections for your hands-on groups that you can also just post into. And about and people will probably reply.
[Jaz]Amazing.
[Lakshmi]And the good thing is international. So like you will get a reply pretty quickly ’cause there’s someone awake somewhere.
[Jaz]It’s good you mentioned that because they got different slots that you said two to 9:00 PM but they have like a European cohort and like a American cohort and Australian cohort. So time zones are, are covered which makes sense ’cause then you have so many different mentors as well available to help you at any point. In the interest of time, I’m just gonna just hone in on what’s next for you actually. Like, you are learning so much, you are applying it.
One thing that Lincoln talks about is how when delegates do the Ripe Global fellowship, their income does go up. Do you think, I know it’s a taboo subject, but do you, ’cause that’s not why we do it. We do it to grow as a clinician, but when we grow as a clinician, you know, we put so much into it.
We then also gain the communication skills to be able to take on these cases. And they are challenging. They’re back breaking, but they are high risk, high reward as well. Do you think there’s been a return on investment?
[Lakshmi]I think at the moment I’m getting there. I think once I moved into private practice, it was definitely a very big drop in income initially because you’re not seeing that many patients. You’re kind of building your book slowly. You’re now spending an hour for like a consultation, which even still doesn’t feel like that’s enough time for the amount of stuff you need to cover in that time.
So I would say now that I’m in the right place, seeing the right sorts of patients, and now I’m applying exactly what I’ve been taught in action now because I’m presenting it in the way they’ve taught you to, it is definitely building a lot quicker and I’m like seeing a lot less people and earning relatively the same.
[Jaz]And I think, you’re only in the middle of it. There’s still some modules to go and you only really are gonna grow when you get to now over the next few years, implement that. But what are great foundation that you’ve gained? What are your aspirations for your career? Do you wanna be a practice owner? Do you want to be a super associate? Do you want to go into implants? Like what’s next on your mind, Lakshmi?
[Lakshmi]I think for the moment, I really wanna become really good at restorative and just being able to do what I’ve been taught to a good enough level. I suppose in a five year, 10 year, if I’ve been able to grow this much in like a year, basically I’d hope in five years time I might be doing implants, just to cover the restorative fail of work you can do potentially. I don’t think I’d wanna own a practice alone. I think seeing everything that’s involved there.
That might be a 10 year plan of being a partner somewhere, if that’s where life takes me. But I do enjoy teaching as well, so I’m not particularly sure. I mean, you dunno where family circumstances take you, but I think for now I just wanna be really good at being a restorative dentist and ensuring that I’ve really kind of put to the test of whatever I’ve learned from all these amazing clinicians so far. You know, one step at a time, not over pressuring oneself.
[Jaz]As you were talking there, I was checking out your Instagram. I was looking at your cases. Well done. So looking at your reels and looking at your posteriors, this is a sign of someone who’s really enjoying their dentistry. This is a, oh, lovely.
You used the articulating paper. Thank god. Good. Look, you’re doing good work. And oh, some dance stuff as well. Brilliant. I like that you incorporate, I was gonna ask you, are you still making time for the passion of dance? ‘Cause just ’cause you’re not doing professionally or maybe you are not on the side, but you’re still making time for dance, right?
[Lakshmi]I did a little bit, actually. I was trying other styles ’cause I think you do grow out of these things a little bit. ‘Cause I did really kind of really put to use whatever I learned from that. ‘Cause I was obsessed with it really. So I think now you just can’t physically balance both. But I do go to performances still and it’s really nice to see that you’ve still made a mark in that community for people to still remember you and feel that you touch them with the art that you produced at the time.
And that’s the same implementation I wanna do with dentistry. And just know that you’ve helped people grow or you’ve taught people or just through you enjoying what you do. I noticed even my nurses, when they work with me, they feed off your energy with like, if I can hear the click of that flops at the end of that call too, I’m like, did you hear it?
And they’re automatically smiling and happy at the end of that procedure and they’re looking forward to working with you. So I think essentially, like I still keep the arts there. Like I’m a lot, I still am very active as an individual. Yeah. I’m trying other styles.
[Jaz]Cool.
[Lakshmi]Away from the classical form, but it’s definitely helped a lot.
[Jaz]You need to do that for your mental health, physical, all these things. So well done for continuing that. And also what you said there about the whole floss thing, that is truly beautiful because I think the way that we are gonna gain longevity in this long career is falling in love with the small details.
Really enjoying being a little bit of a perfectionist, but not in a toxic way, but really diving deep into, just giving your patient your everything and trying to do 1% incrementally better. Every procedure, every time, and document and share. And the days where I’ve taken more photos or videos, I look back and say, yeah, I really enjoyed today compared to days where you don’t document as much.
So I can definitely see that coming through from the work you’re doing and more power to you. It’s great to touch base with you after that recommendation I gave you for a few years ago now. So I’m glad it’s, it actually was fruitful for you so far, but as obviously only partway through, you’ve still got to go.
So maybe in a few years time, we’ll, we’ll touch base again, but I’m really excited to see your career. You’ve got your head screwed on, right. It was great to see you at the BACD. It was great to see you again a few weeks later at our event. And I think you are a great role model for young dentists, new grads, to be open to consolidating your knowledge that you already gained.
So I like the fact that, okay, you took a break. You realize that, okay, let me just find my feet. I like that it’s very mature. You are already looking abroad, you’re looking beyond what’s out there. You are looking to learn from the best. And I like that. And you are someone who’s very good at implementing.
So congratulations for everything so far. We’re early on in your career, but, I’m rooting for you and if ever you need anything, the Protrusive community are here. Obviously you’ve got great stuff with the Ripe Global crew as well. Thanks so much Lakshmi. Any final reflections or messages for those who have listened and watch about your journey so far?
[Lakshmi]Well, thank you for having me. I’ll just say that, you can find yourself on Jaz’s podcast two years later. Like little did I have fathom even having this conversation with you now and that things are possible. Like, honestly, like this time last year, I was like aimless in mixed practice churning out UDAs and still doing good work, but I wasn’t happy and very kind of demotivated, and it’s just a complete 180.
A year on and it doesn’t take years, it’s just every day improving yourself with the little wins and ticking those boxes off and going back and reflecting and moving forward and understanding. It’s not like a straight line trajectory, like you’re gonna have a few squiggles here and there, but it will even out at the end.
And yeah, like whatever course you choose to do, it doesn’t necessarily have to be Ripe. Like I did additional courses as well, which all fed into each other and it’s just applying what you’ve learned and making your days happy and enjoying what you do really. And then you’ll just see the results very quickly.
[Jaz]Brilliant. Lakshmi, thanks so much.
Jaz’s Outro:Well, there we have it guys, thank you so much for listening all the way to the end. Hope you’re inspired by Lakshmi’s journey, her mindset of growth. You can see how Lakshmi’s very driven and she’s really mature. Like I wish I was as mature of her when I was just four years qualified.
We’re rooting for you, Lakshmi, and do give her a follow on Instagram. I’ll put her Instagram handle in the show notes as well. Many of you’re also probably thinking that this Ripe Global fellowship sounds pretty good. Remember that you can get a guaranteed 20% off by visiting protrusive.co.uk/rgdiscount that way, just like Lakshmi did.
You can book a call to see if you’re a right fit for the course. And yes, as a shareholder and as an affiliate, I have a financial interest here. But as you can see, I only recommend people and organizations and courses that I truly believe in, and I’ve been a huge advocate and supporter of Ripe Global from the very beginning.
They’re good people. They’ll look after you. You heard about the kind of things they do and how considerate they are towards their delegates. Hope you’ve enjoyed this insight into a young dentist mind of decision making when you have a plethora of different fellowships and continuums out there. I’ll catch you same time, same place next week.
Bye for now.

May 13, 2025 • 1h 6min
Understanding TMD Radiographic Imaging – Pano vs CBCT vs MRI – PDP223
Which imaging techniques should you prioritize for TMD patients? Does a panoramic radiograph hold any value?
When should you consider taking a CBCT of the joints instead? How about an MRI scan for the TMJ?
Dr. Dania Tamimi joins Jaz for the first AES 2026 Takeover episode, diving deep into the complexities of TMD diagnosis and TMJ Imaging. They break down the key imaging techniques, how to use them effectively, and the importance of accurate reports in patient care.
They also discuss key strategies for making sense of MRIs and CBCTs, highlighting how the quality of reports can significantly impact patient care and diagnosis. Understanding these concepts early can make all the difference in effectively managing TMD cases.
https://youtu.be/NBCdqhs5oNY
Watch PDP223 on Youtube
Protrusive Dental Pearl: Don’t lose touch with the magic of in-person learning — balance online education with attending live conferences to connect with peers, meet mentors, and experience the true essence of dentistry!
Join us in Chicago AES 2026 where Jaz and Mahmoud will also be speaking among superstars such as Jeff Rouse and Lukasz Lassmann!
Need to Read it? Check out the Full Episode Transcript below!
Key Takeaways:
Imaging should follow clinical diagnosis → not replace it.
Every imaging modality answers different questions; choose wisely.
TMJ disorders affect more than the jaw → they influence face, airway, growth, posture.
Think beyond replacing teeth → treatment should serve function, not just fill space.
Avoid “satisfaction of search error” → finding one problem shouldn’t stop broader evaluation.
Highlights of this episode:
02:52 Protrusive Dental Pearl
06:01 Meet Dr. Dania Tamimi
09:04 Understanding TMJ Imaging
16:00 TMJ Soft Tissue Anatomy
21:04 The Miracle Joint: TMJ Self-Repair
24:26 The Role of Imaging in TMJ Diagnosis
28:15 Acquiring Panoramic Images
39:35 Guidelines for Using Different Imaging Techniques
41:26 Case Study: Misdiagnosis and Its Consequences
45:46 Balancing Clinical Diagnosis and Imaging
50:17 Role of Imaging in Orthodontics
53:18 The Importance of Accurate MRI Reporting
58:27 Final Thoughts on Imaging and Diagnosis
01:00:54 Upcoming Events and Learning Opportunities
📅 Upcoming Talks & Courses by Dr. Tamimi
🔔 AES 2026 Conference (Chicago):
Topic: “Telling the Story of Your Patient Through Imaging”
Focus: Understanding patterns in imaging and how they reveal the patient’s full clinical picture
💻 “How to Read a Cone Beam CT” Virtual Course (Concord Seminars)
If you enjoyed this episode, don’t miss out on [Spear Education] Piper Classification and TMJ Imaging with Dr. McKee – PDP080.
This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.
This episode meets GDC Outcomes A, B, and C.
AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Imaging techniques)
Aim: To enhance clinicians’ understanding of TMJ imaging modalities, improve diagnostic reasoning, and empower dental professionals to make evidence-based imaging decisions for temporomandibular joint disorders.
Dentists will be able to –
1. Differentiate between panoramic radiography, cone beam CT (CBCT), and MRI for TMJ evaluation.
2. Identify the appropriate imaging modality based on specific TMJ diagnoses (e.g., soft tissue vs. hard tissue pathology).
3. Recognize the risks of under- and over-imaging and apply a diagnostic question-driven approach to imaging selection.
#PDPMainEpisodes #OcclusionTMDandSplints #OralSurgeryandOralMedicine
Click below for full episode transcript:
Teaser: We do need to make sure that our teeth are in an orthopedically stable situation. And you should never trust what you see in the mouth 'cause the teeth may fit beautifully. But if the condyles aren't seated properly in the fossa, then it's like basically having a house built on quicksand. And this is a big thing that I see a lot in orthodontic treatment and others, they're just thinking about, alright, let's fix these.
Teaser:And they’re not paying attention to the foundation of the house. The teeth are the window dressing. You are not a carpenter, even a carpenter diagnosis. You need to diagnose your patient prior to doing anything to them, to figure out what really is going on.
Medicine, including dentistry is seven parts, diagnosis, two parts treatment planning, and one part execution. So if you get all that, those first nine parts wrong, you’re not treating the patient. You may be treating a symptom, putting a bandaid on something, but you’re not getting the full picture. But we’re really storytellers, we’re detectives and we are looking at the imaging to try to find the stories and the history that the patient can’t verbalize themselves.
Jaz’s Introduction:In our day-to-day dentistry, we take bite wings, we take periapical, and if you’re lucky enough to have a panoramic or a CBCT machine, we may take some of those. But what do we do when we have that TMD patient, TMD, obviously being an umbrella term. Listen to a lot of the other episodes on this podcast.
Learn more about TMD and how we can help as general dentists. But the question we’re really going to explore in today’s episode with an absolute sensational guest, the author of this book right here for the audio listeners is Temporomandibular Joint and Sleep Disorder Breathing by Dr. Dania Tamimi. And let me tell you guys, you are in for an absolute treat in today’s episode.
Some of the analogies she uses and the ways to explain certain elements of TMD, like for example, the clicking joint or the posh way of saying it is disc displacement with reduction. And so many colleagues get confused with that part with reduction. They still have no idea what it means. I’ve spoken to board certified prosthodontists on the phone and even they have been confused about what this actually means.
And so what Dr. Tamimi does in this episode is gives you one word to substitute in a way that suddenly all of this makes so much more sense. All her analogies are brilliant and we will explore, does a panoramic radiograph have value? When should we be considering taking a CBCT of the joints instead?
And are there any special instructions when doing so? And when do we need to take an MRI scan for the TMJ? And a little bit of the spoiler alert. My experiences with the MRIs have been just crazy in the sense that the person who reports it, will make a huge difference to the diagnosis. Let me say that again.
If you send your patient for MRI of the TMJs, well done. You might have helped it. And for the certain patient, we may be getting closer to the truth or to diagnosis, but the report can be so shockingly poor in my experience that, that MRI report ends up being a waste of money. I’ve seen this a few times down in my short career so far, and we discussed that.
I confronted the radiologist, Dr. Tamimi, on why this is happening and she had a really good answer actually. So get those onions ready, Protruserati, lots of chopping to do as you listen to these gems.
Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This is the first AES takeover every year the AES put on a show in Chicago around about the second, third week of Feb, and Dr. Tamimi is one of the guests. And so what we’re doing basically is we’re getting on these absolute superstars in the world of occlusion comprehensive dentistry to create these awesome and engaging podcasts, but also shine a light on the good work done by the AES. Our guest today, Dr. Dania Tamimi, is one of the speakers, and guess what?
Yours truly me and Mahmoud will also be speaking at the AES 2026 in February. Our topic is Occlusion Basics and Beyond. Basically, we wanna put something together for the younger colleagues and cover the foundations of occlusion that you can apply on Monday morning. But the AES has a reputation of actually being leading and at the cutting edge of comprehensive dentistry.
Let me just talk you through the lineup, right? So this is the Protrusive Dental Pearl, by the way, get yourself to AES 2026. Okay, well, I’m kind of kidding, but I’m kind of not. Okay. The real Protrusive Pearl behind this is don’t lose touch with the magic of in-person learning and the magic of conferences where you get to meet your peers. Online is great.
I’ve been a fan of online since I graduated, but I also mixed it with in-person events. Obviously, minus covid. If all you’re doing is going to in-person events, then you’re missing out a lot online. And if all you’re doing is sat in front of a laptop watching videos and webinars, you are really missing the true essence of dentistry, which is the people around you, the new and old friends that you get to see, and the connections you get to make.
And this is what me and Mahmoud loved a few years ago. We went to AES, we met our heroes in occlusion, and it’s absolute honor to be invited to speak. The theme of the conference is the evolution of the oral physician. It’s on Feb 18th and 19th, 2026, so that’s so Wednesday and Thursday. I just name a few of the speakers.
Okay. We have Mariano Rocabado talking about orthopedic stability. If you don’t know about Mariano Rocabado, he’s a big deal in the world of TMD. He’s a world famous physiotherapist from Chile, and really a pioneer when it comes to craniofacial therapy and physiotherapy and the temporomandibular joint. We then have Javier Vasquez talking about facial growth, development of functional aging and the foundations of joints, muscles, airway, and teeth.
I mean, it brings together all the systems. There’s nothing more comprehensive than that. Then it got THE Jeff Rouse, who will also be coming on the podcast as part of the AES takeover and his title’s really interesting. It’s shifting paradigms from mechanical to biological explanations of dental wear.
So we see tooth wear on a daily basis, so that is very exciting. We have Tracey Nguyen on proactive dentistry, the cost of watchful waiting. Look, in the UK especially, we like to watch things. Okay, we like to monitor and watch things, but at what point are we doing a disservice to our patients? So I really like that, especially with cracks, I’ve become more proactive with cracks over the years.
Not so much invasive or aggressive, just more proactive. The next speaker is our guest today, Dr. Dania Tamimi. And her title is so fitting with the podcast today, right? Her title for AES is Telling the Story of Your Patient through Imaging, and you’ll definitely catch glimpses of that from today’s episode. We then have a very clever chap called Jay Levy.
I sat next to him at lunch at AES, and honestly, one of the most intelligent people I’ve ever met, the title of his lecture is The Biotensegrity of Occlusion. Look, I either know if I should be admitting this or not, right? But I have no idea what Biotensegrity means. Maybe this is embarrassing, I don’t know, but you know what?
I can’t wait to find out. Biotensegrity, here we come. And lastly, we have Jeff Salzenstein, who’s a former pro tennis player, and he’s talking about mind matters, prioritizing mental and physical health for the oral physician. And so what the AES like to do year by year is have a non-dental topic, but something that’s made relevant to us as dentists.
So I just want to walk through day one and the next episode, I’ll walk you through day two. But if this sounds interesting to you, and it should be because you listen to Protrusive Dental Podcast, you’re probably interested in these topics, head over to aes-tmj.org and have a think about joining us in Chicago.
If enough of you tell me you’re coming, we’ll arrange some sort of like a protrusive get together. So me and Mahmoud are so, so excited. But let’s get to this main episode now with Dr. Tamimi and I’ll catch you in the outro.
Main Episode:Dr. Dania Tamimi, welcome to the Protrusive Dental Podcast. So, so nice to have you here. I’ve heard so much about you. I’m excited to see you next month. Fingers cross all being well, and you are a podcast veteran. So welcome to our podcast now. How are you?
[Dania]I’m very well, thank you. I’m very happy to be here and happy to be talking to you as well.
[Jaz]For those who haven’t heard of you yet, tell us about your career so far. Tell us about your journey. Tell us about what gets you excited.
[Dania]Oh, gosh. About me, I mean, other than Mom of three and all that stuff, ’cause like that’s central in my life. I am an oral maxillofacial radiologist. I’m a dentist just like you guys, and I’m trained in oral maxillofacial radiology.
I’m board certified by the American Board of Oral and Maxillofacial Radiology, and I’ve spent almost two decades now trying to figure out this TMJ thing. And I’ve been very lucky to have some really amazing teachers like Dr. David Hatcher and Dr. Ronald Auvenshine, who’s an anatomist. All dentists and these people and many others have basically shaped the way I think.
Shape the way I see imaging and as radiologists, you tend to think of us as the people who are trying to find pathology, get you outta trouble. But we’re really storytellers, we’re detectives and we are looking at the imaging to try to find the stories and the history that the patient can’t verbalize themselves.
So what gets me excited? Many things do get me excited, but when it comes to this stuff, this radiology stuff, what gets me excited and what gets me excited to teach imaging interpretation is the light in people’s eyes when they realize it’s more than just a static image.
It’s a chronicle of someone’s life. And through the patterns of bone trabeculation, through the morphology of someone’s face, you can see those patterns manifest. The patterns of movement, the patterns of function, the patterns of growth. And that tells you a lot about you’re patient that they cannot tell you in their words, you know? So, yeah. So that gets me excited. And I guess we’re here to talk about TMJ, so I’m very happy.
[Jaz]Amazing. Well, I love that storyteller reference and allowing patients to verbalize it through the medium that’s presented and being a storyteller that I’ve never heard that, that I’m never gonna forget that.
That is wonderful. I mean, I have so many questions today to ask, and just so I know, I would’ve mentioned this, the intro, but this is part of the AES takeover. We’re planned to be speaking in February, 2026, one of the biggest stages when it comes to TMJ and occlusion. So very, very excited to build up excitement for that event.
At the end, I’ll ask you again to describe what you’re talking about at that event, as well as where else we can learn from you. But the place I wanna start with in this exploration of TMJ imaging with you is starting with, I guess, radiographs that dentists are most familiar with, which is 2D, and let’s go with OPGs, right? OPGs. Call ’em what you want because my first question to you Dania is, is there enough diagnostic value in OPG? To give you some context, in the uk obviously we have an international audience, but in the UK they will not accept a referral to the OMFS department without an OPG, even if my diagnosis is purely muscular, right?
And I have a fantastic mouth opening and I know that clinically there is no evidence of disc displacement and all these things, they will still reject your referral unless you have an OPG. What do you think?
[Dania]Hmm. That’s kind of interesting. I’ve never heard that one before. Here in the states, the surgeons will just take anyone without, well, I mean, of course with the referral.
[Jaz]This is the public route. This is the public referral route.
[Dania]So, yeah, so I got it. Okay. I guess they want you to do your due diligence and make sure you rule out anything osseous. But I mean, when it comes to TMJ, that’s kind of shortsighted and for a community that kind of cares about, like, makes a big hoopla about cone beam CT and radiation, that’s kind of interesting to hear.
[Jaz]Isn’t it just?
[Dania]It is. And a big portion of TMJ disorders, many of these TMJ disorders are muscular, they’re extracapsular. There are things that reside outside of the area of the TMJ. Yes, you can have referred pain from other places. Like you can have referred pain from the sinuses, from the teeth, from the neck and whatnot.
But in the end, the diagnosis is more of a clinical diagnosis and that kind of makes me a little upset that they would expose someone to radiation for no reason, just to satisfy it, to tick a box, to satisfy that requirement.
[Jaz]I was unsure how you were gonna respond to that. I’ll be honest with you, because as a radiologist, I would’ve thought that you would have a bias towards, yes, imaging more images, the better I was a little bit, and I’m happy for guests to disagree with me, but I’m so glad that you were also as feeling the same way that I was when these referrals get rejected.
Now dentists, most dentists will tick the box and get the OPG and send it to them. And get that referral done. I feel very uneasy about that. But then let’s just twist it a little bit. When the dentist, who most dentists, unfortunately, I dunno what it’s like in the states, but when a patient comes with a temporomandibular joint complaint, dentists often get a little bit nervous.
Like, for example, dentists will tell me, hey, Jaz, I had a patient who had TMJ, they’ll call it TMJ, patient had TMJ and they had canine guidance on the left and group function on the right. That that’s kind of a descriptor I’ll get from the dentist. And then the next thing like, I’ll take an OPG. And so where does that come in, in terms of the decision making and when is it appropriate?
[Dania]Gosh, you have to really, this is multifaceted. You really have to think about this, first and foremost. Okay, so I’m a radiologist, so I am, as you said, you’ve thought correctly. I am biased towards imaging because that’s my job.
But I’m also, I have enough knowledge about imaging indications, contraindications, pros and cons and things like that. In addition to a healthy respect for radiation, but I also have a healthy respect for getting the right diagnosis, because if you don’t get the right diagnosis, then you’re not treating your patient.
It just boils down to that, you need to have the correct diagnosis in order to come up with the correct treatment plan and execution of that treatment plan. Medicine, including dentistry, is seven parts diagnosis, two parts treatment planning, and one part execution. So if you get all that, those first nine parts wrong, you’re not treating the patient.
You may be treating a symptom, putting a bandaid on something, but you’re not getting the full picture. And you’re not treating that person. And unfortunately, as you know, in healthcare, and I’m sure it’s the same where you are, things are pretty disjointed, no pun intended. People tend to specialize and sub-specialize and have extra, extra specialization in interest in certain things that they get tunnel visioned.
And you get to just see that thing that you’re interested in and everything else blurs out. And that is a big problem. And when I teach people to read radiographic imaging, regardless of what that is, I tell them, here’s what you need to do. First thing is lose the tunnel vision. Okay.
And what that is is and that comes from our biases. We’re trained as dentists. We like teeth. If I like shoes, I would look at shoes. If I liked handbag, I would look at handbags. When you meet someone with class three caries, you can’t help but think of a spoon excavator going into that soft caries, right?
Or round bur or whatever you’re doing the procedure in your head. You can’t help yourself. If you’re an orthodontist, you’re classifying people, right? Class one, class two, class three. So what it boils down to radiographic imaging and the choice of what image needs to be obtained. It boils down to the diagnosis.
So a clinical diagnosis, and let’s talk about an ideal world where insurance and NHS and all these things don’t exist. You diagnose the patient, you have to see your patient first. And I know that this doesn’t fall into many assembly line clinic forms that we have in in the world right now where tick, tick, tick, get to the next patient, you know?
But the right thing to do is to diagnose your patient clinically first. Figure out what they have clinically, and then choose the appropriate imaging for it. It may be no imaging, if it’s a muscular temporomandibular joint disorder, it’s going to require no imaging. If it’s, for example, trigeminal neuralgia, you’re not gonna be doing a pano for that, right?
It’s gonna require an MRI, because that’s a soft tissue kind of thing. You need to figure out what’s going on in terms of like the trigeminal nerve and all the vessels that surround it, if any. Right? And if you decide it’s a sinus issue. Then that’s gonna be another set of radiographic imaging. It’s different for every single indication, every single diagnosis.
And I also understand that not everybody has access to the toolbox. We have a big toolbox in imaging. In dentistry, we have our plane films, we’ve got our Cone Beam CT, we’ve got an MRI, some people have ultrasound as well. Not everybody has access to all that. So sometimes we just have to make do with what we have.
But if we do have access to the toolbox, then we have to think about what is the best thing for this patient. Now, when it comes to TMJ, if you decide that it’s an intracapsular disorder, then you have to think, is it a heart tissue or a soft tissue kind of situation? Because if it’s soft tissue, MRI is the way to go.
And if it’s heart tissue and you determine that through clinical examination, and also viewing what’s happening in the face, the bite changes, the mandibular symmetry, the growth of a mandible, that sort of thing. Then you’re gonna need heart tissue imaging, three dimensional heart tissue imaging and Cone Beam CT would be the way to go.
[Jaz]Can you explain more about the soft tissue for our younger colleagues who may not be familiar or remember the anatomy class they had some years ago about TMJ?
[Dania]Oh gosh. The intracapsular soft tissue, right?
[Jaz]That’s right.
[Dania]Oh, this is gonna be hard for the audio people to listen to, but I’m gonna try to describe it as much as I can. So you’ve got a condyle, I’m gonna just hold my hand up here if you guys wanna watch those audio people while they watch this later in my head. That’s the condyle right there. And then you’ve got the fossa. So you’ve got two rounded surfaces against each other. And the place where the height of maximum curvature of those two rounded surfaces is an area of constriction.
And that’s where the thinnest part of a bow tie, which is what the disc looks like, sits, right? So the disc looks like a disc. Like if you take it out of a cadaver or a human, like another person, a normal disc looks like a disc, it’s an oval and it’s circumferentially thickened. But when we cut this in a cadaver, or cut it in MRI, you’ve got a posterior band, which is thick, and then you’ve got an anterior band, which is thick, and then you’ve got the intermediate zone, which is thin.
Think of a red blood cell. Take that red blood cell and cut it in half. That’s what it’s gonna look like on MRI. Okay, in that sagittal cut. Now, in order for the joint to function properly, all the components need to be sitting in the right place. Okay? So this is a very high loading joint, right?
Your condyle is an osseous surface. The fossa and the eminence are also osseous surfaces. What sits in between those two and what cushions these two is that disc, that red blood cell, right? Shaped thing. The bow tie, right? So now this disc has the ability to dissipate a lot of the loading has the ability to get rid of all the majority of the loading if the person is functioning properly.
But it’s a material and all of us have studied material science and dental school and everything in the world around you is a material, right? And your disc is a material, and your bones are materials. And every single one of those components have limits, have thresholds. So if you surpass the threshold that this disc can function at, then it starts to break down.
It’s made out of collagen. There’s a lot of collagen. There’s water as well. And if you just load it too much, it will break down. It’ll change shape and it’s no longer gonna fit nicely in that configuration that I talked about. Think of a jigsaw puzzle.
The disc sitting in between those rounded surfaces like a jigsaw puzzle fitting perfectly. And then just imagine your dog chewing up that disc part of the jigsaw puzzle. Try to fit it back in. You won’t be able to. All right. And it so that disc doesn’t fit in that area and it’s all mangled and it cannot stay in the place where it can protect those osseous components.
So that is an internal derangement and disc displacement. Okay, so disc displacement, you guys have probably heard of reduction and without reduction and that is just confusing. Like heck, the terms reduction make people like, I think go cross-eyed. Alright. So reduction can be very confusing for people, especially, in our minds, if we’re not medical, when we first start as dental students, whatever, we have an idea of what reduction is in the real world, which is basically the subtraction of something, making less of something, something that you make in the kitchen with red wine, poured out over some meat, that kind of thing.
And so it’s hard for you to conceptualize what reduction means. TMJ and unfortunately in our dental school programs, they don’t do a very good job of explaining it to us. Okay, what is this reduction thing? So I’m going to just give you a word to replace reduction with, and then everything’s gonna be clear.
Recapture. So when you have a disc displacement with recapture, as the condyle rotates forward and slides forward, it will snap back onto the disc and it’ll move. The two will move forward together, and as the condyle goes back into the fossa, the disc slips off again. Okay. So that is with recapture or with reduction.
[Jaz]Okay. I love it.
[Dania]Alright. And then that can progress as more morphologic changes happen to both the condyle and the fossa and the disc. There will be no recapture. So as the condyle moves forward, it doesn’t recapture the disc and there is disc displacement without reduction or without recapture.
In the beginning of that, when that first part of disc displacement without reduction occurs, there is a closed lock, there’s a mechanical inability to open the mouth, okay? But with time, the TMJ, which it by the way stands for the miracle joints, will fix itself, will regain range of motion.
So you may have noticed a little click when there was recapture. That’s the clinical symptom for that. And then when there’s no recapture, there’s no click. Your patient may be already at that end stage, disc displacement without recapture, and have full range of motion and no clicking and popping, but they have a compromised disc, a compromised TMJ, because that disc is supposed to be the cushion for the bones.
Now what happens to the bones? After not being cushioned for a while, they’re gonna start to change shape, and they’re gonna start to remodel and flatten out. Instead of being two rounded surfaces against each other, they rub against each other. It’s called Eber Nation, where bone starts to flatten out as two bones rub against each other.
They become parallel to one another. And then the bone is also a material. And when the bone can’t take it anymore, it’s gonna break down. And that’s gonna look like erosions low density areas in the articular surface of the condyle, and also the fossa, which will eventually heal itself and remodel. Okay.
And repair itself. The miracle joint will repair itself to bring you back to function. Okay? Now, there are consequences to this. There are consequences to the destruction of the condyle, which by the way, is a very important factor in the growth of your face. And if your TMJ is compromised before your face stops growing, then you have facial growth problems.
You have asymmetries, or you have retrognathia. A lot of your class two patients are not class two because that’s the way they were conceived or not conceived, but that’s the way that they were wearing, the genetic makeup. It’s a consequence of a younger version of degenerative joint disease called idiopathic condylar resorption, which I don’t like the term, but that’s what they call it. Okay.
Now what is all this? This whole thing is a continuum, right? The soft tissue destruction, followed by the heart tissue destruction, followed by the repair. In the end, the miracle joint will repair itself so that you can come back to function because you need to do a lot of things with your mouth.
You need to eat, you need to drink, you need to breathe. If your nose gets clogged up, you need to speak and communicate, and if your joints don’t work properly, you won’t be able to do any of that. So I believe in God, and I believe that he created this so that in a way that we can still regain function and still maintain our lives after the destruction of our TMJs, unlike any of the other joints that need to be replaced.
When they’ve gone whack. The TMJ rarely needs to be replaced after degenerative joint disease. So I think we need to circle back to imaging, right? Because like you were asking yeah. So, which-
[Jaz]I mean, I just wanted to just clarify the importance of what you said there for our colleagues listening, because I still meet so many dentists who believe that when the click happens, that’s the disc moving out of position.
That’s the wrong thing is quite the opposite. Like you said, I know you summarize it beautifully with that word recapture and substituting that word reduction to recapture has helped hundreds of dentists finally get it. Because you’re right, reduction is a very confusing term. So that’s a real pearl right there.
[Dania]Right. So now what imaging do I use? Okay.
[Jaz]Essentially the crux we’re going then is, okay, so where do OPGs come in? Where do cone beams come in? Where do MRIs come in? I know we talked about countries having difficulties and access, but an ideal world through you, through your eyes and through your mind. What we can develop some indications and ideals.
[Dania]Absolutely. So if you’re looking, like I said before, if you’re looking for soft tissue changes like this disc displacement with reduction, without reduction, some other intracapsular changes that I won’t have time to really talk about much today. Those need to be looked at with MRI.
An MRI is not a negative CT. It’s not a negative cone beam CT. There’s a technology behind it that helps us visualize fluid and fat, which is a big component of what we’re looking at here when it comes to the anatomy that we have. Especially in a world of the TMJ. So, yeah. I don’t wanna get too much into MRI technology unless you want me to, you know?
[Jaz]No, I think we can go over the broader indications and that’s better. I think.
[Dania]The point that I’m trying to make throughout all this is that with the destruction of the TMJs, there are gonna be downstream effects. There are gonna be downstream changes to the face. There are gonna be downstream changes to the occlusion.
There are going to be downstream effects to the airway because of the nature of the connectedness of your occlusion in the TMJs. You don’t just have two joints at the TMJs. You’ve got all these other joints, which are not synovial, which are the teeth as they come together. You’ve got heart surfaces coming together and functioning in against each other, and they are related to your TMJs.
So if your condyles are reduced in size, then with that reduction of size, that creates a space in your joint space. Just imagine, if you were to take a condyle, whatever it is, you know that that condyle is chopped off from top, you know? So the space that that condyle inhabited is now going to be wiggle room.
And it’s not chopped off, but the destruction that I just described here with the erosion, the active destruction of the bone, secondary to biomechanical extra, extra loading and inflammation and all that, that creates wiggle room. And this wiggle room is orthopedic instability. So your joints need to be orthopedically stable, and if the condyle is out of the fossa, then there’s a high likelihood of that condyle sitting back into the fossa and changing the occlusion.
If it happens on both sides and both condyles move upwards, then the bite opens up in front. If it happens on one side, then you can have a contralateral open bite on the other side and you can have occlusal cans and all kinds of things occur. So, so tying it back to dentistry, we do need to make sure that our teeth are in an orthopedically stable situation, and you should never trust what you see in mouth ’cause the teeth may fit beautifully, but if the condyles aren’t seated properly in the fossa, then it’s like basically having a house built on quicksand.
And this is a big thing that I see a lot in orthodontic treatment and others where they’re just thinking about, all right, let’s fix these. And they’re not paying attention to the foundation of the house. The teeth are the window dressing. And you don’t put the window dressing up before you build the foundation and the walls and all that. And the foundation and the walls would be the TMJs and the airway.
[Jaz]I love that you described the teeth as joints. That was really nice. And it reminds you, everything you said there really reminds me of something that Jim McKee said on this podcast for think not how the occlusion affects the joints. Think how the joints affect the occlusion. And I think when people really understand that, that’s the next higher level thinking of occlusion beyond the teeth.
[Dania]So now let’s tie that into the imaging. When you acquire a panoramic image, which you guys call it OPT or an OPG, right? What do you do with the teeth? How is that acquired?
[Jaz]Use your cotton roll or the little plastic stick.
[Dania]You use a bite stick. So what happens with the TMJs if you come into protrusive.
[Jaz]It’s translate or pretend to translated right?
[Dania]They’re gonna move forward, right? So you’re not gonna capture the joint space. You’re not gonna capture the relationship between the condyle and the fossa. You won’t be that. That’s a very integral part of your diagnosis. And yes, there are clinical ways to evaluate for orthopedic instability, but when you have the entire craniofacial complex in one view. Like you do on Cone Beam CT with the teeth together, which you can’t get with a panel because you need to have the mandible in Protrusive in order to capture the jaws in that focal trough.
If you go back to your pano textbooks, whatever, you’ll understand that’s how panels are acquired. There’s a focal trough and everything outside of this blurred, and if the things aren’t in the focal trough, then they’re gonna be blurred. And that’s why we bring the mandible into protrusive to make sure that we can see all the teeth and in the jaw.
‘Cause the lower jaw is usually a little bit inset. So we bring it forward in order to bring everything into the same focal trough. So another thing that the panoramic image isn’t really great at, other than, looking at that orthopedic stability, the position of the condyle in the fossa is the actual morphology of the condyle.
Okay. So when you think of the condyle, it looks kind of like a spatula. If you look at it head on, right. It’s rounded on the top. And like if you look at it anterior posteriorly, it’s rounded on the top, you know? And then it’s got a thin neck, so kind of tapers in, like right now, if you turn that spatula to the side, usually a spatula has a little rin to it.
Okay. Now that spatula isn’t aligned completely medial laterally on a pano. Because the nature of the projection geometry here, because of the way the pano is created, what tends to happen is the lateral pole moves down and forward. So this is what you’re looking at for those who are in audio, if you wanna come back to the video, this is what you’re looking at.
You’re looking at a distorted view of the condyle on your panels, not the true medial lateral dimension like you can with the cross sections that you get in on Cone Beam CT . And also, you’re not gonna be able to pick up the erosions, the erosions that are indications of early active degenerative joint disease or inflammatory arthritis.
And that diagnosis is super important before you start working, because you don’t wanna be working on someone who has active degenerative joint disease because through the changing of your biomechanics, the biomechanics of the patient, you can actually create more of a problem. You can create a greater magnitude of destruction in that area of the condyles.
So the inflammation, it’s inflamed, you’re not gonna pour fuel on the fire, you just wanna let it be. You don’t wanna start moving teeth or doing orthognatic surgery or anything like that. If somebody has an active disease process, active degenerative joint disease process and these erosions, when they’re small, you really can’t see them on Cone Beam CT.
And in fact, many times you can’t even see the big ones because of all that projection, geometry, distortion, anyway, so pano, okay, if that’s all that you have, that’s all that you have, but then the ideal way to to image for osseous change, in my opinion, is using Cone Beam CT. And I’m not gonna just say, okay, just get a cone beam CT of the TMJs, like one small one on the right, one small, one on the left, because then you’re just getting the anatomy, right?
This is the functional joint and the place of interest for you as a dentist is the teeth, and you need to know how these two are related. Are the teeth in maximum intercuspation during the acquisition of the Cone Beam CT? That’s a very important thing to know prior to interpreting the joint space of your condyles, when you’re looking at their imaging right, so the teeth in maximum intercuspation is important.
And also acquiring a field of view that encompasses, I mean, in my opinion, everything from glabella down to hyoid so that you’re viewing this craniofacial complex as a whole. There are downstream effects of temporomandibular joint disorders to the mandible, but also also to the growth of the face, the growth of the airway and position of the neck. How much space you have here. And I know not that too many people are on the airway, bandwagon, but you know, what’s the most important thing to-
[Jaz]Well, the people with your face, listen, this will be, especially those who come into AES and subscribe to this, we are speaking to the converted in a way.
[Dania]What’s the most important thing that you’re gonna do with your face?
[Jaz]Breathe.
[Dania]Breathe. Try not breathing for two minutes. You cannot eat or drink for whatever you, there is an alternative, IV whatever for nourishment. But breathing, that’s it. Well, unless you do like a trichotomy or something, who wants to do that, right?
But the way that your face forms is very highly related to the function of your TMJ and your jaws. So you need to look at all of that together and determine the patterns of change the story in the patient’s scan by looking at the whole thing together. And part of my frustration when I get scans from Europe, is those small fields of view.
One here and one here. I’m like, okay, I’ll tell you what the condyle looks like and where it is, but I can’t tell you if it means anything to you. And I can’t tell you if it’s doing anything anywhere else, you know? And sometimes even a condylar hypoplasia can be very subtle. And the only way you can tell it it’s a condylar hypoplasia is what it does to the rest of the mandible. Because the mandibles gonna follow the TMJ. And if the condyle doesn’t grow to full potential, the mandible doesn’t grow to full potential either. Anyway.
[Jaz]So if you have a patient then who you suspect it is either degenerative joint joint disease, or it is osseous issue, and you’re requesting, you’ve laid out your guideline that you’d like cone beam, which shows more than just small views, you want encompassing so much more with that, and you want it in MIP or their teeth together, or at least the description of what position it is in. But then is that enough or do you need another one with a mouth open as well?
[Dania]I don’t think that you would need an open Cone Beam CT. You can tell where the condyle is just by palpating. And that’s basically the information that the Cone Beam CT will give you. It’ll just tell you where the bones are in relationship to one another.
If you’re looking for things like, intracapsular changes the disc, whatever, that’s an MRI kind of thing, and that’s where you would get an open and closed. But I don’t think that an open is indicated. Now some people will argue with me and I’m gonna say, okay, if you really wanna do that, then get a small field of view.
‘Cause you don’t need to get a large field of view in the open view. You already have the anatomic information from the closed view in order to limit the imaging radiation to the patient. You can get a small one here and a small one there for that open view. But once again, I don’t think it’s important.
[Jaz]Okay.
[Dania]There is, I mean, someone once challenged me and said, okay, what about with coronoid hyperplasia, coronoid hyperplasia where coronoids are really large and we wanna see what they do with opening. I mean, sure. But you can tell that there’s a coronoid hyperplasia. You can tell how big it is, in relationship to the level of the condyle and whatnot.
So, I mean, what more is it gonna tell you? What is the imaging going to tell you? That’s a question you always need to ask yourself. Can I get the diagnosis without imaging? Okay, what is my question? What is the question that I want to answer? And if I can’t answer the question clinically, then I have to find another way to answer it.
Let me choose amongst my toolbox something that may have less radiation. So for example, I’m not gonna send a patient for medical CT because that’s a lot more radiation, but if that’s the only thing that I have and it’s really indicated and I can’t get the information any other way. And that’s the way it is.
Just yesterday I was working with someone who has, their patient goes through the VA system, veterans affairs system here in the US and the only way that they could get that reimbursed was to get a medical CT. And of course I’m like this, but it is what it is.
[Jaz]I appreciate that. I think that’s a very honest, real world view of that. You have to work with what you have. So, so far we’ve covered Cone Beam CT and you gave us the guidelines in terms of don’t take it too small. We know we’re looking for osseous changes. We talked about soft tissue changes, intracapsular, we’re gonna go MRI.
Are there any situations where an OPG has value, therefore, like in a perfect world, if you have access to all this, are we suggesting that we don’t need an OPG ever, or I never say never, obviously, but that is a inferior choice. And you as a radiologist, once it gets to a point where the clinician’s unsure of a diagnosis and they need the imaging to help their clinical, that perhaps that doesn’t have as much value.
[Dania]It’s a case by case kind of situation. It’s a case by case kind of situation. And I just have to say that, if you get a panel for let’s say for example, an implant case, you know that you’re gonna put a three-dimensional object in a three-dimensional object that has anatomy that you have to avoid.
So why do you get the panel to start with? It’s just using your mind, just use your brain. Think about what you’re gonna do in the long run. Let’s say it’s a surgeon who has impacted, wants to remove impacted third molars or partially impacted third molars and wants to see where the canal is.
Depending on where the level of the tooth is, if the tooth is slightly apparent in the oral cavity, maybe it’s far away from the canal and they don’t have to really worry about it. Let’s say that the teeth are fully erupted or partially erupted, but if the tooth is submerged, then most likely it’s gonna be close to the canal.
And then the question is, where is the canal in a relationship to the tooth? You know? ‘Cause like the canal can be going through the roots. It can be behind like lingual or a buccal or inferior, whatever. So it’s the level also the confidence of that surgeon that would maybe wanna do this with a pano, not get a Cone Beam CT.
And as we know, insurance also dictates this. They’re not gonna pay for a Cone Beam CT they’ll pay for a pano. And that’s what they have to what the clinicians have to contend with. My point is that if you clinically believe that a cone beam CT is indicated, you should not hesitate to get that as your first imaging, okay?
Don’t get the pano to just see what’s going on and then get the cone beam CT. Clinically, if you make the decision that the procedure that you’re gonna do is gonna require a three dimensional evaluation, you’re gonna be moving things in three dimensions. You’re gonna be removing things that may be impacted right in contact, compromising other structures.
Don’t fudge with the 2D. My opinion may not be popular, but as an expert witness in many malpractice cases, I’m just gonna tell you that the first thing that the lawyers do when things go wrong is put the patient in a cone beam CT to see if that whatever it is that was done wrong could have been avoided by getting three dimensional imaging versus 2D.
I hate to bring lawyers into this, but I know that’s not like forefront in many people’s minds.
[Jaz]No, it’s true. Because we need to bear that in mind when we’re making decisions. And also get the right information to do justice for our diagnosis. But in terms of just a quickly about a CBCT.
Are the units that dentists have in their practice that are suitable for implants, usually suitable to get that level of imaging that you desire from condyle all the way down? Are the units that we have, are they adequate nowadays?
[Dania]Well, there are different types of units. When you choose a unit for your practice, you have to look at your practice space. If you’re an endodontist, you’re not gonna need a large field of you. You’re gonna buy yourself a small field of view to just look at the area of the couple of teeth that you’re gonna be treating. And in the case of someone who, where you think that the pain is coming from elsewhere, then you can send them to an orofacial pain specialist.
An oral surgeon who may require a larger field of view. So that’s in case of the endodontist in case of the implant dentist. So your periodontist, oral surgeon implant versus people with affinity implants. Let’s put it that way ’cause I don’t think it’s a specialty yet.
[Jaz]Correct.
[Dania]But you know, okay. Implantologists, think about that, what that implant is. You are replacing a functional unit in a functioning being, in an organism. And that functional unit needs to work with all the other teeth and needs to also work with the TMJs. So you need to see what’s going on with the TMJs ’cause, like why would you do an all on four, for example, in the patient who has orthopedic instability?
You need to figure out if the condyles are seeded properly or not. Or if you’re gonna do even a bridge, you don’t wanna implant supported bridge three unit, whatever it is that you wanna do. You need to make sure that the occlusion is sound before putting these pegs that can’t be removed or not be removed, that they can’t be moved orthodontically.
They can be removed with a great deal of bone removal before you make that decision. And I’m just gonna give you an example here of a tunnel vision situation. It’s an expert with this witness case that I was involved in. So I’ll give you the story from the end. A patient shows up in the emergency room, this is the end, and I’m gonna tell you the backstory, okay? The patient shows up in the emergency room. He’s got an all on for supported denture. The surgeon in the emergency room doesn’t have the screw to remove the denture. The emergency was the patient had bit his tongue and it swelled up and he couldn’t breathe. So the surgeon decided, if I can’t remove this, then I’m gonna cut everything out.
And he removed the alveolar processes with the teeth. He was like working in an emergency kind of situation. Of course, me as an expert with this, I told them he could have done a tracheostomy, but whatever. But what’s the backstory of this patient who bit his tongue?
This patient was partially edentulous for a long time. He had front teeth. He didn’t have back teeth. And as you know, your tongue spreads when it doesn’t have support. It goes just like your feet when you’re in flip flops all the time. Like you’re in Florida. And so he had a big beefy tongue and then the general dentist decided that, talked him into an all on floor.
He extracted all of the front teeth or tear wood, whatever it is. So implant supported full dentures. And he didn’t put into consideration that his arches were narrow. He put the implants wherever the bone was. So by the time he put the implants and then the dentures, he’d crammed that tongue into a teeny tiny space.
So, of course, the patient bit his tongue. And it got infected, and then the rest of the story. But that first dentist wasn’t on the stand, it was the surgeon, obviously. But if you ask me, the fault came with poor diagnosis, just thinking tunnel vision, thinking of putting teeth in a person without looking at the whole situation.
So, going back to your question, you need to look at these people more fully. You’re not just putting implants in, you are replacing functioning teeth. And those functioning teeth need to follow the system, and you need to look at the integrity and the health of the system. Airway included, TMJ included, prior to putting these immovable pegs into people’s mouths and then, you know, them having to deal with the consequences of that.
So your question was, so are the TMJs visualized there? They should be. I mean, you shouldn’t be just getting one arch. You need to be seeing what that, you need to do a digital wax up. If not a conventional wax up, you need to do a virtual wax up. You need to see how the teeth fit with one another.
And you need to have to see how they fit with TMJs. So I don’t really advocate those single arch imaging for implants. ‘Cause it’s not about where the bone is. It’s about how it all fits together.
[Jaz]And so in implant dentists would, when they’re dealing with patients, often older patients who’ve been through a lot more wear and tear to check for orthopedic stability of the condyles, is another important factor in their overall occlusal stability and their planning. Would you agree with that?
[Dania]Yeah. You have to look at everything. Implant placement has been oversimplified for I believe for material gain in many places. The vendors want more dentists putting in implants. The patients want implants. The dentists wanna make more money putting in implants.
But it boils down to the importance of diagnosis. You are not just doing a mechanical procedure, you are not a carpenter, even a carpenter diagnosis, you need to diagnose your patient prior to doing anything to them. To figure out what re what really is going on. In the example of patients who, let’s say even a class one, class two restoration patient has a second molar class two restoration that he keeps breaking, and then you do an amalgam buildup and that doesn’t work out, and then you put a crown and then he splits the tooth. What’s going on here? It’s not that too, there’s something mechanically wrong and you’ve gotta figure that out.
[Jaz]You got to think bigger picture.
[Dania]So, yeah.
[Jaz]With the CBCT, I wanna ask you about timing, and this is a really important question, and I’m happy to tell you at the level I’m practicing and I’m always happy for my guest to scrutinize me, criticize me in any way.
I’m always happy to learn, but I’m just gonna tell you what I do and my philosophy on imaging and with my experience so far, when I have a good history and a thorough clinical examination, and I have arrived at my differential diagnosis or a diagnosis that, you know what, I’m fairly happy with this diagnosis, and I don’t think I need imaging with that level of confidence I have for my diagnosis of the various different diagnoses with TMD being an umbrella term.
And if I have diagnosed, let’s say, a unilateral disc displacement without reduction or without recapture, without limited opening. So this patient can’t open normally the role of imaging then, in terms of, some of the previous guests, to give you some more context Dania, some of the previous guests I’ve had on. One has been a maxillofacial surgeon who’s not that keen on imaging at the forefront because he says, if I can make my diagnosis and I’m choosing that, I don’t think we need to do surgery here, then I don’t need the imaging ’cause I’ve got a good diagnosis.
Whereas I’ve had someone else on the show and they’re like, every patient needs an MRI, not every patient, but if you suspect any sort of disc derangement equals MRI. And so there’s a spectrum, right? And so where would you lie in the spectrum in terms of relying on your clinical diagnosis and then if the imaging is not really gonna add much or change much, when does it come in?
So to the bottom line is, when do I do it? If something’s not going right, if I’m like, hmm, I’m doubting myself. Hang on a minute. Is my diagnosis correct? Or I’m not sure of my diagnosis from the outset, that’s when I reserve imaging. What do you think?
[Dania]Well, exactly what you just said, and I think I kind of alluded to it in the beginning, what’s the question that you want to answer and what are you gonna do with the answer? You see, because just like this oral surgeon said, if I’m not gonna do surgery, if I’m pretty sure with my diagnosis and I don’t see changes occurring, and I can treat this without using imaging, I will, right? I can. But people tend to be lazy, tend to get lazy, say, okay, I need this whole spectrum of stuff because I need to make sure that everything is okay.
And you know what? It’d be wonderful if we could do that. It would be wonderful if there wasn’t a radiation tax to pay and there wasn’t an actual monetary tax to pay as well. Because many of us, we rely on insurance to pay our things and they can deny it and then it can get very expensive, especially here in the US it’s very expensive, okay?
So it really is a case by case kind of situation. And what I would recommend to everybody listening, you included, is you just have to hone in on your diagnostic skills and broaden your mind and broaden your knowledge base. Because even with a clinical diagnosis, your eyes will only see what your mind knows.
And if you’re indoctrinated like with a certain philosophy and you’re only doing it that way and you’re not looking at it in the big picture kind of thing, you’re only gonna see it through that lens. And that’s not how human beings work, you know? Everybody is different.
Everybody has a different story to tell through their bodies, through the patterns of movement, through their patterns of function, through their whatever’s going on in their head, psychologically, whatever. As we know, there’s a lot of psycho stuff going on with TMJ too, right? The psychosocial component to that.
So we really do have to take a step back and diagnose our patients and learn more about how to diagnose our patients differently from other practitioners and step away from our ego. Stepping away from the ego, I think is the single most important thing a healthcare professional can do, because then if you believe that there’s another way to do things, your mind starts to grow.
Your mind starts to open up. So with that arsenal in mind, and if you don’t, can’t diagnose the patient properly, you have to step away from the ego and give the patient to somebody else. And then decide if imaging is indicated or it’s not. Once again, it’s about the question that you need to answer, and what are you gonna do with the answer.
Okay. I mean, you can do an MRI for every single person that walks in through the door, and you’re gonna find a big portion of them have clicking joints, have disc displacement with reduction or without reduction. So, but what are you gonna do with the information? Hey, yeah, it’s a nice little thing to add to their clinical diagnosis. But what are you going to do with this diagnosis? So that’s the question here.
[Jaz]Okay. That was beautifully answered. That’s fantastic. Now, to give you a perspective of a radiologist that I’m very fond of in the UK, his MRI reports have been the best. And this is a two pronged question.
First is that, whilst I really respect this radiologist, he has this strong opinion that I want to just ask your opinion. All it is an opinion, but I’d love your opinion on this. He is of the camp that believes that any patient before orthodontics should have an MRI of their joints to confirm orthopedic stability prior to starting orthodontics. Okay. And so this is his belief. Where do you line that?
[Dania]Yeah. There are many people who think different things. First of all, orthopedic stability is a clinical diagnosis. It can be verified or detected even with imaging. Okay. But the orthopedic stability, the wiggle room, is really a clinical diagnosis.
And there are different people who do it differently. Different people who will determine that differently. Whether you’re from the Dawson Camp or from the OBI or Face Group or whatever, Roth Williams, whatever it is. There are different ways to do this. It’s a clinical diagnosis that can be supplemented with radiographic imaging.
And in an ideal world, wouldn’t it be nice to have MRIs of every single person that comes through your door? But, we know in reality that’s not the case. And it’s gonna be hard, very hard to convince insurance or NHS to pay for it, because there is no standard of care when it comes to that.
Okay. I’d like to satisfy my curiosity and know where the disc is in every single person, but is that practical? I don’t think it is. Simply because there are too many things that come into the obtaining of an MRI, you know? Or obtaining of any kind of imaging and too much politics. So-
[Jaz]I appreciate that real world view. I don’t think it’s always practical, but, I think what I took away from that is there is a time that we need to do our full history, full clinical examination, and then if we have a doubt prior to commencing something which is essentially full mouth rehabilitation in enamel orthodontics.
Or someone’s doing related work to then escalate to imaging is a very good thing, then therefore you can be a bit stronger in your recommendation. Whereas if you just did a blanket thing of, if you’re having ortho, if you’re having implants, which is a big deal, if you’re having a full mouth rehab, we better check your joints then, I think to do a full clinical diagnosis first to make to see whether the role of imaging is strengthened and to make it practical for your patient.
[Dania]More importantly than the orthopedic stability that can be detected clinically is if there is active degenerative joint disease or not. And a cone beam CT is better for that than an MRI simply because of the voxel size, the resolution, spatial resolution and all that stuff that goes along with cone beam CT versus MRI. Okay.
[Jaz]Well the second part of that question, Dania was that this radiologist, who I really admire gives brilliant reports. And unfortunately when I’ve had some patients come my way and they have an MRI report and I read it and I thought, hang on a minute, this is really not matching my clinical diagnosis at all.
Okay. And that’s not my ego saying, hang on a minute, I’m right here. Those few times I really doubted it ’cause it was such a strange one for me. And then I sent the images, the actual images to this radiologist, and the report I got back was completely different. And the quality was obviously much better, much thorough.
This is him being a brilliant radiologist. So I started to then do this a few times and I’ve been amazed at the level of, this is the UK, I dunno how it is in any other country, but I’ve been amazed at the quality of reporting. And so there’s image quality that comes into it and having the right equipment and stuff, which I don’t, we don’t get into, but there’s different MRI equipment, different centers, whatnot. And the quality of that varies as it naturally would, but also the interpretation of it will depend on your training. So have you experienced this as well?
[Dania]The majority of the MRI reports that I write are rewrites.
[Jaz]Wow. There we are.
[Dania]Let me just give you like how things work in the US. Okay. So when you acquire an MRI in order for insurance to reimburse it, that MRI is the technical component. There has to be a professional component and the professional component is the report. So whoever gets the MRI like in the pile, of course now it’s not a pile anymore, it’s the list. Whoever gets it and reads it, gets paid for it.
Okay. Now if you’re lucky, a head and neck radiologist is gonna read it for you. If you’re not lucky, it’s gonna be a general radiologist, okay? My husband’s a radiologist, a medical radiologist. He’s a cardiac radiologist. And he says like in his entire residency, he maybe got one or two TMJ cases to read.
Okay. So unless you really care about this area and you really focus on it, then you’re not gonna really understand it. And even amongst the head and neck and neuroradiologist, they don’t get it like we do, like dentists do. They don’t understand what, all the stuff that I just explained to you, the occlusion and the facial growth and whatever.
I mean, I speak at the American Head and neck radiology meetings and whatnot and they, prior to my talks, They were talking about this morphologically. Where this in relationship to the fossa but the basic understanding of what all that means is kind of lost in the medical world. Now I’m saying there are a lot of good head and neck radiologists who dedicate their lives to learning the TMJ.
In fact, one of the pioneers in TMJ imaging was a renal guy. He just had an in. His name is escaping me right now. But God rest his soul. He passed away recently. Yeah. So if you go back and look at the literature back in the nineties. His name was all over the place. He was a medical radiologist who had a genital urinary radiology kind of practice, but he had an interest in the TMJ.
His name will come to me. I know after we talk, we stop talking here. So if you don’t dedicate the time to learn this, you’re not gonna be able to really interpret it. And unfortunately a lot of the education in the medical world also, the people who are teaching at TMJ don’t understand it.
Like we understand it. So they teach it, they propagate that same information or misinformation, okay? And I’m not saying I’m right, you’re wrong, whatever. Everybody has their opinion. But I’ve pretty much spent the past 20 plus years, trying to understand this thing and also understanding it from a perspective of a dentist, because I am a dentist and I serve dentists, right?
So when it comes to the choice of who to choose for, to read the scans for you, if you have an oral and maxillofacial radiologist, you’re golden. If you have a head and neck radiologist, you’re close to that. Depends on his understanding and how much he’s willing to invest in and learn, he or she, of course, learning more.
And I think a big part of it is your communication with them. And that’s the missing link right there is dentists educating medical people what they want and what they care about and what all this means to them and what they wanna see in their reports. Okay, so.
[Jaz]I’m glad you said that really validates my experience in a way. ‘Cause for the first time I had this thought some years ago and I felt alone. I was like, am I being silly? And then to ask the patient to pay for the fee for the new report. So, you know what I did? I paid it out my own pocket.
‘Cause I was genuinely curious. And then that validated it. And then in the future, when I then got patients to get re reported, it’s amazing. And so that really taught me a lot. It taught me a lot. And so I gained a newfound respect for your field more than ever before. So it’s amazing what you do.
And I love everything you said today in terms of really bringing the patient into it. I think that is the beauty and the crux of it, rather than there’s just these images, is that storyteller analogy. Going back to the beginning. Any final points that you want to leave to a general dentist listening right now when they’re thinking about imaging for their TMD patients? Before we close off.
[Dania]Listen to your patients. Take the time to listen to them. A big part of the TMJ disorder spectrum that they have is going to come from things that are going in on inside their heads. Okay. I believe in the psychosocial model as well as believe that the biomechanical model, maybe I’m a little bit, I’m on the fence, which is which, and I think that there are many little-
There’s a lot of interrelated stuff going on here. You can’t just say everything is psychosocial and you can’t say everything is biomechanical. You gotta talk to both fields and both, educate yourself in both camps. And then come up with what you feel is best for your patients.
And every patient is going to be different. You can’t treat people with a cookie cutter kind of approach, a cookbook kind of approach. It’s not like that. The most important thing is to listen. Okay. And observe and put your ego aside. And when you’re evaluating a patient, the last thing you want to look at is the chief complaint.
Chief complaint or the area of your interest. So look at everything else and then look at the chief complaint or the area of interest for you. Okay? If you’re an orthodontist or an implant, whatever, that’s the last thing that you look at. Because if you don’t do that, then you’re going to fall into the satisfaction of search error.
Satisfaction of search error is when you come up with the answer to the question that’s burning inside of you or burning inside the patient. Your brain checks out and you don’t approach the patient as pragmatically as you would’ve if you were to look at everything else first, and then the chief complaint, or-
[Jaz]It’s really about being more comprehensive. And I think that really, really, describes you well.
[Dania]Systematic and non-biased.
[Jaz]Not so easy, if we have to really work on that as clinicians. That’s not so easy to do.
[Dania]It’s the ego.
[Jaz]It’s the ego. There we are. You’re so right. Dania, you’ve done a really wonderful job on a tough topic, so thank you from all of us at Protrusive for doing such a harmonious job and the way you explain and the whole thing about recapture, I think the penny really dropped for so many of our colleagues today. Can you tell us about your topic in Chicago, AES 2026? You know, I’m so glad to kick off the a s takeover series with you, but tell us about your talk.
[Dania]Well, it’s gonna be called Telling the Story of your Patient through Imaging.
[Jaz]Perfect.
[Dania]And it’s basically understanding the whole system and looking at the patterns that are predictable and some not predictable, but looking at that through imaging, I mean, really cone beam CT has opened up a whole world of diagnosis for us and for us to poo poo it or to, to try to minimize its its importance in our diagnosis.
We’re no longer in the 1950s or the 1980s, we are in a new era where the diagnosis are evolving and our ability to diagnosis evolving, and we shouldn’t be afraid to use the correct diagnostic method for the patient who’s presenting to us at that single moment at this time. So that’s basically what I’m gonna be talking about, using the imaging to look for the stories and the bones. To look for the patterns in the bones and how all the moving parts come together and work together.
[Jaz]Well, you are really part of a star studded lineup, and so we’re very excited to learn more from you in Chicago. So hopefully many colleagues will join us for that. You also said you do a fair bit of teaching. Is there anything that you help with dentists? How can we learn more from you? How can we connect with you?
[Dania]Yeah, every other month I give a how to read a cone beam CT course online. So virtual, you can zoom in from wherever and it’s run by Concord Seminars. Okay. So Concord Seminars, if you look them up, you’ll find that there-
[Jaz]I’ll add the link in the show notes for everyone.
[Dania]Fabulous. Yeah. And I just do it for the dento-alveolar part because in order to do the whole thing, I did have a longer course, but it was just too much to sit for four days. So it’s a two day, half day kind of situation. So five hours, five hours, and it’s a time that works for pretty much every time zone. Not too late at night, not too early in the morning, something in between. I mean, people in Australia struggle, but-
[Jaz]Aussies always struggle. God bless, right?
[Dania]And I do have a book. I mean, I don’t know if you know anything about it or not.
[Jaz]Yes, yes, yes. I’ve seen it. Special copy sign from you in Copenhagen. So I look forward to that. Well, fingers crossed that all goes ahead. And of course, again in Chicago. So thank you so much Dania, for giving up your time here to talk about something that you do so wonderfully. You know, when Bobby Supple was discussing with me about all the different guests you had planned and stuff, and you told me a bit more about you and he told me that you recently, I dunno, where you were teaching, was in Milan or something, I dunno.
And you got a standing ovation. I forget where it was that he mentioned. And so I can see why I, honestly, having this first experience of chatting to you, I can see why you are so respected and so keep fighting. Good fight. We are absolutely loving it. Please keep it up.
[Dania]Thank you very much. It was such a pleasure talking to you and everybody have a wonderful day wherever you are in the world.
Jaz’s Outro:Well, there we have it guys. Thank you so much for listening all the way to the end. If you manage to listen, why not claim your CE credit? All paying subscribers to Protrusive can answer the questions.
Make sure you get 80% and we will issue your CPD certificate. We are a PACE approved provider. About 96% of our previous episodes are eligible for CE and we’ve also got a whole bunch of masterclasses and clinical videos are also eligible for CPD. So if you’re a returning listener or watch at a Protrusive, it’s well worth checking out our Protrusive Guidance network, home of the nicest and geest dentist in the world.
Head over to protrusive.app and we’d love to see you on there. Thank you so much again to our wonderful guest, Dr. Dania Tamimi. More to come as part of the AES takeover. Really excited to share with you the episode with Dr. Jeff Rouse coming very soon. And don’t forget to head over to aes-tmj.org to see if you could escalate this to the next step.
Can you now ask your spouse for permission to come to Chicago in February to learn more about comprehensive dentistry? I gave you a teaser of day one. I’ll give you a teaser of day two in the next AES takeover episode. Can’t wait to see you there. If you’re coming, let me know if you’re coming. DM me on Instagram or DM me on protrusive guidance.
Thanks again, my friends. I’ll catch you same time. Same place next week. Bye for now.

May 7, 2025 • 57min
Connective Tissue Disorders and Dentistry – PDP222
Why do some patients struggle with anesthesia, requiring multiple cartridges just to get numb?
Could your TMD patients have an underlying systemic condition that’s been missed?
Are you overlooking the signs of a connective tissue disorder?
https://youtu.be/gaoJKPTV_Z0
Watch PDP222 on Youtube
”When you can’t connect the issue, think connective tissue!”
Dr. Audrey Kershaw joins Jaz for a fascinating deep dive into the world of connective tissue disorders and their hidden impact on dentistry. Together, they explore how hypermobility, unexplained joint issues, and even a history of spontaneous injuries could be key indicators of an underlying disorder.
They also break down why dentists play a crucial role in screening and identifying these conditions, ensuring better patient outcomes and a more holistic approach to care. Because sometimes, when things don’t seem connected… they actually are.
Protrusive Dental Pearl: Don’t just take a “relevant” medical history—take a comprehensive one! Encourage patients to share all health issues, even those they don’t think relate to dentistry. You might uncover important clues about conditions like connective tissue disorders or sleep-disordered breathing, leading to better care and stronger patient trust.
Need to Read it? Check out the Full Episode Transcript below!
Key Take-aways
Ehlers-Danlos Syndrome is often misunderstood and underdiagnosed.
Patients with connective tissue disorders often face skepticism from healthcare providers.
POTS is a common condition associated with EDS that affects blood pressure regulation.
Many TMD patients may have undiagnosed connective tissue disorders.
Awareness and education about EDS are crucial for better patient outcomes.
The healthcare system can be challenging for patients seeking diagnoses.
Research on local anesthetic effectiveness in EDS patients is lacking.
Personal experiences can help in understanding and diagnosing connective tissue disorders.
Collaboration between healthcare professionals is essential for patient care. Genetic testing is crucial for diagnosing rare types of Ehlers-Danlos.
Dental professionals should be aware of the signs of connective tissue disorders.
Diagnosis can empower patients to understand their health better.
Holistic care is vital in managing symptoms associated with EDS and TMD.
Medical histories should be seen as relevant in dental practice.
Highlights of this episode:
02:17 Protrusive Dental Pearl
04:21 Dr. Audrey Kershaw’s Journey and Insights
09:45 Personal Experiences and Professional Observations
11:55 Diagnosis and Management of Connective Tissue Disorders
13:31 POTS (Postural Orthostatic Tachycardia Syndrome)
15:30 Understanding Ehlers-Danlos Syndrome (EDS)
24:55 Hypermobile EDS and the Need for Awareness
27:53 International Consortium of EDS GP Checklist
28:34 Genetic Testing and Red Flags
31:44 The Role of Dentists in Identifying EDS
40:32 Journey to Diagnosis
43:47 The Value of a Diagnosis
48:43 Dental Implications of EDS
55:00 Final Thoughts and Resources
“If you know one case of EDS, you only know one. Every case is different. Many are severely debilitated, unable to work or carry out daily tasks, often denying their struggles after years of being dismissed.” – Dr. Audrey Kershaw
Promised Resources
Podcast Recommendation:
Linda Blustein’s Podcast (about POTS and connective tissue disorders)
Specialists & Research:
Dr. Alan Hakim – A specialist in Ehlers-Danlos Syndrome (EDS) research based in London.
Norris Lab (U.S.) – Researching genetic markers for hEDS
Local Anesthesia Information
Resources for Screening & Diagnosis:
Diagnostic Criteria for Hypermobile Ehlers-Danlos SyndromeDownload
5-part-questionnaire-for-hypermobilityDownload
Symptomatic Joint-Hypermobility GuideDownload
Red Flag PatientsDownload
Educational Conferences & Talks:
Scottish Dental Show – Audrey is involved in raising awareness at this event.
Podcast with Periodontist Reena – Discussing HbA1c meters for diabetes screening in dental practice.
“If you can’t connect the issues, think connective tissues”. An EDS talk for professionals.
Advocacy & Support:
Learn more about EDS and Dr. Audrey Kershaw
Ehlers-Danlos Support UK Scotland – Audrey collaborates with them for better patient care pathways.
EDS PATIENT EMAIL Template April 2025
GMP EDS EMAIL TEMPLATE April 2025
Connect with specialists like Dr. Audrey Kershaw
Pack to aid identification of possible HCTD/EDS cases in the dental setting
1. Watch YouTube video made for Prof Tara Renton, by Drs Kershaw and Bluestein
2. Read this – https://gptoolkit.ehlers-danlos.org/
3. Fill out Oral Surgery Scotland Advanced Medical History Form
4. Fill out this – International Consortium of EDS GP Checklist
OR use this link – https://apps.apple.com/app/id6642710534
5. If appropriate, give patient EDS information email EDS PATIENT EMAIL Template April 2025
6. Send email to GMP GMP EDS EMAIL TEMPLATE April 2025
7. For any issues, or feedback, please contact Dr. Audrey Kershaw
If you loved this episode, make sure to watch Periodontal and Systemic Link – Correlation or Causation?
This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.
This episode meets GDC Outcomes B and C.
AGD Subject Code: 150 Health medicine and nutrition
Aim: To enhance dentists’ awareness and understanding of connective tissue disorders (CTDs), particularly Ehlers-Danlos Syndrome (EDS), and their impact on dental treatment, local anesthesia effectiveness, TMD, and overall patient care.
Dentists will be able to –
1. Identify key dental manifestations of EDS, including local anesthesia failure, TMD, and periodontal considerations.
2. Apply a multidisciplinary approach to managing complex TMD cases with suspected connective tissue involvement.
3. Appreciate the dentist’s role in identifying and supporting patients with suspected connective tissue disorders.
#PDPMainEpisodes #BestofProtrusive #BreadandButterDentistry
Click below for full episode transcript:
Jaz's Introduction: When you can't connect the issue, think of connective tissue. This message has really hit me like a bus. As you know from a few episodes ago, I had my own health issues with a spontaneous lung collapse. Don't worry, I'm okay now. That was scary and strange, but it made me look into my own health.
Jaz’s Introduction:Like I’ve had a dislocated shoulder and I’ve got stretchy skin and numerous other things, which you’ll see from this podcast with our amazing guest, Dr. Audrey Kershaw. She’s an oral surgeon and she’s so passionate about screening for and helping patients connect these seemingly unconnected issues to discover that they may have a connective tissue disorder.
And so why is it important for dentists to know about this? Well, me personally, and for Audrey, our TMD patients are highly likely to have some sort of connective tissue disorder, or at least have this label of hypermobility. And you’ll see why in the podcast where this label perhaps does it in justice also, we would’ve all had a patient at some point that was just difficult to numb up.
Like, you’ve given like five cartridges and this tooth is not going numb. Did you know that this could be a sign of a connective tissue disorder? And nowadays, we’re not tooth mechanics, right? We are really integrated in the health of the patient. The clinics that I see thriving are talking about the patient’s health.
Think about sleep disorder breathing, and how dentists are playing a key role in managing and screening for patients, obstructive sleep apnea, how we are giving this message of reducing sugar that’s so important for a patient’s overall health. Periodontists are getting very good at screening for and helping patients get diagnosed with diabetes.
And now we get to screen for connective tissue disorders. So for those of you who want to play a role in the patient’s overall health, which I think makes our career more fulfilling, this episode will really be right up your street. This episode is of course, eligible for CPD or CE credits. We are a PACE approved provider.
The way to get that is through the Protrusive Guidance app. The website for that is protrusive app. We have over 3000 dentists on there. It’s the nicest and geest community of dentists in the world. And we don’t use the Facebook group anymore. The Facebook group is now defunct, so please do join us on the app. So I would suggest going on Protrusive app, the website, making your account, and then downloading the Android or iOS app and then using those credentials to log in.
Dental Pearl:Now, every PDP episode I give you a Protrusive Dental Pearl, and one of the messages from this podcast is about the medical history. Now, I know we all take a medical history and we update it, but the problem is the word relevant.
We often take a relevant medical history, and if you only take a relevant medical history, you miss out on the patient’s overall health. For example, if I was going to the dentist where it says relevant medical history, I would never have thought to write about my several dislocations I’ve had on my right shoulder or various other health issues, which I just don’t think are relevant for my dentist.
So for example, your patients might have IBS or other things, and they aren’t telling you ’cause you’re the dentist. Why do you need to know? How is it gonna affect dental care? But actually all these things are important in the medical history ’cause part of screening for a connective tissue disorder, they are incredibly powerful and incredibly relevant.
So let your patients talk about their medical health and really encourage ’em to open up about everything. You’ll have a bigger and more complete picture about their general health. And the patient will also understand that, hey, this dentist, he’s more than just a dentist. This dentist, he or she is genuinely interested in my health.
So if you’re trying to practice dentistry in a way that looks after the patient’s general wellbeing, then this is a really important step. Like I said, it makes our job more enjoyable, more fulfilling, and it’s why I think airway and sleep disorder breathing in dentistry has really lifted off ’cause clinicians really feel that they’re making a difference.
Like for example, when I do my sleep testing and I get it reported from a sleep physician, and those times I’ve got a positive diagnosis, which is more often than not. So more often than not when I suspect that a patient has sleep disorder breathing and they get tested, I’m right. And you know what? That gives me a huge boost that I was able to help potentially add 10 quality years to this patient’s life.
Now you would’ve heard about that when I recorded that episode with Max Thomas. Go back a few episodes, check that one out if you haven’t already. We go deep into sleep testing and the role of the general dentist in screening for sleep disorder breathing. But I very much see this in the same realm. It’s all to do with the patient’s general health and wellbeing.
So hope you enjoy this podcast and I’ll help you to look out for things which perhaps seemed unconnected, but actually you’ll see that they may be connected. I’ll catch you in the outro.
Main Episode:Dr. Audrey Kershaw, one of the newest members of our community, and it is so, so nice to finally see you virtually, I guess, and have this long anticipated chat. Now, honestly, since I spoke to you on the phone, since my lung collects happened and everything just aligned, people are messaging me saying, have you spoken to Audrey? And like wow, there you are. How are you doing?
[Audrey]I’m very excited Jaz to be here. It’s just like everything is falling into place to try and help a lot of our patients and a lot of ourselves.
[Jaz]Yeah. And the first thing I wanna unpack is, just tell us about yourself into your journey into oral surgery, but then also why are you so well known? Why did you niche into connective tissue disorders and Ehlers-Danlos and relevance to dentistry, which we will unpack today, but your journey is gonna be really fascinating I think.
[Audrey]So I qualified from Glasgow in 1987 and I didn’t want to go straight into GDP, so I left Glasgow to Birmingham. I got a house job there, enjoyed oral surgery, so just kept sort of traveling around England. I fell into a lot of good jobs, Jaz, and at that time the Sunderland job probably still is a brilliant job.
Sunderland job came up after Birmingham, and then the Walton job in Liverpool. Your younger listeners won’t maybe recognize these names, but there was word booth in Sunderland and or in Liverpool. There was Il and David Vaughan. I just landed in good jobs. I enjoyed oral surgery, so I kept on, I got my fellowship. Ended up in Dundee, made it back to Scotland and ended up in Dundee.
[Jaz]At that time, Audrey, were there many women in oral surgery? ‘Cause I see so many women in oral surgery now. Was it always the case when you were training as well?
[Audrey]I don’t think there were just so many, Jaz, weren’t so many. So I have always changed what I’ve done in my career. ‘Cause I think if we’re going to be working for 35, 40 years Jaz, I don’t think we can keep doing the same thing. And I think you are doing that, aren’t you as well? So, I was doing a lot of Max Facts jobs and then went into sort of Dundee, dental hospital, the teaching there. Then I went into medicine and surgery teaching.
I left there about seven years ago, seven or eight years ago, and I went into private practice. I’ve always kept sort of just moving on and do you know those patients, Jaz, that we know there’s something going on. Local anesthetic doesn’t work. I’ve known my whole career, there’s something going on. The patients are not making it up.
They’re not putting it on. They’re trying their very best. And we have some colleagues that will say to these patients, you’re just feeling pushing. This isn’t sore. You’re just feeling pushing. I dunno who these colleagues are ’cause nobody will admit to it. But I knew there was something going on with all these patients. And about seven years ago or so, I discovered what it was.
[Jaz]And just to clarify, this wasn’t just the redhead patients, which are famous also for that. And so sometimes, we as dentists, we think that, oh. The patient is just very nervous. Hence why they’re feeling it, but it’s not always just the case.
[Audrey]So I discovered what it was chatting to a very good medical friend, joy, and she said, do you think this is Ehlers-Danlos surgery? I said, you’re talking rubbish joy. You’re talking rubbish because Ehlers-Danlos, as we all know, Jaz is blue sclera, stretchy skin, and very mobile joints. Now that is what I was taught back at dental school, and that is really still just about what’s taught these days.
As far as I can see. I didn’t understand Ehlers-Danlos, and a lot of our colleagues don’t understand it. So what I say in the lectures we give here is there is no place for doctor or dental bashing in this. Everybody’s trying their very best. There’s probably a very good lecture that I gave Tara Renton asked me to do a lecture for them. We gave it in December. Could you maybe put the link to that on your site?
[Jaz]Certainly.
[Audrey]On that talk, we have Linda Bluestein, who does a Bendy Bodies podcast in the States. I think I sent you her details already. Linda’s amazing. Linda is now 59. Linda shares her details very, very openly. She was only diagnosed when she was 47.
Now Linda is a doctor. I’ve also picked up several doctors on my travels now who have been unaware that they’ve had Ehlers-Danlos. Linda speaks very, very openly. She does amazing podcasts on this. She’s got 140 podcasts on all different things to do with connective tissue disorders, and we don’t pick it up unless we know what we’re looking for, and that is why I am excited to be here Jaz, and be excited to share all this with your listeners.
[Jaz]It’s something been so topical for me and you helped me so much because as many of our listeners know that last month I had a spontaneous pneumothorax.
[Audrey]Could we also add the word minor in there? Love that word. Minor pneumothorax Jaz.
[Jaz]Minor pneumothorax, this is a small little thing, which I mean, that hit me hard, right? And so when I was looking into that, and then you sent me some literature, show me that, okay, there’s actually a red flag for a connective tissue disorder. And that’s saying, I’m seeing it crop up everywhere when you can’t connect the issue, think connected tissue.
And it makes so much sense. And then you told me I was on the phone in the taxi on the way back from hostel and you said to me, how stretchy is your neck? And I was like, well, it’s about this stretchy. And then so you’re like, okay, well, and then my shoulder dislocations sub locations, history of that stretch marks in my chest.
I dunno if that’s one, but it’s a strange location to have stretch marks. So who knows? And then obviously because I’ve been so strung up trying to get my lung actually sorted. So seeing the thoracic people now, they weren’t interested ’cause I had this chat with ’em. No one was interested in exploring further or even thinking about, it wasn’t even their remote differential that this could be something, anything to do with connective tissue. They just think, well, it happens sometimes.
[Audrey]So just to tell your listeners, I think it was on the Wednesday that a colleague in Glasgow, Lorna. Hi Lorna. Lorna put my name forward to you saying you might want to talk to Audrey to learn about connective tissue disorders. Julia was organizing for us to talk on the Monday and she sent me a message at the weekend saying, Jaz should be okay to talk.
But he’s had a minor collapsed lung and I spent a fairly sleepless night Jaz thinking, I just feel this guy is an undiagnosed connective tissue. And then on the Sunday morning I put a lovely message to you saying I know that you’re asking what could this be? And you think it’s nothing.
And I thought, I’m blowing my chances for a podcast with you here, and then 12 hours later, you replied saying, Audrey, you’re a hundred percent right. And so the timing of this Jaz was just out of this world. It was like, how do these things happen? Yeah.
[Jaz]It’s the universe’s way of telling us.
[Audrey]You feel that there’s maybe some underlying cause for your pneumothorax?
[Jaz]Yes. The more I think about it, the more I look at everything and the more I look into it. But again, like I said, the doctors were just not interested. Now I know you put me in touch with some people that I’m gonna chase up on the emails, but it very much is the onus on the individual to get your diagnosis. So I’d like to know how you ended up getting your diagnosis.
[Audrey]Just to take a step back, your story is so, so familiar. Nobody is going to suggest a connective tissue disorder to you with everything. It’s gonna be some crazy dentist in Scotland that’s gonna send you a text on a Sunday saying, oh, do you think?
It’s such a familiar story. I laugh ’cause if you don’t laugh, you’re gonna cry. I found last year, 120 patients with a possible undiagnosed connective tissue disorder, 120, and it breaks your heart, Jaz, because these people go to their doctor and say, I’ve got this, I’ve got that. They get nowhere, absolutely nowhere.
So you’ve got to have all your ducks in a row before you go and get help. And then you’ve got to be very, very, forceful is not the word I want to use, but you have to be very, very sure of what you want. Now it is easier for you and me to do that because we have the knowledge education, eloquence sort of to do that.
Can you imagine what that’s like for somebody from one of the less well off areas, less well educated, less confidence to do that? It’s very, very hard. So Jaz, this is the first time being open about my diagnosis. This is the first time I’m being open about it. This is not about me, this is about our patients.
And I haven’t been open before because the journey has been very hard. I still have people in my life that don’t believe me, and it’s taken time after my whole life to get my mind around this and to be able to be confident enough to be able to talk about it. I also professionally don’t want people knowing too much because I don’t want people pointing the finger thinking, oh, well, if she’s got all this going on, how can she possibly be a oral surgeon?
So I’m still finding my feet on this. Whereas you are much maybe more open about it. But I’m very, very happy to share my journey. I’ve made a few notes here, Jaz, so excuse me if I just sort of read them. So I knew for my whole life, Jaz, there was something going on. I knew there was something that wasn’t making sense.
I knew it and I couldn’t put my finger on it. So I will tell you from a professional point of view, some of the things that people would notice if their colleagues are like me. So I said my first job was in Birmingham. Every Wednesday in Birmingham, we had a GA list for six months. Without fail, everybody waited for me to fall over to faint. Now that’s a sign of low blood pressure, maybe POTS, something like that. I thought I was going to have to give up being a oral surgeon because I couldn’t stand upright.
[Jaz]So it wasn’t necessarily like the site of blood, which some people might associate with that is, yeah.
[Audrey]I didn’t have a clue what it was. I think in those days, I don’t think the diagnosis of POTS was around, people didn’t know.
[Jaz]Tell us more about POTS, ’cause POTS only came into my radar when one of my TMD patients, she had POTS and I looked further into it basically. And obviously it’s all interconnected.
[Audrey]POT says Postural Orthostatic Tachycardic Syndrome. It’s all quite difficult ’cause some people fit the criteria of pots on certain days, but not others. So it basically means your blood pressure can be low. It doesn’t have to be low, but it means when you stand up, you can’t keep your blood pressure up. There can be many different reasons for pots, and at this point I would ask you maybe to put on the notes for this Linda Blue’s podcast on it because she gives a really good, yep.
[Jaz]A hundred percent.
[Audrey]So it basically means we find it very hard to stand up. Now, I don’t know about you and I don’t know if things will come out in this conversation that you think, ah, light bulb’s going on here again. I have had several nurses, they sit with their arms crossed on clinic. They stand with their arms crossed, they’re being told off on a regular basis.
Would you stop crossing your arms? And I don’t know if you can see me. We sit with our legs crossed as well. Now what we are doing there, we’re not just being closed off, we are pushing on our vena cava to try and get the blood back up to make ourselves feel better. Now we just think we’re being difficult ’cause everybody’s told us we’re difficult.
So when we’ve pointed out a lot of these signs and symptoms, I hope that your listeners will just spot people and they can maybe help them. So that’s POTS. When I was 28, I went to the doctor because my blood sugar was so low and I was told there’s no reason for having low blood sugar unless you’ve overdosed on diabetic drugs.
[Jaz]How low is low? Do you remember the measurement?
[Audrey]Somewhere between four to eight millimoles per liter is the normal blood sugar. Depends if you’re a diabetic or not a diabetic. And when I taught medicine and surgery, this was argued about every year anything under four can be seen as low. Anything under three, definitely low.
[Jaz]So the reason I mentioned that is just so the chiming in basically, it’s nice little self-discovery here as well. I did one of those, not Zoey, but there’s another brand, I forgot which one it was and I was like, it was like a blood glucose monitor the whole time. I don’t know how accurate they are, but mine was consistently 3.9, 3.8 at rest, basically.
[Audrey]Very interesting. Very, very interesting. I have also tried one of those monitors a few times because with Ehlers-Danlos syndromes, you can also get a higher blood glucose than you deserve with your lifestyle and your diet. So you can have it low, but you can also have trouble controlling your blood sugar.
The way that I found a 10-year-old patient few years ago was she came in to have ortho teeth out and the letter said, a borderline blood sugar. And I thought, okay, so we’re going to see quite a maybe und. Girl come in here quite, quite a grown up girl. She looked like a seven or 8-year-old stick thin. We then asked more and more questions.
Why did they find the blood glucose like this? Oh, because they sent us to Glasgow because she had GI symptoms. And GI symptoms are also a sign of Ehlers-Danlos syndrome. So, it was like more and more of the story came out. She was anxious, she was whatever. She ended up being an undiagnosed Ehlers-Danlos case.
[Jaz]What this is already reminding me of, you know how TMD tempomandibular disorders. They are known as the the great imitator, but already, Ehlers-Danlos with this varying presentation and this multisystem effect, it can be really difficult to nail a diagnosis. So I’m excited to see how actually. What advice do you give throughout the episode for our patients ultimately?
[Audrey]I think we’ve discussed TMD before Jaz. Almost every TMD patient I get referred to me as an undiagnosed connective tissue disorder. Now you’ve got to remember, I don’t see representative sample of the population. I see T MDs when people have struggled for like 18 months and think, what can we do, send it to Audrey.
But almost all T MDs I see are that and TMD is a sign of, yeah, so when I was pregnant, really bad. Really bad morning sickness. That’s not the correct term these days. I can’t remember what it is, but really bad morning sickness. That’s a sign of Ehlers-Danlos childbirth. Age of 31st one almost bled to death.
You just gotta laugh. They saved me, but almost bled to death. Again. Bleeding is a sign and symptom of undiagnosed connective tissue disorders. I then moved to Dundee at the age of 33. People thought I was a final year student at the age of 33, this is another sign in symptom of Ehlers-Danlos.
I’ll come a little bit nearer to the camera. I am in my sixties. It’s not showing off in any way, but it’s another thing is when you go out to the waiting room to call your patient in, you’re looking for a 35-year-old and there’s a 17-year-old sitting there. Had a patient last week, 38-year-old curriculum lead for the English in a busy high school.
People mistake her for a pupil in the school. It’s just a bit funny really. And the thing to say to somebody with Ehlers-Danlos is not, it’s so lucky you look young every other sign and symptom going, I think most people would give a good old wrinkly body to just not have it. But hey, you’ve just got what it is.
You’ve got, so I was always cold and cold as well as a sign of dysautonomia. But you get with, so lot of our colleagues are very, very cold. They come in with their leggings on underneath their chin X. They always have the long sleeve top on things like that. That is me. Everybody knows I’m always called. We also forget names. Jaz, that’s another thing amongst our colleagues. We forget names. I think it’s you’re raising those eyes to the ceiling there, Jaz. What’s that?
[Jaz]I’m terrible at names. Like I refuse to go to events where people don’t have their name on their chest. I mean, that is so reassuring to me. When I go to an event and have people have a name badge, I feel relaxed. When people don’t have name badges, I get anxiety.
[Audrey]Jaz, I can’t even remember my own son’s names. I call one of my nurses my dog’s names. But it takes it as a compliment, Jaz, it’s a compliment. There are all these little things. We don’t do caffeine very well after a certain age maybe. So we don’t seem very sociable, if you don’t go for coffee with the nurses or the staff, it can sort of look as though you’re not trying to fit in. We also don’t do well with sugar and an unhealthy diet. So, if somebody’s offering you a cake and work, you say, oh no, no thanks.
It’s not that I’m being really good, it’s just I know I’m gonna suffer a high gi. Diet as in too much sugar in your diet that makes your POTS worse. So, there’s many reasons and what we find about a lot of people like ourselves is we’ve already taken on the lifestyle without knowing there’s something wrong with us.
So we always make sure we’re well wrapped up. I noticed a post you put on today, Jaz, about going to bed at nine o’clock. We need a lot of sleep. We get tired really, really easily. So that’s another thing as well.
[Jaz]Very relatable.
[Audrey]So that was basically my journey. I had failed LA when I was 47. It was surgery under spinal. And I said, excuse me, because some of us elders done lost patients. We’re very polite. We do have our faults, Jaz, but excuse me. I can actually feel what you’re doing to be told by one of the team? No, no. You’re just feeling pushing. I left it a few minutes longer and I said, excuse me. You just got to laugh, Jaz.
It was horrendous. I said, and excuse me. It’s not just pushing, I do actually feel it very, very sharp and sore, just really to be told. No, you’re making this up. I hope I don’t have a those down. ‘Cause like you said, you wish you don’t have it. So my lower four incisors. Loss vitality.
Huge apical infection. We think it’s because orthodontics, yes, that’s the only source of trauma I had to her teeth. So, loss of vitality, my lower incisors. Fast forward many years. I now have a resin bonded bridge for my lower incisor. One of ’em lost, fractured, and my old principal, Amit, shout out to Amit Mahindra.
He was there removing my retained root of my lower incisor. Now, lower incisor classically an easy area to numb up. Okay? And he’s luxating it, and I can feel everything right. I can feel everything. So a lot of relatable things that you are saying. I don’t know. I haven’t been officially diagnosed, but just connecting all the dots.
[Jaz]There’s a very good paper as well that you could maybe put up on the link to it. It’s the best. We’ve got, I think it’s a 2019 explaining about local anesthetic. We need so much more research, Jaz, and if any d listening to this, wants to help in any way, wants to get into research with all of this, we need so much more research.
Certain types of LA work. Better than others. It’s all in the paper. So I always knew there was something wrong. Every so often I would find myself sitting in my doctors thinking, what am I here for? I just know there’s something wrong and I now know. So it was when I was 53 years old, a very good friend of mine, joy, who is medically qualified.
Joy, knows everything about me. We have wonderful chats and joy just said in the middle of a conversation, oh Audrey, do you think you’ve got tell, it’s Ehlers-Danlos. I said, you’re talking rubbish, Joy. And then within two or three minutes it was, oh my goodness. Oh my goodness me. So one of the things that’s a little bit confusing, but it didn’t delay me finding out Ehlers-Danlos is I am not overly flexible.
I don’t have the shoulders of pop out Jaz. I am flexible. If you come to a Pilates class or a yoga class with me, you’ll think, my goodness, she’s fairly flexible. That’s good. I used to think it was the rest of the population, Jaz that had issues, they really need to do a bit more exercise ’cause they’re just not all that flexible.
And then the discovered is me. That’s the one that’s just that little bit more so I can’t do the thumb back to the wrist trick, like that doesn’t come up. My elbows are not overly flexible. It’s not easy to see how flexible you are when you’re over 50 or whatever. Or sometimes it’s just not easy at all.
But you know, I was always a little bit more flexible, but I was never overly flexible, and that is one of the things that confuses patients and confuses everybody, these are called hyper mobility syndromes. I don’t like the term because it’s not easy to see if somebody’s hyper mobile. There may be where in the past, but not now.
And some people like myself really, were not overly hyper mobile at all, but we do have Ehlers-Danlos. It’s interesting because that’s worth exploring because what I was taught in the past and what I’ve been doing in clinic as well is yeah, we do the BA score, like a mock version. Can you put your thumb and stuff?
And if they can’t do all that, we think, okay, maybe you’re not a hypermobile and therefore maybe that’s not important in your etiology. But what you’re really saying is just ’cause they don’t have that feature doesn’t mean that they don’t have Ehlers-Danlos. But we’ve been using that as like a yardstick.
[Audrey]So we have a specialist in London, Alan Hakeem, who I’ve sent you his details. Alan is an amazing man. Alan is internationally, I think one of the leaders in Ehlers-Danlos. Alan will say, if you have a bait and score high enough, good. And if you don’t have a bait and score high enough, still fine. And the bait and score, I mean that’s only looking at what so many joints out of 300 joints in your body.
And sometimes we have people that had a patient last week, she had very, very bendy was the dislocated and hips, but she wasn’t doing well on the beaten or the Alan and the Hake and Scream score is out of five, and that’s maybe a better one to use for your clinic. But as Alan says, if you score over three on the Hake and scream score, fine.
But if you don’t, and another thing Alan will quite often say is they get annoyed because if you don’t score highly enough, if you’re not hypermobile enough, you don’t get let into the party. And we need to let these other people into the party. It was actually Alan that gave me the Ehlers-Danlos label. He saw me in London. Yeah.
[Jaz]And how does one get that for myself, but also for patients? Because I had this conversation, like I told you on the phone, I had these conversations with my TMD patients that, look, you are hyper mobile and that could be a sign of a connective tissue disorder. And we talk about it.
But really, I’ll be honest with you. I haven’t found, like no one ever says, okay, can you phone me to a GP? Because then they get lost. Like there’s no clear pathway. So I’m sure we’ll develop into how to do that. But how does one get a label? How does one get a diagnosis? Is it only through genetic testing or how is it done?
[Audrey]Up in Scotland, I struggled until about two years ago. I got this email out of the blue from Janet Ner and she’s a osteopath now working in cell Daikin fife, and it was one of these emails, I got Jaz. I thought, who is this from? Are they winding me up? No, she wasn’t. She had moved up from Chichester. I think Janet, excuse me, I’ve got that wrong.
And she had come up to Fife to settle and Janet also says on our website that she is also a bendy and I send my patients to Janet. Now, I have completely swamped Janet with patients. If you can see, I found sort of 75 patients last year and 55 or so others. Janet cannot keep up. With the number of cases that I’m finding for her.
So we have to be very, very careful who I now send on to Janet. So I am lucky up here. I I’ve got Janet, you know Janet can diagnose Ehlers-Danlos. Now, I love the way Janet works. Janet’s got a mind probably like mine and yours, Jaz. We don’t just assume, we want to look for all the evidence. I know where my knowledge is lacking.
I think the more you know, the more you realize you don’t know. So it’s very easy just to get a diagnosis of hypermobile e Ds ’cause that’s the most common. There’s another 13, 14, or so different types of Ehlers-Danlos. But they’re very, very rare, supposedly now any type of Ehlers-Danlos, when my friend Joy first said to me was supposed to be one in 5,000 people had it.
So I thought, right, I’m really, really rare. Hey, I’m special. And I thought it’s going to take me 1 77 years at the rate I work, I’m going to find an Ehlers-Danlos case. So when I found my first one, I thought that’s it for seven years or so. I see one in eight of my patients with an undiagnosed connective tissue disorder, one in eight everyday. I’ll say that again.
Speaking to other people, there’s a Welsh study that says one in 500. There’s a Northeast of England study from last year that said one in 227. There’s limitations to these studies because these are only the people that have been diagnosed. So I feel one in eight is maybe a little bit high, but that is what I find in my patients because people suss me out.
They don’t know why they’re sussing me out, but they suss me out and they find me. Yeah, I think it’s maybe more like something, one in 30, one in a hundred, but it’s definitely much, much more than we think. I’ve gone off at a tangent. How do we manage this? I have got Janet up in Scotland for this. Even the patients I see from the north of England, they come and see Janet. People will travel three hours or so to see Janet. It’s very hard if we don’t have a Janet in our lives. Have you seen Jaz, the international consortium of EDS GP checklist?
[Jaz]Unless you sent it to me. ‘Cause you sent me some things that I-
[Audrey]I can send to you, whatever we need. This is a checklist to see if you fulfill the criteria for having hypermobile Ehlers-Danlos, and it’s in three different sections, you have to have the bait and score, you have to have all the other signs and symptoms. And then the third paragraph is you have to not have other genetic conditions going. It’s okay, but it’s got it’s drawbacks.
I believe that is going to be updated by the International Consortium this year. If you fulfill the criteria for that, great. Fine. You get your diagnosis, but there’s those people that don’t quite fit in. If you have got a rarer sort of Ehlers-Danlos, that’s where I was starting to talk about genetic testing.
The leaflet I sent you, it was talking of the red flags. If you’ve got any of those red flags, you should be able to get genetic testing. We have patients that go to rheumatology, genetic. They get turned away from rheumatology ’cause maybe rightly so. That’s not the right place for them. I personally have been through all of this and it’s very interesting as a experienced clinician sitting in front of someone who will not take you seriously.
And I have come out and I’ve walked around the nearest park. Crying my eyes out in floods of tears because it was so, so difficult. So Janet and I are also picking up many, many more rarer types of Ehlers-Danlos, and they go for genetic testing. It takes time to pass through that national health service.
We can try that. We can go privately as well. Janet would be better talking at this than I am NHS. If you go to get tested, you don’t get tested for all the other 300 or so connective tissue disorders as it could be. If you go privately, which is about 500 pounds, you can, so it’s not easy. In Scotland, I work with the Ehlers-Danlos support UK, Scotland.
Got a family friend who’s an MP member of the Scottish Parliament. Okay. I got him involved. Mike Mara. Mike has been great and he has been helping us get this through the Scottish Parliament to try and get better care pathways for patients. So the answer, how do we do this, is we say to the patient, you’ve got a few signs and symptoms of a connective tissue disorder.
I am not qualified to diagnose you. I’m not an expert, but I do know something on this. I sent them some links, I think they were maybe the links I sent to you for the Ehlers-Danlos websites and whatever. And also Linda Stein’s, Betty Bo Bendy body podcasts, ’cause I’m finding that so much more useful now than anything else.
‘Cause Linda’s great as I kept saying. So we give them that. We say, do you want us to write to your doctor? I have a standard letter to write to the doctor to say, we’ve met so and so. They’ve got all these signs and symptoms. It may be suggestive of a connective tissue disorder. They’re interested in taking this further.
Some patients get places other patients don’t. So it’s basically very, very hard Jaz. Very, very hard at the moment, and that is what we’re trying to campaign for and push for through the parliaments and the healthcare providers. I’m also trying it in my own way by doing these podcasts and lecturing, going to the Scottish Dental Show.
We have now lectured to about a thousand healthcare professionals, and I now have people who have been on my talks saying they’re now picking up. Undiagnosed Ehlers-Danlos cases or undiagnosed connective tissue disorders.
[Jaz]But just to clarify, the main way, therefore, for those who don’t fit in the consortium sort of standard pathway is genetic testing.
[Audrey]There is no genetic test for being hypermobile EDS. There is no genetic test at the moment. The Norris lab in the states, they think last year they’ve maybe found four different causes that could be genetic for hypermobile Ehlers-Danlos, but we’re not there yet. So we’re in this no man’s land of, there’s no genetic test.
It’s a clinical diagnosis. You need to find somebody who can clinically diagnose you, that knows what’s going on. GPs should be able to clinically diagnose, but to me the problem is it’s like somebody saying, I’m a dentist. I should be able to diagnose your perio disease. I’m a oral surgeon, Jaz, don’t they asking me to do this?
Yeah. Very hard because as I said before, there’s no place for doctor bashing. These GPs have been taught very little about connective tissue disorders. They’ve been taught that it’s blue sclera, stretchy skin and mobile joints. If you don’t fit into that, that’s not you. I’ve been there with my GP and it’s very, very difficult. You’re told you’re being anxious. You’re depressed. It’s like I don’t get depressed.
[Jaz]Interesting. It reminds me of something that James and Spencer in the US taught me, right? He taught me that, and I share this and I always name drop him is TMD patients are NUTS. Okay. I’m sure you know where I’m going with this.
And so it sounds like, these suspected ED patients are nuts. And really what NUTS stands for is not understanding their symptoms. Right? That’s what NUTS stands for. And then that is a whole plethora of consequences, but let’s just connect it all together. One in eight patients that you see, now, is that one in eight of your TMD patients?
[Audrey]One in eight of all my patients. All of them.
[Jaz]Okay. So what about specifically your TMD patients? What percentage or what ratio of those?
[Audrey]Almost every TM joint patient I see is an undiagnosed connective tissue disorder.
[Jaz]Okay. Let’s go with that then.
[Audrey]Yes.
[Jaz]Because I see plenty of these as well that individual, what should the dentist be saying to them, because I feel as though the pathways, like you said, aren’t quite clear yet. So what is our role in communicating and screening and helping them?
[Audrey]Jaz as I was making up my own template and I had a massive medical history that I would ask everything going, and I would send this to Janet and it would be all over the place, and I couldn’t ask enough. Linda Bluestein, again, has come to the rescue and she has got a sheet on her bendy body’s website, and it’s basically just listing all of the possible signs and symptoms or most of them. So what I do now is I go through this and I just tick them off.
Did this for a patient yesterday. I just go through it. So do you have acid reflux issues. Do you have irritable bowel syndrome? Do you get anxious? Do you have poor sleep? Do you this or that? We just go through it. It doesn’t give you a score or anything, but it just has the patient opening up.
Just to go back to what you said about TMD, what I feel sometimes throughout my career on TMD was we just see the TM joints. We don’t think the TM joint is connected to the rest of the body, and I do remember whether it was, what, 20 or so years ago, 30 years ago. It was said people with TMD were more likely to have GI issues.
One thing that you had said in a podcast, a TMD podcast, because I’ve listened to so many of yours when I’m traveling, so thank you for keeping me company on that. You had mentioned that you can only see a certain number of TMD cases because they exhaust you. For want of a better word. They are so demanding is not emotionally.
[Jaz]Emotionally, no, yeah. Not in a bad way for them, but like as a clinician, like, therapists need a therapist. It is draining mentally and emotionally. And concentration.
[Audrey]Absolutely. And that wrong, true for me when I was listening to it, and I so appreciate you being so honest in these podcasts. ‘Cause I find it because I’m highly sensitive with my elders Danlos. It may be difficult to, to find people that can understand and talk to about this. What I find about my Ehlers-Danlos cases is, I so want to be there. But I have to give so much a consultation telling somebody who came in thinking they were fit and well saying, do you think your unconnected signs and symptoms are connected?
I think you might have this. The supporting them through it, we absolutely want to be there. My job wouldn’t be the same if I didn’t, but it really does take it outta us, and we have to be so, so careful to look after ourselves when we’re doing these things. Some cases are much more draining for want of a better word than others. I mean, I will be drained by any day. I’ll give as much as I have. Some are more draining than others. All of them are so rewarding.
[Jaz]Rewarding is a huge element and that that balances out and it’s so great to do that. But you know, TMD patients, it’s a category of chronic pain and they are just like any sort of medical issue, dental issue, once they have it, once they’re prone to have ebbs and flows, right? And so flareups are normal course of TMD, it’s not like a straight line goes up and down, up and down and it varies depending on so many factors. So I’ll give you an example, right?
The other day I opened my email inbox and a patient who I’d seen who travels hundreds of miles, see me. She saw me and she was having a flare up, and I’d just read her email and I started to get palpitations. Now, I haven’t done anything wrong here. I helped her big time. She was in a really bad way.
Some conservative care. Later she was feeling amazing. A year later I see an email, and now she didn’t mean to upset me. It was me that I got upset. I’m not upset, but like I started getting palpitations. Just reading that she was getting a flare up and it affected, it is like it really affected me. Cut me. And so this is how, just a peripheral. Drainage that can happen as well on the side when you feel everything your patient feels.
[Audrey]Yes, and I think the T MDs and the Ehlers-Danlos centers, we’ve gotta be so, so careful that we keep our energy levels up so we’ve got enough to be able to give these patients. Because I think if I didn’t have Ehlers-Danlos patients to pick up, I don’t know if I would still be a working because it is so rewarding. And I think another thing I meant to see was I feel very humbled that I have discovered about Ehlers-Danlos syndromes, and I am in a position to be able to help so many people, and that is not supposed to sound bigheaded whatsoever. I am so humbled to be able to do this, and as I said before-
[Jaz]Even a major facilitator.
[Audrey]Yes, it is not just me that can do this. I have taught others to do this and before I stop working, I dunno how many years next year, five, six years, seven years, I need to have left enough dentists to be able to pick up all these cases and to help them. And it is such an honor to be able to do that Jaz. I think you u of D can get that as well.
[Jaz]The famous study, the opera study-
[Audrey]And that is so well known about these days. If you listen to Tara Renton, go on about TMD these days. TMD is related to sleep disorders, headaches, migraines. There are papers to say migraine sufferers and Janet knows this paper are 95% chance of having an undiagnosed connective tissue disorder. So if I see on a patient’s record reflux headaches and migraines, you are just, it’s like, oh my goodness. There’s another one. So this is one of the things I’ve got in my list to speak to you about here, Jaz.
We need a better dental flow chart for how we manage this. Until very, very recently, Jaz was very alone with this because I was stepping outside of what all my other colleagues did and I was willing to do it because I’m in my sixties. An outlier.
[Jaz]An outlier-
[Audrey]And it’s like, I know there’s still a lot of people out there thinking, what is she up to? Don’t care, Jaz, don’t care. I feel we are just having a chat together. We’ve gotta remember so many other people going to be listening. I want and I need help to get something sorted. Last year I listened to a talk, Tara Renton did, and it was a TMD one, I think to do with sleep apnea and oh. Tds and everything else.
It was a great talk, as in all Tara’s talks are, and I thought, I’m going to email this woman. I’m emailing her a as I do a lot of people, I thought, I don’t expect her to answer. And she wrote back saying, dearest Audrey, count me in or something. And it was like, Tara, I love you. And so Tara has also had her eyes opened to Ehlers-Danlos syndromes.
So that was the start of me feeling I was getting somewhere. I was so pleased to hear from you as well, Jaz. I need people to join with and we need to sort this out for our dentists to be able to take this forward. We basically need to go over the medical history. Tara says as well, lot of medical history says relevant medical history.
I get so annoyed about that. Tara gets so annoyed about that. I want to know everything. I want to know if your shoulders pop out. I want to know if you’ve had a collapsed lung. I want to know things that don’t seem to tie in, because all this is very relevant. When we do go through the medical history with the patients with the Linda Bluestein sheet, they’re just so funny.
They’re just so funny because you say, do you have any acid reflux issues? Well, I don’t really listen, want a yes. I don’t, no. Do you or don’t you? Because throughout their whole life they have, and this is me as well, the normalized it. It’s just, oh, this doesn’t matter. This is just ’cause I’m being silly.
It’s because I’ve eaten the wrong thing. It’s because I’ve done yoga too soon. We had a very interesting patient, Beth, who appears on the talks with me and Beth is great, and she’s so funny. Beth says, she just always knew. She had to eat a few more veggies and do a few more yoga classes and she would be okay.
And she came in to see me to have a wisdom tooth out. And we just laugh about this now. We knew before she came in from Poppa’s in her medical history, she’s going to be another Ehlers-Danlos case.
[Jaz]And so let’s talk about her, if that’s okay. ‘Cause she obviously comes on with you with these talks. How did she in this individual came to you for a wisdom tooth distraction. You noticed these things and then how did she end up as a case study, get her diagnosis.
[Audrey]I also wanted just to say, Jaz, how would you like to do another podcast with four or so of my dental patients that I’ve picked up? I’ve been looking for somebody to help me with podcast Jaz, and I was so delighted to hear from you.
I’ve got great patients that would come on and tell their stories, and I think it would be great for your listeners to hear. So, when Beth came along, she needed a wisdom tooth out. Her medical history had a few little bits in it. Maybe like reflux anxiety. There wasn’t a lot in it, but I work in about eight or nine different places, Jaz throughout Scotland.
The reception team, my treatment coordinator. The nurses, they pick them up before I do. Now they pick them up the same way as I sort of wondered about you. We just need a little hint and we’ve picked them up. So most of the time we know before these patients come in. So Beth, thank you so much for letting us share your story seriously.
So Beth came in, she had horrendous wisdom teeth. She was very anxious. Absolutely lovely girl. We’ve been for dog walks on Ti Ferry Beach together. Patients with Ehlers-Danlos can also Jaz, have a very similar personality and that was one of the things that made me write you that message on the Sunday morning.
You are very sensitive, you’re very caring, you’re very kind, you’re very in touch with your feelings. And we can pick this up with patients, you know that patient, that sort of phones a couple of times before they come to ask. Would it be okay if they come 15 minutes early? Where are they going to park their car?
Blah, blah. It’s like, ah, we think they’re s done lost, we can pick them up. So Beth, we suspected it. Wisdom teeth were horrible. I told Beth, there’s no way I’m doing those wisdom teeth for you, Beth, because you’re so anxious and you need to get Beth on because she gives a really good story.
Beth knew what I was saying was right. Beth knew that she could trust me. This is very, very humbling, Jaz. And these patients know when they can trust you because we listen to them. We don’t tell them they’re talking rubbish. We listen to everything nobody’s ever listened to before. So in the end, Beth ended up in tears and said, there’s nobody I’m going to trust apart from you, Audrey.
So, my treatment coordinator wondered what I was up to and we brought her back later on. But Beth trusted me. Beth, I said, I say to some of my patients, you need to see Janet. Beth went to see Janet. Beth found Janet. So, so helpful. And Beth and Janet have got on and Beth got her Ehlers-Danlos hypermobile diagnosis from Janet. Beth will tell you how their lives have been changed.
It is utterly life changing. Now, it’s not just me that can do this. It’s any dentist listening. It is utterly life changing. I know how life changing it is, Jaz, because when I discovered what I had completely changed me as a character and changed my life.
[Jaz]And let’s talk about that. In what ways? Because it may not be obvious to someone who hasn’t had any health issues before. Because ultimately there’s no treatment. There’s no cure, there’s no, what is it that you gain from that label and how important that is.
[Audrey]A lot of doctors and gps will ever say, there’s no point in knowing about this ’cause, nothing we can do. We cannot cure it ’cause it’s a collagen defect. But if we take the POTS for example, there are so many different things you can do to make that better. I go to little because the cues are shorter. If I go to Tesco, I feel so ill, I can’t go into Tesco. ‘Cause of the bright lights, the heat, and the standing in cues, you don’t stand around. You move from food to food.
You have a chair in clinic, you have to drink plenty of fluids. That was a way that a colleague discovered I was, I had Ehlers-Danlos syndrome because I’d agreed the great. Big water bottle. You have to increase your salt intake. You need to get very, very fit. You have to exercise. There was a German study that showed most of the symptoms of pots could go if you had a really good exercise regime.
That’s not what it’s like for every day, and that’s an interesting study in good on them. But you have your fluids, your salt, your exercise, your sleep. But we’ve also got to remember with all this Jaz, and it’s the same for TMD, you cannot see one thing in isolation. Everything is tied in.
If your POTS is worse, that’s going to make you more anxious. If your anxiety’s worse, that’s gonna affect your sleep. If your anxiety’s worse, you’re not gonna be able to cook so well and everything. And then if you’re not eating so well, it’s just everything is so tied up. So one lady I found.
She said that what her son always said to her was that she is always living on a knife’s edge. And that’s how I sometimes feel. We have to be so, so careful to do everything we need to do. And you’ve had a podcast, I think with Simon about this and that was a really interesting podcast ’cause he was saying about the really important things, and this really goes for patients with Ehlers-Danlos syndromes.
The fluid, the diet, the exercise. He had some letters that said about it. Sorry Simon, I can’t remember what they were. And that is so, so important. So there are very much things we can do, but what it matters. Getting the label is you don’t doubt yourself anymore. You don’t let people put you down.
Oh, why are you being so difficult? Or why you’re always so cold? Or, why do you have to do that? Why do you have to sit with your arms crossed? We can now say to people, yes, I know. It’s funny. I always sit with my arms crossed. But this is me trying to keep my blood pressure up. So can we just laugh about it and get on?
Can you just remember I’m one of these funny people? For example, you were saying Jaz about not remembering people’s names. I was in one job. Where I got such a hard time for not being able to remember people’s names. And that was before I even knew about Ehlers-Danlos. And I would say, listen, it’s just something about me.
I cannot do names. I don’t even do my children’s names nowadays, when it’s on about names. I can address these people with much more confidence and eloquence. I say thank you so much for bearing with me. I don’t even give my own names, my own children’s names. This is something just to do with the brain fog, with the low blood pressure, and it’s just easier. Rather than people saying, you’re just being stupid, Audrey.
[Jaz]I totally get that. I think it’s to understand a lot more about yourself and when you stand about yourself, you can then live a life more purposefully, more optimized for you. And then when things just make sense in your life, then you can actually proceed with be your best foot forward. I think that’s the main benefit.
[Audrey]I think just being allowed to own our own issues, like I luckily don’t really get sore joints because I’m not allowing myself to have sore joints. But a few years ago I got really sore joints. I had to stop learning Spanish on my phone because moving my fingers hurt my elbows.
Sometimes I have to get rid of my big herbal tea cup because that was hurting me. Just to understand that we’re not being silly and think I need to exercise, I need to do more weights, I need to do more Pilates, rather than just I’m just being stupid and go away in a corner and hide away. What I would say though, Jaz is, a lot of people are striving to get a diagnosis.
A diagnosis is not a be all and end all. And I would say to patients, if we get a diagnosis, fine, good. But what I say to them is, I’m not telling you anything you don’t know, but all I’m saying is do you think all your seemingly unconnected signs and symptoms are actually connected?
Go away and live with that. It doesn’t really matter at the moment, the label we’re slapping on it. Yes, it would be nice to get a label at the end of the day, but let’s just work with what we’ve got and let’s get you off to the exercise classes. Let’s get you increasing your fluid, improving your diet, improving your sleep. Yeah, that’s what I feel. I love that.
[Jaz]I mean, it is a total health message and so as we come to the last 10 minutes of the show. Patients, I know you see so many TMD patients as an oral surgeon for the general dentist listening, what other things that do you want them to know to look out for, for example, anesthetic.
That doesn’t work. Okay. We know, I remember from dental school that s dentist was linked to periodontal disease. Okay. I remember that, but not much more in terms of relevance. It has to-
[Audrey]What I do is direct your listeners to my lecture that is on YouTube channel. I think I’ve sent that to you already, but I’m very happy to send it all on again.
[Jaz]Yes, I’ll put that one.
[Audrey]Have a look at that, because that is really the dental implications of EDS. So local anesthetic doesn’t work. They can have white spots on their teeth. Molar incisal, o hypo mineralization. I’m on only a neural surgeon. So I don’t know when something is hypo mineralization or a white spot.
So I just call it a white spot because I don’t wanna get in trouble with anybody. So patient I saw this week, even before we said very much, I could see the white spots on her teeth. I made a little list just to remind me because I knew there was so much to talk about. So failed local. When you give the local, these are the ones that don’t like adrenaline in it because they get palpitations.
MIH. These are the patients that are anxious because anxiety and depression goes with Ehlers-Danlos. So they’re anxious. But Jaz, if you listen to these people, if you’re on the right side of them, if your receptionist gets them sorted. They will trust you to the moon and back. And they will not be anxious.
They just need to know. So the anxious ones, they have a narrow V-shaped palette. Orthodontics works faster than usual. They have pulp stones. So they are the big ones that I find. I think that’s about all of them.
[Jaz]Great. And then, so what’s the main message that from that lecture that you did, for example, what’s the main takeaway that you want dentists who have enjoyed the listening to your journey, but also how we can look out for things in our patients, how we can support them, and how the saying when you can’t connect the issue, think connected tissue. What’s the main message that you want to give to the general dentist?
[Audrey]All the medical history is relevant. If we are aware of connective tissue disorders, we can make our lives much easier. ‘Cause we know those patients are gonna need a couple of minutes more chat on the phone before they come in to get them less anxious.
We can make it much easier for us when we’re doing the local, we might pick up that it’s not going to work, it’s just gonna make our lives much easier. If we know we are also going to make the patient’s life’s much easier and those patients are gonna be so delighted, so loyal, we’re just gonna make it so much better.
We also have to remember, Jaz, I have had many, many of our, let’s call them practice staff come to me after watching my clinics and say, Audrey, I think I’ve got this. I was trying to figure out how many practice staff I’ve picked up. We’re probably talking about 50 or so people who come to my lectures.
There’s always people afterwards that contact me saying, Audrey, this is me. So we need to see everything is relevant. It was last week I had a 26-year-old man in with really hypoplastic sixes. That’s very likely Ehlers-Danlos, he was anxious, he was depressed and he had gastric reflux. Now, if somebody had picks up those, I dunno why anybody hadn’t sorted those hypoplastic sixes, but I was taking one of them out.
He was educated, he was at whatever else, but nobody had said. Listen, I think maybe something’s going on here. Luckily the local anesthetic worked, so I think it’s just be aware and if we can, I’m not saying everybody needs to pick up every case, but this is gonna be life changing. All these patients, I see it’s absolutely life changing.
[Jaz]I think it’s important because before dentists used to be very much tunnel vision, the tooth, and we’ve grown so much as a profession away from that. And so now we are incorporating sleep disorder breathing. And screening for that, we’re a stop back and in generally steep, in general, we helping to manage patient’s anxieties and this is one facet of it, right?
Looking a reminder, a really helpful reminder today to look at the patient as a whole and connecting the systems together and helping to speak about health. A wonderful thing to speak about health ’cause who’s not speaking about health to patients? The general, the GPs, because they’re seeing when the patient has a problem, they’re speaking about that problem or one or two problems. We have a great opportunity in dentistry to speak about their health in general, and you know what? I think that makes our career more fulfilling.
[Audrey]What I would say about the GPS is. As somebody that works privately, I can have as long as I want for a patient. I’ve heard you say before you have 75 minutes for a TMD patient. If a GP is listening to this they are wondering, how can they manage on a 10 minute appointment, so I really, really feel for the GPs, but I listen to the talk from the very nice per girl who, I can’t remember her name, obviously.
[Jaz]Rena?
[Audrey]Rena. She has bought a, was it a hba one C meter?
[Jaz]Yes.
[Audrey]How wonderful is this? Because all of these things tie in with everything we’re doing, you know? I’ve started asking for hba one Cs whenever I can for patients because it is also relevant, whether it’s a burning mouth or, and also vitamin D levels as well. And I know this has said a lot in your podcasts, Jaz, we’re all thinking along the same lines and I’m so glad you contacted me, jaz, and I am so glad we’ve got a chance to spread the message and a chance for all those guys to get to know each other and maybe work together.
[Jaz]Well, thanks for joining the community on Protrusive Guidance. It’s been great to have your contributions on there already. And also thanks for making us all vulnerable today in this episode. Honestly, thank you for doing that. That really is-
[Audrey]I appreciate that.
[Jaz]A real, real pleasure to to hear your story. Thank you for sharing that with us. ‘Cause it’s gonna inspire so many of us and I think to continue to pedal that health message. I think this podcast has been so good and eye-opening. And this might then trigger a chain of events to help us help, get that health message across to our patients. Talk more about health to our patients. Do some further learning for me, I mean, you’ve been incredibly helpful in terms of getting me to think more about my own health. And what’s more precious, valuable than that. Right. So, hoping everyone enjoyed that. And Audrey, I appreciate your time.
[Audrey]Pleasure, Jaz. A pleasure to come on and chat to you.
[Jaz]I will put all the resources in the show notes, so your video, any links. So basically if you just send me a mega bundle and so I just don’t miss anything and I’ll put it in the show notes. So in Spotify they scroll down, YouTube rather. They can find your lecture, they can find any goodies that you think will help dentists. That will be one.
[Audrey]I want to say to any of your listeners if they have any questions, whether they’re personal or work related, please my email is hello@oralsurgery.scot, if you just Google me, Audrey Kershaw, you’ll find me. Please, we’re here-
[Jaz]Also on Protrusive Guidance so you can DM you as well and that’d be great.
[Audrey]So pleasure guys.
[Jaz]Thanks so much all appreciate you.
[Audrey]Take care.
Jaz’s Outro:Well, there we have it guys. Thank you so much for listening all the way to the end. Slightly different theme of the podcast. So for some of you who love the clinical details. You may have not loved this episode as much and that’s, that’s totally cool, right? But I think the vast majority of you really would’ve loved Audrey’s journey because this is an oral surgeon, really, she wears her heart on her sleeve and she really made herself vulnerable and shared so much.
So thank you so much again, Audrey. And dentists were humans first, then dentists. And you may be able to recognize things about your journey, about your life and your health. Anytime we can talk more about health that conversation that we have with yourself about looking after your health or the conversations we have about health with our patients.
It can only be for the better. So if you’re watching or listening to this episode on the app right now, scroll down. You could download the premium notes, you could download the transcript. You can download all the goodies that Audrey promised, and of course, answer the quiz. Get 80% and you get your CPD certificate, like you’ve done all the hard work, you’ve listened all the way.
Why not get that certificate now to prove you’ve learned something? It also gives you opportunity to reflect, which is important for your personal development plan. Yes, all this requires a subscription, but I think it’s genuinely one of the most valuable subscriptions going in dentistry, especially if you listen to every single episode.
Or most episodes, it just becomes cost effective for you and you help to support this podcast and help it grow. So if you wanna join our best plan, that’s the Ultimate Education plan. You’ve got all our masterclasses as well. The easy link for that is protrusive.co.uk/ultimate, and that’ll take you to the right page.
Thank you once again for listening all the way to the end. Catch you same time, same place next week. Bye for now. Oh, and of course, thank you to Team Protrusive. Without the team, I would be lost and I would’ve quit podcasting four or five years ago. So thanks so much for Team Protrusive and of course, thank you, the listener for helping spread the word and helping us to make dentistry tangible.