Protrusive Dental Podcast

Why should Dentists be talking about screen time with parents? Are smartphones even safe for children? What is the right age to give a child their first phone? Laura Spells and Arabella Skinner join Jaz in this thought-provoking episode to tackle one of today’s biggest parenting challenges: smartphones and social media in young hands. Together they explore the impact of early phone use on children’s health, development, and mental wellbeing—and why healthcare professionals should be paying close attention. https://youtu.be/7RUJZqtEr18 Watch IC061 on YouTube  Protrusive Dental Pearl: Live by your values—not your profession, spouse, or children. Don’t sacrifice for them; choose what aligns with you, so love never turns into resentment. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Screen time is a significant public health concern. Mental health issues are rising due to social media exposure. Early childhood screen time has long-term effects. Parents need clear guidance on screen time limits. Community support is essential for children’s well-being. Health professionals must ask about screen time in assessments. Regulatory changes are needed for safer screen use. The impact of social media on self-esteem is profound. Misinformation about health trends can lead to dangerous practices among youth. Dentists play a crucial role in educating patients about safe health practices. Parents should engage in conversations about social media with their children. Creating a family digital plan can help manage screen time effectively. Collaboration among health professionals needs to raise awareness about the dangers of unregulated products. Empowering parents with knowledge is essential for effective parenting in the digital age. Role modeling healthy behaviors is important for parents. Highlights of this episode: 00:00  TEASER 01:18  INTRO 03:13 PROTRUSIVE DENTAL PEARL 04:54 Introducing Our Guests: Arabella and Laura Spells 09:24 Statistics and Scale of the Problem 18:09 Early Years and Screen Time 22:27 Safer Alternatives and Regulation 27:08 MIDROLL 30:29 Safer Alternatives and Regulation 30:53 Ideal Guidelines for Screen Usage 34:01 The Role of Dentists in Addressing Social Media Issues 44:59 Parental Guidance and Digital Plans 53:53 Final Thoughts and Resources 56:06 OUTRO ✅ Action Steps 🔹Seven Habits of Highly Effective People by Stephen Covey for habits that support balanced parenting and leadership.🔹 Kindred Squared School Readiness Survey on how early screen use impacts child development. 🔹 Follow Health Professionals for Safer Screens for practical tips to share with families, and on their Instagram for bite-sized advice🔹 Support the Smartphone-Free Childhood Campaign to delay smartphone use in children. If this episode gave you new insights, you’ll definitely benefit from Parenthood and Dentistry (Even if You’re Not a Parent!) – IC025 #InterferenceCast #BeyondDentistry #Communication This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A and B. AGD Subject Code: 550 PRACTICE MANAGEMENT AND HUMAN RELATIONS Aim: To provide dental professionals with an understanding of the health risks of early smartphone and social media use in children, and how dentists can play a role in safeguarding and guiding families toward safer digital habits. Dentists will be able to – Recognize the health and developmental impacts of early and excessive screen use. Identify how social media contributes to anxiety, body image concerns, and misinformation (including dental-related fads). Discuss practical strategies that families can use to create healthier digital habits. Click below for full episode transcript: Teaser: We have to address the issue in early years because if you've had your child sitting on a screen from day one, by the time they get to eight or nine and they want a smartphone, which is the ubiquity in their pocket, it's really hard to explain to them why they can't have it. Teaser:What is the right age for a smartphone? Yeah. We would say that smartphones with full internet connectivity and everything involved and social media, it’s- This smartphone usage has become almost the norm for every teenager across the country. And of course what a smartphone does is allow people 24 hours to access to the internet, to social media, to all the unfettered things that we need to, they can see. If you think about whole child health, and that’s how we should be approaching health for our children. Obesity’s gone up. There’s huge linkages between the seditary behavior of being on screens, but not just the seditary behavior. Because actually if you are sitting on social media or you’re sitting on gaming, you are targeted by fast food manufacturers in a way, way more than you would be on TV. You could have a big argument about the quality of what children are doing on screens when they’re 15, 16. Or they learning to make music. Are they revising and doing things, but for a two, three, 4-year-old, there are no benefits of being exposed.  Jaz’s Introduction:What a time to be alive as a parent. Back when I was a kid, I would go and play football for hours. My parents, they kind of knew where I was, but there was no way to reach me. And the other thing I remember is that when I was a kid, I wanna go to cinema. And then so you agree with your friends that, look, I’m gonna see you at 11:00 AM, at the cinema on Saturday. And there was none of this like texting and WhatsApp and Snapchat and that kind of stuff, and you would just show up at 11:00 AM on Saturday, and that’s a simple life that we lived. But now with smart phones and social media, I really worry for our children, which is why I brought some experts on to discuss phone use in children and best practices for screen time and smartphones. And so you are thinking Jaz, what has this got to do with dentistry? Well, we have an active role to play as healthcare professionals. Early smartphone usage and social media is absolutely detrimental to the health of our children. And as healthcare professionals, we have a duty to know about this and to spread the good word. And many of you, like me, are parents, and we need to hear this stuff. We need training. We need guidance, and that’s exactly what we bring you today. You’re gonna love our guest, Arabella and Laura. But I wanna say thank you to Protrusive community member, Lydia, Dr. Lydia Roulston. It’s been so nice to chat to you on the app, give each other book recommendations, and you are part of this very organization that’s helping schools and communities to realize the dangers of having smartphones in young hands. Dental Pearl:I’m so grateful that you’re part of our nice and geeky community. Now, this is an Interference Cast, which is like the nonclinical arm of the podcast, and I usually reserve my Protrusive Pearls for the actual PDP episodes. And as many of you know, I actually struggle when it comes time. I freeze up when it comes time to give a pearl, ’cause I’ve given like 300 in the past. I’m kind of running out of nuggets. Like obviously there’s an endless amount of dental nuggets and gems out there, but to suddenly pull one out can be a bit tricky. But you know what? I’ve got one from the heart. So even though it’s an icy, I still want to give a pearl. And it’s like from the heart as a parent. In the book, I think it was Seven Habits of Highly Effective People by Stephen Covey. It talks about being value centered and not being like a profession centered, like your entire world shouldn’t be about being a dentist. Your number plate shouldn’t be dentist. You shouldn’t introduce yourself to, hey, I’m Jaz, I’m a dentist. Like, your identity should not be your profession. The world also shouldn’t revolve around your spouse, nor should your world revolve around your children. Your world should revolve around your values. And how I’m linking it even more to this theme of parenthood is that, I have a 6-year-old and we go through all the tantrums and behavior issues that all parents do. It’s very normal. And I love talking about being a parent to my patients. I learn a lot from my patients. I do have an elderly patient base, and so I do get to benefit from their wisdom. And one thing I’ve come to conclude over time is that if you want to do something for your children, don’t do it for them. For example, if you’re making career sacrifices, make sure you are clear that you’re not doing it for them. Or if you are not going to the gym because you can’t fit in because everything you’re doing, you’re prioritizing your children and you’re doing it for them, then I’m gonna suggest you’re doing it for the wrong reasons. Don’t do it for them, do it for yourself. Whatever you want to do for your children, do it because you want to do it. Because when the messy times come in, any family dynamic and they start answering back and you have an argument and it gets be heated, you don’t wanna be like, oh, that little s*** can’t believe how much I sacrifice for my son or daughter, and that kind of stuff. You don’t wanna feel like that. They don’t owe you anything. Any sacrifice you do, anything you do, do it because you wanted to do it. Not for them. I hope that made sense. It just came from the heart, was totally unscripted, spontaneous, and for those on Protrusive Guidance particularly, I wanna know what you felt about that. Anyway, hope you enjoy the main interview. I catch you in the outro. Main Episode:Laura and Arabella, welcome to the Protrusive Dental Podcast. I’m so, as a father of two boys, i’m so excited. I read books like Anxious Generation and I follow so much, and I wanna thank Lydia for connecting us. There’s so much I wanna speak to you about, but before we get into the meat and potatoes of this, I’d like some introductions. Okay. Start with you, Laura. Laura, tell us about yourself, you in healthcare, but also you and your vested interest in this really important public health concern.  [Laura]Well, good morning, and thank you so much for inviting us on to speak about this very important topic. It’s become a passion of mine over the last 18 months and is starting to take over my life a little bit. So how have I got to that point? So essentially, I’m a mother of three boys also in the boy world. The eldest is just turned 11, so we’ll be going into year six in, going into year seven, sorry, in September. I knew from the minute he was born that this was gonna be one of our biggest parenting challenges and I think I’ve been proved right that this is absolutely where we’re at. And then alongside that, professionally, I trained and worked as a GP. And then three years ago I stopped being a GP and had realized I’ve got an interest in child and adolescent mental health, and that’s where I work now. I now work as a specialty doctor in child and adolescent mental health, and obviously I see the issues that phones, how they affect young people on a daily basis now.  [Jaz]You are in the trenches, Laura, you are in the app, so you are the first person to see the negative connotations of this manifest.  [Laura]I think in the trenches is a very good phrase. I’m absolutely in the thick of it, and yes, I’m seeing the children that are struggling the most with their mental health in this day and age.  [Jaz]The tip of the iceberg. But there’s so much that we don’t see that’s brewing, and that’s like the whole clinical iceberg model, which we’ll talk about, I guess. Thank you so much for that. Arabella. Tell us about yourself.  [Arabella]Well, I’m joining in the mother of boys. So I have teenage boys. I have, a slightly higher end of Laura. So I have 19 and 15, so I’ve kind of seen it change and seen it develop. My background’s quite different, so I started life as a business and marketing strategist. So I worked in very big corporations and so I understand how we get people into these things and how they want to do this. But I retrained and did a masters in psychology and then got involved in campaigning for children. And got into the screens area because parents post pandemic were particularly worried around screens. And in 2022, started working with an organization called Safe Screens, who were one of the first organizations calling for regulatory changes around screens. And then when we started working and talking with Dr. Becky Foljambe, who set up Health Professionals for Safer Screens. We sort of jumped on Becky and went, who? She’s a GP. And we went, why are you the only health professional here? Why is no one else talking about this? And Becky put out a little tweet. This was all mid 2020 oh, early 2024, little tweet and said any other health professionals out there within 24 hours, she had 30 health professionals she’d never met before. And that’s how we met Laura and connected to this growing, growing group of health professionals from every single type. We obviously have dentists, we have pediatricians, we have psychiatrists, we have psychologists, lots of speech and language therapists, occupational therapists, mental health nurses, you name it, we’ve got them. And I work as policy director for health professionals. And our role is about really trying to get the message across that this is a public health emergency and that it needs treated like that. And that this is a problem from 0 to 18. We are volunteers and we’re a volunteer organization, and we are helping to create resources and guidance and working with Westminster and policy makers to try and make those shifts. [Jaz]I got into space from being recommended some from books from my within my dental community and some dentists who are members of your, and supporters of your organizations and the book Anxious Generation. It starts off with anyone who hasn’t heard of it. It gives this wonderful analogy at the beginning, like, imagine we were gonna send our children to space and they were gonna live there. Yeah. And then, what kind of discussions would we be having? And then so essentially it drew this comparison of giving someone a device and how it changes their brain. And there’s so many unknown unknowns. Why are we agreeing to allow the manufacturers and marketers of devices to, and apps that go with it to be able to access our children’s minds? There is. So it’s a huge problem. You described it as an emergency, and I absolutely agree, but we need to have some structure in this debate. I want to start with the scale of the problem, right? So I think one thing that I think every, I think probably 90% of people listening or watching this right now would’ve seen adolescents on Netflix, which I think, done a great job of really putting this for a while in the forefront of everyone’s minds. Everyone was talking about this. I just wanna throw that in there and get your opinions on adolescents as a show. But Laura, what is the scale of the problem that we’re facing?  [Laura]I think to answer this question, we have to look at the statistics in terms, well, I think first off, we need to look at the, there’s some different nuances within different arguments. So screen time argument, the amount of screen time that children are spending is different to whether they should be on social media, which is a different argument to whether they have a smartphone. And they’re really important differentiations in what we’re talking about. So in terms of the scale of the problem. Essentially, if we’re looking at smartphone usage, we now know that I think it’s 27% of five to seven year olds now own their own device, their own smartphone to do that. And by the time they’re 11 to 15, it’s over 96% I think. So, this smartphone usage has become almost the norm for every teenager across the country. And of course, what a smartphone does is allow people 24 hours to access to the internet, to social media, to all the unfettered things that we need to, they can see. And that’s where the arguments sort of merge. But then in screen time, if you add in the fact that we’ve got, they use PCs at school most for a long time of the day. They then come home and play on gaming devices or sit on the smartphones to scroll. They’re then asked to do their homework on a computer again. So before you know it, we now know that children are spending almost 4, 5 hours a day on a screen device outside of school so that turns into about I think one of the statistics is 35 hours a week. That’s the equivalent of a full-time job. So the scale of this when you’re talking about screens and how much time children are looking at a screen is huge. It’s really big.  [Jaz]Laura, when I was growing up, I watched a lot of tv, like my parents were actually very pro tv. They let me watch as much as I wanted to and I look back and I really regret that. I wish I read more, all those things, but I am where I am and it is what it is. And that’s the tools that they had at their disposal. I didn’t have access to clubs growing up. Personally, I didn’t have access to those kind of privileges, but I consumed a lot of tv, so I’m very mindful with my own children for that. Arabella, anything that you want to add to the stats? Because really thing, the next thing I wanna ask after this is. Okay. Which is worse? Is it? Are we really, is the public health worry? Is it the social media use? Is it the phone? Or is it just any screen time, including what they’re doing at school? Yeah, so please, Arabella.  [Arabella]Well, I think I’d add to what Laura was saying is that we frame this as a whole child health problem. So often this debate, as Laura says, can get caught up in tiny pieces so it can get caught up in, does this cause a mental health problem for a 16-year-old, or does this cause X for this? And all of those are valid questions, but actually we need to look at it in the round. So if you think about. Whole child health and that’s how we should be approaching health for our children. We know from all the research and there is oodles and oodles of evidence out there. We know that myopia has gone up to sort of 34% of the population from 20%, sort of 15, 20 years. [Jaz]Well, what is myopia for those who are not familiar.  [Arabella]It’s shortsightedness. So shortsightedness and we know that it’s about outdoor time that makes the difference on it. Obesity’s gone up. There’s huge linkages between the seditary behavior of being on screens, but not just the seditary behavior because actually if you are sitting on social media or you’re sitting on gaming, you are targeted by fast food manufacturers in a way, way more than you would be on tv. We’ve got lots of legislation around tv. But you don’t have that on gaming. So we know that not only are you sitting there watching it, but you are also getting the messages that these are good things, things to eat. So there’s all these subliminal things that people don’t necessarily pick up. Then you’ve obviously got all the anxiety, you’ve got the suicidal, indentation, all these things that Laura’s dealing with on a daily basis. You’ve got the comparisons, then you’ve got the societal issues, which was picked up in adolescence. You’ve got the numbers of children who are radicalized and ended up in extremism. So 20% of arrests last year for counter-terrorism were under X. 10 years ago, that was 2%. And the Met Police are absolutely clear that that is a direct link to social media. So there’s lots of things within this debate that often get ignored because we are concentrating on one exceptionally important area, which is the mental health of 16 year olds. But actually we need to think about it in the round, and that is why we don’t think it’s dramatic to call this a public health emergency. [Jaz]Laura, with the kind of child who ends up needing your services and needing your care. If there was an avatar, would you say it’s what the Anxious Generation book recommended, which was suggested, which is 14-year-old girl who is almost suicidal. And that is tragic, you know, but would you say that is an accurate representation of the kind of children who need mental health services as as a child? Is that the kind of demographic that you’re seeing the most?  [Laura]At what, 14-year-old girls?  [Jaz]Hmm.  [Laura]There’s a lot of 14-year-old girls. I don’t know if that’s the most, I wouldn’t know the statistics on what app. I think it’s across the board, to be honest, of all teenagers. And obviously I’m seeing the real tip of problems and there’s lots of children that I see that, you know, with awful backgrounds and really traumatic experiences in the mix. Very, very difficult, hard times. And the smartphone is, I think, I’m trying to think of the number of children I’ve seen, in terms of who’s been affected by a smartphone. There’s a few. Definitely, we absolutely, without a doubt seeing children that are only in cams because they’ve had been bullied on side on WhatsApp. And the bullying has got so extensive that they’ve then tried to take their life. And I can say that with my, I have dealt with that child in my clinic. So there are a handful of children in there in the services that are directly impacted purely by social media, by their anxiety levels, that their depression, their mood is all affected by what they’re seeing on social media. But then there’s a huge majority of children in camps that the smartphone is not the cause, but then a child will become depressed, but then they spend their time scroll through on social media to think they make themselves feel better. But it’s then ends up in this vicious cycle, you get the dopamine hit, but then you end up in dopamine deficit and then it just have this absolute slump afterwards that whilst they think they’ve made themselves feel better, it’s made them feel 10 times worse because all they’ve done is compare themselves to other people in their perfect lives without any backstory to that. So I think, I don’t know the numbers. I would love to get that research in terms of what’s the impact on our campus children. But I can absolutely say there are a handful of children that have, are there purely because of the phone use and social media use, but then everyone’s there that’s not got a direct impact. It’s making their symptoms worse, I would say.  [Arabella]And if I just add to Laura’s point, which is really valid, so Laura’s saying we don’t have the figures of exactly that point. And the reason we don’t have those figures is because we are not asking the question. So it’s only a lot of enlightened doctors like Laura or speech and language therapists who are actually screened for the question. It’s not commonplace to have a child coming in with self-harm and ask them about their online experience.  [Jaz]Wow. I mean, I would’ve thought it would be one of the first questions.  [Arabella]It’s not, and this is one of the things that we want, we want to change in public health policy, and we’ve created a GP screening tool. So we are trying to roll that out, which has those questions, but it’s not standard, particularly if you’ve got a 10 minute slot to ask these questions. It’s not standard that you are asking those questions. It’s not standard that if you’ve got a 5-year-old who’s nonverbal coming in as a speech and language issue, and speech and language is a massive problem, it’s not a standard question to ask how much time they spend on screens. And how much linkage, and that’s part of the change we need to get within the health profession because we can’t measure this question because we are not asking this question.  [Jaz]Very valid point. Now, Arabella, from your perspective, something that Laura touched on earlier is that we’re actually dealing with, there’s so much to talk about because we’re dealing with multi-facets. So there’s screen time, i.e., how much time someone might spent in front of tell your computer, which is one thing. Then at what age they get introduced a phone, right? Which is their own personal device. And then the apps that are on the phone are a completely separate problem, but they all encompass in this theme. What do you think, Arabella, which of these, if we go with the Pareto principle, right? 80% of the problems come from 20% of its usage. What is the most worrisome aspect of screen use that we need to focus on perhaps as part of the emergency?  [Arabella]I would say, I think we probably all came to this conversation because of older children, because of the adolescents, because of the awareness, because it’s very dramatic. I think the vast majority of our members are now more worried about early years and in early years, early years the problem is very much about how much time they’re spending on. You can have a big argument about the quality of what children are doing on screens when they’re 15, 16. Are they learning to make music? Are they revising and doing things? But for a two, three, 4-year-old, there are no benefits of being on screens. Even the so-called educational apps are not beneficial. They’re not researched. But as Laura talks about, they send the gamification of education. So you’ll constantly have a dopamine hit, which means that by the time you’re meant to be sitting in school and paying attention, you can’t do this because you are used to having buzz, buzz, buzz, buzz for every single thing that you do. So if we had to be really simplistic. It’s very hard to be, because this is stunningly complex. We have to address the issue in early years because if you’ve had your child sitting on a screen from day one, by the time they get to eight or nine and they want a smartphone, which is the ubiquity in their pocket, it’s really hard to explain to them why they can’t have it when everything they’ve seen is is on phones. As a country, we give no guidance to parents on phones or screen times or screens for little ones there is pretty much unique across the world with nothing there. So we don’t have anything in the Little Red Book. We have nothing in Start for Life. We have absolutely no guidance at all on how much time your kids should be on screens. So much so that we’ve actually, I’m gonna try and show, but you can see us on our website, and this has been taken by quite a few NHS. We’ve created guidance working with the World Health Organization, guidance with other pediatric associations, with academics, which gives recommendations because we can’t expect parents to know the best thing to do with their children if we never tell them. Or health professionals haven’t had any guidance on this. So yeah. If I was being simplistic, I would say we need to focus on early years and we need to focus on that clear message. ’cause then we have half a chance of protecting our children as they get older.  [Jaz]And Laura, would you agree with that?  [Laura]Absolutely. Yeah. And I think the issues and the challenges change as the age ranges change and you go up and that’s again, makes part of the argument very complicated. And there’s two very different clear messages as well. The message at the beginning of trying to delay a smartphone for as long as possible, I think we’ll probably talk about age and letting a bit, is a different, very different argument to those children that are already in the world of having a smartphone and on social media. And they’re very different messages that need to be dealt with in a very different way. But I think in terms of how we start to turn this, the new norm where everyone gets a smartphone, certainly by year seven it would seem to start turning that around. We need to focus on the younger years to do that.  [Jaz]Well said. I think part of the issue is this generation of parents, myself and my wife included. And that when I was a kid I could just, when I was eight, nine, I would just be in the street and I would come back three hours later. My mom wouldn’t know where I was. And everyone was okay with not knowing where someone was for a while. And now we get anxiety about not being able to see, or not being able to track even with GPS something. So we are partly to blame as a culture of parents. And so this very, very difficult, I mean, one thing, slight digressing, but I think is very relevant. I saw on my facebook ads recently. A watch targeted for children that allows you to call your parents, which I like the idea of. ‘Cause all you can do on this watch is call and receive a call. That’s it. Okay. And I mean, I like the idea of that as a way to have that sort of inner safety, that my child’s okay and I can reach them at any point without giving a fully fledged device. So I guess that naturally leads into your thoughts on this kind of approach, but then naturally leads into, well, what is the right age for a smartphone? [Arabella]Yeah. We would say that smartphones with full internet connectivity and everything involved and social media, it’s 16 and that’s very much about adolescent brain and it’s about the connection of really developmental tools in there, but also about the stuff you have going on at school and life and the distraction techniques with it to give you the space. But the good news is that. Manufacturers are starting to recognize this problem. As you mentioned, there’s the watch one, but there’s also HMD Fusion are bringing out a phone in which isn’t as, doesn’t have total internet. It still has some connectivity, but has more protective on it. And I actually went to a launch yesterday, a pre-launch of a phone from a company called Sage, which is producing an iPhone, which has its own unique operating system so no children can get through it, and there’s nothing you can do on it and take all these information off so you have the positives that you need. You have your wallet, you have your GPS, you could have certain apps on there that you need to go in. Parents can find you, you can make calls, but it’s not distracting. And we need to get to a world where we are offering parents and children a solution that makes tech work for them. And that’s why we are thinking it’s a very much a regulatory framework that can move this. ‘Cause everything shifts so fast. So, if we’re seeing ads now for sunglasses, which have all the AI in. And have everything in there. I mean, can you imagine how confusing that’s going to be for a teenage brain in relating to reality if actually you are not really seeing reality and you are talking to people through your glasses. It sounds fun, but it’s really quite complex when you’ve got so much going on in our heads and Laura obviously sees the impact of these phones on kids every day and what she’s doing and the children that are coming in.  [Jaz]Would you say Australia’s the front runner here and being proactive in this? I recall recently they made it to age 16 to have, I think it was social media, to have age 16. Is that correct?  [Arabella]Yeah, they’ve, so what’s great about Australia is they’re actually grasping this as an issue and making it very clear and they’ve put the manufacturers, the software companies on the back foot for making them deliver age verification and showing you have to prove a way of doing it, and there are ways to do it. However, you get into a question of what social media. So for example, they have taken YouTube out, but YouTube, from three years old, 90% of UK children are using YouTube. YouTube has fast moving, fast loads of fast moving things in it, and it’s actually one of the key ways that children see pornography. They see violence, they see all these things which they’re not choosing to see, and it’s coming through. They’ve also taken WhatsApp out, and again, WhatsApp is another way for cyber, but massive problem for cyber bullying, grooming all these other areas. So you do get into a problem of what you define as social media. But actually at least they are doing something. And they are recognizing it’s a problem. So that has to be a positive.  [Jaz]Laura, any comments on this theme?  [Laura]Yeah, I think I’ll just go back to something you said about a couple of things. So one was about Jonathan Haidt touched on this, doesn’t he? That we’ve moved from a play-based childhood to a phone-based childhood. And that that’s happened whilst all the devices have come up and become more in enticing to turn the child inside. At the same time, all the parents have been made to feel really anxious about not watching their children. And there’s less eyes on the street. There’s more women at work. There’s many people looking out the houses, checking it, Tommy next door’s. Okay. And he thinks that that’s, he describes that as that phenomena where everything’s come together. And of course, the media is also to blame. It’s not the parents to blame that we’re feeling so anxious as parents, but it’s absolutely part of the solution in that we need to empower parents and we need to free them really, because there’s some arguments against tracking in terms, I’m not saying whether what’s right or wrong, every parent has to make this decision on their own, within their own base, their own element of safety and their own confines of their own feelings. But there are arguments in terms of if your child knows you’re always being tracked, the fact doesn’t develop their confidence in the same way. It doesn’t develop their problem solving skills in the same way they know what are you actually telling them if you are tracking them the whole time that this world’s unsafe, that they, that they’re not safe there to go out and about. So there are some and also do you trust them? Are you saying that you don’t trust your child if you have got constant tracking device on them? So there’s some, I think we’ve got a long way to go before people feel safe to not track their child. And I think that’s one of the biggest problems about the devices. And I think it’s one of the big pools that parents have of buying their child a smartphone because it has the tracking ability on it. But when you do think about it, there are some other arguments. There is another side to the argument whether we should be tracking all the time. And it is sad that children have not got that freedom as much, and as parents, don’t feel we can give it to them. [Jaz]If you were to have a overnight this power to do anything you could. And starting with the age, I know Arabella you said age 16, is the time you should even consider having a smartphone. Laura, would that be your number as well in terms of age based on what you’re seeing? [Laura]Yeah, definitely.  [Jaz]And what other, let’s say we had this perfect society where you two were coming together to set the rules. Can we just spend a few minutes on what would these rules look like? And these are like ideals based on the best available research that you are aware of. And based on you in the trenches, Laura, and all the work that you’ve done, Arabella, what would be the perfect standard? The perfect world? Arabella?  [Arabella]Well, you’d start with no screens before five. And that doesn’t include tv, actually. What’s interesting is we’ve known for 20 odd years that having background tv noise or radio is not good for speech and language in young children, but actually shared TV from brilliant sources like public service tv, such as Bit CBBs, where you are sitting together at, it has a narrative, it has a beginning, it has a middle, it has an end, and it has a discussion point and is defined. Fast moving, boom, boom, boom. Not great, but no screens before five and then really intentional your use within education. Why are you using this piece? What’s its value? Where’s it’s adding to it and we are not saying that there isn’t value in tech, there absolutely is value in tech, but really thinking about it. So it’s not a standardized piece. And we are not gamifying education. We are hearing awful things about children who get to school and they can’t sit up on a rug because they’ve lost their core strength because as babies, they’ve literally just sat on a screen all day. And they’ve been sat on a corner, on the side. And this came from a fantastic piece of annual research by Kindred Squared called School Readiness. And they look at children, it’s got worse and worse and worse. So that’s the first thing I’d start. Really intentional work. Work in schools. Separating the thought process behind what’s the ed tech that makes frees up teachers times to teach versus just putting children in front of it. And then Laura, do you want to pick up on teenagers and what you do around them?  [Laura]Yeah. If I had a magic wand, I think Snapchat wouldn’t have been invented. That has to be one of the biggest cause of some horrific problems.  [Jaz]And YouTube shorts.  [Laura]Yeah.  [Jaz]Like the shorts are absolute so like, dopamine heavy. Short, short, short. I hate that.  [Laura]Yeah. Because they’re just so easy to watch and the before you know it hours have passed by and it’s killing our concentration skills and it’s addictive. I think WhatsApp, I would never also have invented. And I mean that’s the bane of all of our lives. It’s certainly the bane of my life. It’s the only thing I have my screen, it’s what takes up most of my screen time. ‘Cause I’m running four people’s lives on it. And for these poor children that are having to navigate the nuances of WhatsApp in terms of, they make a mistake at school and before you know it, they’re just cut out of a group. That’s it. They’re banned, they’ve been taken out and the impact of that on your self-esteem. You don’t even know what you’ve done wrong. No one’s able to communicate or work out these friendship issues in person. You’re just barred from the group and that’s it taken out. So I would absolutely get rid of WhatsApp, but the positive thing I would do and change if I had a magic wand is improve community. And that’s where argument gets so much bigger because that’s what people are missing, I believe, and that’s what they’re trying to find on social media and through the phones, is that feeling of community. And we don’t have shore start centers, we don’t have community centers, don’t have youth hub clubs, anything like we had. And that’s what that gap is filling, and that’s for me would be where my magic wand would lie. We need to give the children something else. We need to make real life better than the on life version.  [Jaz]Thank you. Now we are speaking to dentists. Mostly it was dentists who listened to this podcast. So I mean, I could say, what advice would you give to parents from their lens, but I think I can give them the websites for the organizations to represent and they can get some really good guidance for themselves as parents. Not only just healthcare professionals, but as dental professionals. What do you think, what kind of message do you wanna give to the dentists and dental therapists and dental nurses listening out there for how to change anything about our practice or the way we take a history. Or the advice that we give to help this problem. Help this, help-  [Arabella]I think, Jaz, you make a really good point because one of the big things we see is about body comparison and it’s about body dysmorphia. And as a teenager, you are meant to be comparing yourself to people. That’s kind of what you do. But your world would’ve been 20 people in your class. And we all remember what it was like and you felt awful. But suddenly you’re comparing yourself to thousands and thousands of people. But also you are getting really dodgy advice from people who are self-professed experts in this area across, across social media. Quite a famous thing, which particularly talks about children’s teeth or teeth. You can fall down your own teeth, so just file them. It’s really easy. That’s a big trend that went around social media.  [Jaz]Yes, I remember.  [Arabella]Which is quite terrifying.  [Jaz]Also, mewing and like chewing hard things to drop your jawline, that kinda stuff. Yeah.  [Arabella]All that kind of stuff. And so I do think some of it will be about actually having the conversation with a child who comes in and isn’t wearing their brace properly because they think they can achieve it through mewing to ask, where did you get this information from? Why do you think this is pointing ’em in the right direction of trusted sources? I mean, one really clear way we are seeing it at the moment is around pregnancies and hormonal contraception. I know this isn’t dentistry, but it’s the same kind of problem. So there’s a lot on online about hormones, hormonal contraceptives or coils or things like that are dangerous and they’re gonna give you cancer and they’re gonna give you all these different things and you shouldn’t do it. We’ve now got the biggest increase in teenage pregnancies that we’ve had in a very, very, very long time. And you talk to our GPs and they will tell you the number of people who, or teenage girls who, young women who come in and go, I want to have X, Y, Z, but they don’t, they refuse to take HRT. They’re having spent a lot of time trying to understand where did you get this information? How did you do this? Not HRT, sorry, contraceptives, which is a massive problem and that’s very similar to the kind of health advice I imagine. You get people who turn up, who’ve bleached their teeth in very odd ways or they’ve try doing different things.  [Jaz]Oil pulling for a while. This was 10 years ago. There’s a huge trend where huge cavities in the mouth that have a structural loss way beyond remineralization, but they were hopeful that magically, ’cause this is what they’re seeing on social media and that kind of stuff, magically animations of teeth with big holes magically growing back. And they believe it and they actually believe that this just, they’ll spend half an hour swishing coconut oil in their mouth. But they won’t spend the 15 minutes in total per day doing the correct oral hygiene routine and that kinda stuff. So yeah, we see this misinformation disinformation all the time. [Arabella]Yes. And I think you have an incredibly important role in when children come into you and have, or young people asking where they got this information from and really trying to explain to them why it’s not safe, why it’s not helpful, which is what a lot of our GPs are now doing and questioning when people come in, particularly with oral contraceptive questions. [Jaz]I think the other role we have, and Laura, beyond you after this, because the other role we have as dentists is that a good, a decent percentage of population, I wish it would be higher still as a public health objective, but a decent population of our decent percentage of our population come to the dentist routinely. Whereas the GP is a bit like as and when you need, and it may be a different GP, whereas hopefully you get a relationship. It’s relationship building with our patients, which is another adult who can guide you. Yes, our remit is oral health, but the key word there is health. So, Laura, the reason I’m asking you here is, you see those in distress. You see, like I said, the very tip of the iceberg. We as dentists can help you in the lower down in the iceberg. In the preventive role. We are also in the front line of healthcare where we can, we want to focus on prevention. We give them advice about their sugar intake, which is very important for us to do. But are we crossing any boundaries if we start saying about, asking parents about screen time, like, maybe not, I think maybe we should be helping with this problem. Well, what do you think a dentist should be doing?  [Laura]Well, I’ve see spoken to lots of children now and there’s children I see that are difficult to engage. They don’t want to be there. They don’t want to talk, they don’t want to talk to you. But as soon as you start asking about their world of social media. They come alive. For me, this has been a real turning point for me, a learning point and a point of acceptance that this is their lives. And once you start inquiring about their online life, they will start to tell you about it. And often you’ll find, they’ve got, they don’t just have one account. They have 3, 4, 5 TikTok accounts. That will all have a different purpose to them. That will then , there’s a reason they’ve got each different account. And until you start asking these questions, you won’t find this information out. So I think as all health professionals, we’ve got a responsibility to check in with that child. And you know, if we’re struggling to engage with one, that’s probably your way in, is to find out what their online life is like. And that’s not in a judgmental way, that’s not in a checking in way, that’s trying to, this is how we now have to engage with our young people.  [Jaz]Well it’s building rapport as well, isn’t it?  [Laura]Absolutely. Yeah. And when you start asking those questions is when you start hearing anything scary or things that aren’t right, or then you can start giving you alleyways about asking where they get their information from and where, who they trust in their life, who are their trusted adults, who’s in charge of, who can help you with taking control of your healthcare? And I don’t think there’s any, I think you’ve got, I think as health professionals, the more of us that understand this message that we have to keep asking and that we come back with, well, did you know the recommendations are no more than a couple of hours a day for your screen time. But as you get older, after that young age, the more of us that can put that message forward, then it’s just gonna be the more they hear it and at some point you’d hope they start listening as do the parents. Just planting that seed in terms of there is more you could do than just be looking at this screen all day, every day. Do you know what the damages could be doing? So I think it’s about opportunistic chat and finding a way in with the teenagers and the young people because they’re become, they’ve got a real risk of just becoming more and more cut off from us as humans from those generations above that still know the balance is really important.  [Jaz]Excellent. And I think the word that was screaming in my head there was safeguarding. Right? We, as dentists, we have a safeguarding policy. We have a safeguarding lead in our practice. We have a separate one for adults. We have a separate policy for children. And I think that as dentists we should probably revisit our safeguarding policy and consider does this actually, are we just there reactive? Like when we see an obvious, real tip of the iceberg kind of stuff, or as proper safeguarding, can we probe a bit further and see if we can help, well assist in these children getting the right help they need. So that was the thought coming to my mind. I see you, nodding there, Arabella, anything you wanna add about the safeguarding aspect in healthcare?  [Arabella]Well, I think this is a safeguarding issue. And actually you said at the very beginning we had a conversation around, would these exist if we were creating them Now these products? Without any safeguarding in? And we’re in a mad world where we have all these restrictions and regulations around things. If you have a teddy bear where the eye comes off. It gets recalled into child safety. Yet we have these products where we know, and the coroners have linked children’s deaths to these products, and yet they’re on the market. And we are having to prove that they’re not safe with ridiculous amounts of causal information, whereas actually it should be the other way round. These shouldn’t be on the market until they’re proven safe. And as health professionals, the core of what you guys do is not just safeguarding, it’s also precautionary principle. Why we shouldn’t, we have more than enough evidence from not only the academic research, but from your day-to-day experiences. You talk to our emergency health consultants, they are having all these kids, not just the mental health issues coming in, but teenage girls who’s been asphyxiated because of the sexual violence that they’ve seen on screens and they’ve seen on, I mean, these are really scary things that are happening. And yet, if it was a drug, it would be banned tomorrow without a doubt. But because it’s tech and because we confuse and conflate benefits and harms, we are not looking at it in that right way. But yes, this is at the bottom line, as you’ve put it, this is a safeguarding issue. This is real genuine harms and you have the most extreme of obviously, suicides, but also the kids that Laura is seeing. But we shouldn’t forget that all these little things are impacting how our children relate and their long-term health. So one thing that’d be wonderful is because, as you say, dentists have a relationship with families from day one. Very young. It would be wonderful if you had some of our leaflets around guidance just sitting there. [Jaz]I was just gonna say that. I was just gonna say that. ‘Cause we have, we were leaflet heavy, we leaflet rich. Even just sending ’em an email sometimes with the correct video of brushing technique, but to be able to distribute your stuff. The volunteer work you do is amazing. We can slowly help and I’ll say any petitions we can sign, I’d love to put them for our colleagues and then for them to spread it amongst the parents because I think all wonderful, as parents, we are concerned. We are in it together. I hope to think, and the vast majority of us want to get, we need guidance. I think we. Now we don’t know what’s the best way to handle this unprecedented, uncharted territory, if you like. And we need guidance. We need help. And what you guys do is you Protrusive Guidance, you give us some advice, some recommendations. So I think if we can distribute that, not only through the safeguarding and children, but actually to parents that come in who also want to help their child.  [Arabella]Yeah, I mean, all parents want the best and it’s very confusing, the information that’s given at the moment. It’s very confusing, this idea of I have to help my child get ahead, which is totally true, but being able to swipe on a smartphone isn’t the same as being able to code or being able to understand how AI works or those, and that’s the critical thinking. And we seem to have conflated these two things and I think it’s very hard as parents, as I said, I’ve got a four year gap between my teenagers who are late teens. The difference between those two year groups at school and their experiences in just four years is mind blowing, and that’s how fast it’s moving. It’s really hard for my experience of being a parent when my kids were four or five, fundamentally different. Fundamentally different, and that’s what we have to get our heads around.  [Jaz]I’m gonna ask you some personal question, and you may decline this, and that’s okay, right? Do your children have Snapchat? [Arabella]Yes. Because it was too late by the time that I realized the issue.  [Jaz]It was almost grandfathered in, right? Because everyone just had it. And before we see what hits us, they’re all in that. It’s a bit like the kids, they pick up YouTube and now suddenly Australia takes it away like, well, we’ve had this since age four, right? It’s a bit like that.  [Arabella]And Laura made a really good point early on that actually we have to look at these in different lights. We have an opportunity to protect our children who are younger by not bringing it in and how we manage those children who’ve already got these things. And in my teenager’s lives, Snapchat is the way they communicate with each other, where they organize it. If I took him out on Snapchat at this point, he’d be no longer in the playground. And that’s why this is a collective action problem, why it’s easier to bring it in in gradually as a possibility. Some schools bring it in. Year seven and they gradually do it. But this is absolutely a collective action problem and we need to start early so that it’s just not even a consideration when currency journals get to 11.  [Jaz]Laura, what advice would you give to dentists who are parents, and they’re worried about their children’s social media use and maybe their kids are on Snapchat and they know about, as you said, one of the apps that we would ban if you had a perfect world will be, will be Snapchat. What advice can we give to those children who are already using that social media and then also separately, before they get onto those apps? The whole thing about delaying it as much as possible, but then the whole thing about I’m the only kid in the class that doesn’t have this, that’s a different thing. So that’s not part B, but part A, what advice for those already using those kinda apps? [Laura]I think my advice would be to educate yourself because power is knowledge and the more knowledge you have about this, the more powerful you feel as a parent. And this is an incredibly difficult thing for a parent to deal with. And you have to be forearmed to do that. I’m an absolute dinosaur. My children would call me. I am so strict and I know that I’m gonna be challenged in September. My real challenges are coming in September. None of them have a phone. We took the iPad away from them. I try to keep them off YouTube as much as I can. They’ve got a switch, which they’re not really interested in because they’ve only got Mario Kart. I’m at the very opposite end, and I know I am about to have a very big challenge ahead of me, and I am just holding off as long as I possibly can. But the only reason I can do it is because I have absorbed myself in this stuff for 18 months and I see the effects and I feel so strongly. I have that I’m able to say no. And whilst it’s me putting my head above the parapet, it’s very difficult for me then to make my son put his head above the parapet, who’s quite a different character to me. So my middle son is standing there with a placard of, don’t ever use a phone that’s why these are individual choices that you have. You know your child, you have to work with that child. And you have to find compromises. So I think my first tip would be to educate. I think my second tip would be we need to empower parents. At the end of the day, you can say no, and you can also, whilst once those children who have already got a phone, they’re already in Snapchat, that is their communication tool. It’s almost impossible to take it away completely at that point, but you can restrict it. One of my very good friends who’s a GP. She’s got four children, her eldest two have got phones. At 15 and 13, she made her eldest daughter who was on Snapchat all the time and once, once my friend got involved in this campaign, she reduced her Snapchat usage to three minutes a day. She said, that is it, that’s all you’re allowed for three minutes. So she can go on, check it and come off and she’s done that. You can do it, but you have to be empowered. You have to know why you are doing it and that you are doing it for the better good of your child to do that.  [Jaz]These are tough family dynamics. I mean, these are some of the toughest things we face as parents.  [Laura]Absolutely the toughest thing we face, and I knew that was gonna be the case from, as I said, the minute my first child was born. It’s not a position any of us want to be in. It’s not a position any of us should be in, and it’s a horrible, horrible topic because you don’t want to be judgmental and try to run these campaigns and not be judgmental. It’s very, very difficult not being judgemental. We are not blaming any parent. This is at the norms that have become normal and no parent wants their child to be left out. And that’s fundamentally the bottom line. You don’t want them to not be communicating with their friends, but we have to encourage this in a safe way. And I think the other thing we can do as parents is reduce their screen time, but got to be proactive and put in other stuff as best as you can. And that doesn’t necessarily mean spending money or going to all the clubs. You just ask your child, ask your friend. Ask your child to invite a friend to your house. Encourage real life person play dates. Encourage them to go to the park together without a phone. And when you have play dates at your house, be brave and say, put your phone in here, guys. And the more you make a stand and do that, the braver you feel the more empowered you become to do it. But it’s really, really scary. It’s a very, very scary move at the beginning, but it does feed on it. You do become more empowered the more you do it.  [Jaz]I just wanna add that, sorry, Arabella go for it.  [Arabella]I was just gonna, and building on where Laura’s coming from. She’s absolutely right because all the research shows that if you work together as a family to create a digital plan and you have guidance in, it’s much more supportive for children, but also adults working. We actually have created family digital plan plans for different age groups, and they’re really simple tools where you sit down as a family, obviously not when they’re very little, but actually very importantly, sit down as a couple. And any other carers to talk about where do you have things, what’s important? What’s there? So yes, they might have things, but don’t have them in the morning. So the first hour of the day. First hour before bedtime. Never ever, ever have them in the bedroom overnight. Any type of devices. Don’t have them at meal times. You might decide that you don’t have them in the car on the way to school because you listen to a podcast or you talk to each other, or you do different things. But you can decide that as a family. What’s important, but also incredibly important is we as adults need to actually show our children what? Because children copy us.  [Jaz]Perfect. This is exactly what I was gonna say. It was that we need to be role models for our children.  [Arabella]Yeah, we absolutely do. And it’s really hard because we couldn’t live without our phones partly because of work, but partly, as Laura said, you are managing all your children. So I spend half my time looking on spawn to find where their matches are meant to be or doing my order or whatever. And one of the things you should be doing with younger children is you should be narrating what you are doing. So when you pick up your phone, you go, mom’s just looking up when your football matches. Or Mom’s just doing so they can understand because otherwise it just looks like you are always on your phone and they probably think you’re on TikTok. Because that’s what they’d be doing. So as adults-  [Jaz]Well one of the reasons I got a smartwatch is just because the odd notification, I can just see it ’cause not emergencies, doesn’t need me and put it away and they’re just, rather than picking up the phone one, that was my main driver for getting a smartwatch is so I can eliminate having the phone in my hand. ‘Cause my son’s watching me, so I’m very mindful of that. I think it’s a great point. Another point, I love the idea of a digital plan. So we have a rule that in the car we don’t do any screens in the car. We can listen to songs. We take turns being the youngest in the middle, and then, and my wife and I, we all have turns about, okay, what’s your song? I am trying to put on a Punjabi song. So I’m trying to teach them a mother tongue and stuff. So, that’s great. Unfortunately, we need a better digital plan at home, right? And hours meaning more boundaries there. And I love that. A great thing, a great reel I saw recently was Jordan Peterson, the guy who wrote the 12 Rules for Life. He said that you need to run your family like you’d run a small business. You need to actually be purposeful and therefore you need to call in the meeting. Okay guys, we’re having meetings, we’re doing meeting notes, like family meetings and actually making plans and being purposeful. So that’s how you run your family. I love that. And what you said about making a digital plan just weaves in so well into that.  [Laura]Yeah. And they’re small actions that don’t feel as scary for a parent to stand up and say to your child, hey, we’re gonna introduce some small rules and we are all gonna do it. It’s part of the parents as well. So things like when you come in, your phone goes in this box for the first hour of the, a first hour after you come home from school, so that you talk to me. And you all do that. You all put some people at the box at the bottom of the stairs where all the phones go in before they go up to bed at night. So you need to do that as well. And obviously, you’re an adult and you’ve got parents that might be, you’ve got your elderly parents that you’re worried about, you have to bear those sort of things in mind. But as a general rule, those are small changes that you can do. The other, the last thing I would say is on this is that, the really, really important part of this is that we are getting so much evidence that the young people themselves want this to change. And this is, they can see that they know that they are spending too much time, that these phones are addictive and taking over their brain. So that also really helps empower a parent and the teachers to know that the young people themselves are really wanting change in this field. They know they’re spending too much time on their phones and social media.  [Jaz]Totally. Amazing. Any last points? ‘Cause I’ve really enjoyed this chat. I think some great action tips in there. Great ideas, and I think people can take action and at the very least, if everyone just download some of your guidance and put your websites, and I’ll put everything in the show notes. What are the best websites to go on to learn more just so I can all, I’ll put it in the show notes, obviously, but just so I can hear it from you, Laura. [Laura]So, obviously, as a health professional, it’s got to be the health professionals for saferscreens.org. As a parent, I cannot recommend the smartphone Free Chartered campaign. High enough. It’s fundamentally changed my life on so many levels. The aim of it is to find other parents that feel the same as you, that you want to hold off together, delaying giving your child a smartphone, and it builds communities in your area, and you can get as little involved or as much involved as you want in that campaign. And I honestly can’t recommend it high more.  [Jaz]Amazing. Arabella?  [Arabella]Those are the key places as well. And if you do follow social media, then please do follow the health professional social media. Sites because we try to do bite-size ideas and easy swaps for parents to try and bring people in and link and raise awareness. But we also really importantly, need to raise our voices. Politicians do respond to parents and they respond to health professionals. And if you are talking to your MP and you’re concerned about this, write to them. Tell them about examples that you are seeing in your clinics if you are having kids coming in. Your example about the coconut oil, I mean, that’s a brilliant anecdote because it shows the real, so things like that, that you can communicate and communicate to your royal colleges, because actually every royal college should have a clear policy on social media. It should have a clear policy on smartphones and digital, and most of them don’t at the moment. So the more that you can raise it up, your professional organizations and say, this is something that you are concerned about from a safeguarding, it brings that message that all professionals, all health professionals, but also the police are worried about it. Education is worried about it. All these different people, that everyone is worried about it, that will drive change. It will shift things.  [Jaz]Well, Laura, Arabella, thank you so much both your time. More power to you. Please keep fighting a good fight. Us as the dental professionals, we will support you. I’m gonna make sure that I plug this everywhere in the community, in our apps and in our channels to get more, more followers for you, more distribution, more political action, wherever we can do to help the future of our world, which is our children. So thank you so much.  [Arabella]Thank you.  [Laura]Thank you.  Jaz’s Outro:Well, there we have it guys. Thank you so much for listening. All the way to the end. Any links and organizations that we promise, we will put in the show notes. If you can help and support these organizations, it will make the world a better place. So please do so. If you’d like to get some CPD or CE, that’d be great. If you’re on Protrusive Guidance and you’re paying subscriber, please scroll down, answer the quiz, get 80%, and we will send you that certificate. Our members easily rack up 50 hours of CPD or CE every year easily. There’s a bank of over 450 hours of CPD on the platform with at least 50 new hours created every year. Head over to www.protrusive.app to join the nicest and geekiest community of dentists in the world. As ever, love to Team Protrusive. Thank you so much for everything you do, and in this episode, love to all the parents out there. The struggle is real. I’ll catch you same time, same place next week. Bye for now.

Discover the secrets behind successful root canal treatments and the ongoing debate between hand files and rotary tools. Learn why rubber dam isolation is crucial for effective procedures and dive into the importance of irrigation techniques. Get practical tips on determining master apical file size and how to enhance disinfection strategies. The conversation also touches on when cuspal coverage is needed post-treatment and how to effectively communicate risks to patients. Perfect for dental students and new practitioners!

How should you  gain consent for ELECTIVE treatments? Is selling in dentistry something to avoid, or an essential part of patient care? How much does emotional intelligence really matter for your success and happiness? Dr. Colin Campbell joins for a powerful episode that dives into consent, sales, and the balance between profit and ethics in dentistry. He also unpacks the huge role of emotional intelligence—not just in clinical practice, but in life. Expect real talk, strong opinions, and communication gems that can reshape the way you connect with patients and approach your career. https://youtu.be/Wtugp1t-IrM Watch PDP244 on Youtube Protrusive Dental Pearl: Read (or listen to) the book Let Them by Mel Robbins — a powerful reminder to take control of your own life and emotions instead of letting outside events dictate them. Need to Read it? Check out the Full Episode Transcript below! Takeaways Building trust with patients is crucial for effective consent. Consent should be a relationship management exercise, not just a legal formality. Understanding the patient’s perspective is key to effective communication. Elective treatments should be approached with caution and ethical considerations. Sales in dentistry is not a dirty word; it’s about providing solutions to patients. Emotional intelligence is a vital skill for dentists to develop. Good dentistry is about doing what is best for the patient, not just for profit. Continuous education and self-improvement are essential for success in dentistry. HIghlights of this episode: 00:00 Teaser 00:44 INTRO 01:44  Protrusive Dental Pearl 02:58 Welcoming Dr. Colin Campbell 04:55 Colin’s Background and Philosophy 05:36 The Importance of General Dentistry 08:40 Finding a Niche vs. Being a Generalist 11:14 Understanding Consent in Dentistry 17:42 Fear of Losing the “Sale” 18:50 Building Trust with Patients 22:09 Consent Process Overview 22:49 Patient Consultation Process – Building the Bridge to Trust 29:00 Developing Emotional Intelligence (EQ) 30:00 Patient Consultation Process – The Mechanics 30:58 Patient Consultation Process – Exploring Options 31:13 Join Protrusive Guidance 34:34 Patient Consultation Process – Exploring Options 34:36 Patient Consultation Process – Follow-Up and Consent Pathway 35:54 Patient Pathways After Consultation 36:48 Treatment Plan Letters & Legal Angle 38:45 Approach to Consent Letters 40:21 Personality Types in Consultations 42:21 Systematizing Your Process 43:37 Ethics in Elective Treatments 53:15 Guidance for New Dentists on Elective Treatments 56:33 Interjection 57:48 Guidance for New Dentists on Elective Treatments 57:56 Sales in Dentistry  01:03:05 Conclusion and Final Thoughts 01:05:20 OUTRO ✨ Transform Your Dentistry ✨ 🦷 Campbell Clinic – world-class private care in Nottingham. 📚 Campbell Academy – ethical implant training from beginner to expert. ✍️ Colin Campbell Blog – daily insights to challenge & inspire. If you liked this episode, check out ‘How to Win at Life and Succeed in Dentistry’ with Richard Porter #PDPMainEpisodes #CareerDevelopment #Communication #BestofProtrusive This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A and D AGD Subject Code: 550 – Practice Management and Human Relations Aim: To explore the ethical, emotional, and practical aspects of private dentistry, with a focus on gaining valid consent, balancing profit with ethics. Dentists will be able to – Explain the importance of trust and rapport in the consent process. 2. Recognize the ethical challenges of elective treatments. 3. Outline strategies for building long-term career satisfaction and avoiding burnout. Click below for full episode transcript: Teaser: When you think about the number they have per hour, less than five is normal, right? Less than five of these breath holds is normal. Between five and 15 is your mild category. 15 to 30 is moderate, and above 30 is severe. You see patients that have what we call an AHI Apnea-Hypopnea Index of 60, and sometimes these breath holds can be 30 seconds. Teaser:Profit is oxygen for my business. Get that? It’s essential for life, but it’s not the meaning of life. I do not wake up in the morning going, oh, I’m gonna get some oxygen today, but if I don’t breathe, I’m dead. Right? So we need to- I don’t think that’s the question. I think the question is what would I do if you or my wife, brother, mother, daughter, son? And so I’d say what you want me to do is use the experience that I have to pigeonhole you as a member of my family. The world consent is a relationship management. You can’t treat your patient as if they were you. You have to treat them as if they are them. I would like to say to the guys is if you want to be really successful in the industry, both in terms of financially and in terms of the respect you get from your peers and in terms of the satisfaction you get from your job, try and- Jaz’s Introduction:Gaining consent for elective treatments, selling in dentistry, the monumental role of emotional intelligence for your happiness in your life and your career. Hello, Protruserati. I’m Jaz Gulati and thank you for tuning in to what I think will be a Protrusive Hall of Famer. This episode gave me vibes of Richard Porter. The OGs will remember way back when we did an episode called How to Win at Life and Succeed in Dentistry, and we talked a lot about emotional intelligence in that episode. Brilliant episode Richard Porter. Do go back in the archives and check it out, and this episode builds so nicely on that. Dr. Colin Campbell is absolutely scintillating inspiring. I’m so excited for you to be able to listen and watch this from wherever you’re tuning into. Thank you so much. There are some real great gems on communication and some absolute real talk, controversial, real talk from Colin, which I absolutely loved. So if you’re doing a lot of composite veneers, you may wish to skip this episode. Colin does not mince his words. Dental PearlNow this is a PDP episode, so I owe you a Protrusive Dental pearl. And you know what, I might have actually given you this pearl before. Like recently, maybe I perhaps gave it in a recent episode, but it’s in my head and it’s so relevant for this episode, right? This audiobook, I listen to, “Let them.” Now if you are even slightly into audible books or had a look at which books are on sale right now. This book Let Them is everywhere. And for good reason, I listen to an audiobook and Mel Robbins, honestly, this audiobook is so, so brilliantly done. You literally feel like she’s talking to you. It’s so easy to listen to, so conversational and my friends, I think this book will change your life. I’m desperately pleading my wife to read this book and she won’t because she doesn’t read. So as per the philosophy of this book. Let her, let her not read, let her not gain from this book, but let me drip feed the lessons to her. Let me induce a degree of osmosis, informational osmosis, and take control of the situation. So you kind of get a flavor of this book already. I’ll put the link in the show notes. This book is all about taking control of your life and not letting what happens around you to control you and your emotions. It’s about you taking control of your life. So once again, Let Them by Mel Robbins. I put the link in the show notes. And now let’s check out this absolutely cracking episode with Colin Campbell. Main EpisodeDr. Colin Campbell, welcome to the Protrusive Dental Podcast. How are you, my friend?  [Colin]I’m very well, and I’m very excited to be here. Actually.  [Jaz]You’re the one who’s super excited.  [Colin]No, no, no. I just spent a few minutes, when I was preparing just eyeing Jaz Gulati and who he was. So I always like to do my research just to get the background because I don’t think we’ve ever met. So I’m really pleased I used to be on. Thank you very much for inviting me.  [Jaz]Well, I’ve been on the receiving end, some of your lectures, and I want to start by saying that as a public speaker, honestly, up there with one of the most charismatic, energetic and human, like really the way you speak, when I’m listening to you speak, Colin, it’s like no one else in the room. You are speaking to me honestly, like you have this gift. I dunno if anyone’s told you this. If not, then you need to hear it then, the way you came my radar is dentinal tubules. Maybe in 2019 or something you might done a talk about leadership. Do you remember?  [Colin]Yeah. Maybe.  [Jaz]That and a few other lectures you done on, on digital dentistry, implants kind of stuff. So honestly, the pleasure is all mine to have you on the podcast and I know of all the wonderful things you get up to, but for those who are listening around the world, many in the UK, some in Australia, many in the US. Tell us about yourself, Colin.  [Colin]Geez, that’s a terrible question. So my name is Colin and I’m a dentist. I’m Scottish and I’m very proud of that. I live in England, so I’m doing, I’m trying to do the good work at, do missionary work in England of converting them to the way of the Scottish guy. And I’ve been doing that, I’ve been here for nearly 30 years. And so I live in Nottingham in England, home of Robin Hood. I am married to Allison and we’ve been together nearly 30 years. I have three children, Grace and Rosie, and Callum. I’m a big into family, love my family to bits, so obviously, and that’s a big part of my life. I am very proud to be a dentist. I’m like first generation university student in my family. So no one had ever been at uni before. So my mom and dad, did amazing things to get me to university, which I’m so grateful for. And then I’ve had this absolutely just grandstand, extraordinary journey of madness through dentistry for the past 31 years. And I honestly, like, I feel like someone will tap me on the shoulder any minute and tell me there’s been a mistake and I’ll have to stop. And that’ll be fine because I’ve had such a great time. But if they don’t and I stay well, I’m 53. I have another 32 years left to work, so I’m working till I’m 85. So that’s the story. I mean, if there’s more detail, I’m an oral surgeon, by trade, but I don’t believe in specialized dentistry anymore, which is an interesting, probably separate podcast, I believe in general dentistry and good general dentists. And that’s what we do a lot of here. But I’m big in the implant world in terms of that’s my world. And I get to do some super ridiculous cool things because of that and travel to places and meet lots of amazing people. And that’s been a joy. So I have a very brilliant portfolio life doing crazy things, and I don’t really know how I got here because none of my plans ever came true. So, that’s, I hope that works as a brief introduction Jaz.  [Jaz]Absolutely. I knew that your area of interest and what you are known for, you’re known for many things, but like implants is your thing. I didn’t, I must have forgotten that you were actually, on the specialist register, they oral surgeons. So I forgot about that. So great to have you on about that. So, like you said, though, general dentistry and the fact that good general dentistry is what matters rather than specialism. So I like that little snippet. Could you expand on that?  [Colin]Yeah. Well, I think in the UK we ran down the route of specialization a lot, right? And we sort of lauded the specialist and we never did it properly. I don’t, in my opinion, so we never created the specializations properly and we never really let the public know what the difference was or even just categorize it well enough. And so look, I got on the specialist list by default in 1999. When it first opened, in surgical dentistry, and then it was moved to oral surgery because they closed that, because they hadn’t done it properly. But the problem is that like a lot of specialists are not very good dentists, in my view. And a lot of journalists are the most extraordinary dentists and the guys that I work with around the world now. And I get the privilege of working with, because I run education for a hundred countries for a foundation, I get the privilege to work with the best dentist in the world. And I do, and I get to meet them and see their work. And most of them don’t consider themselves specialists. I mean, they might have a ticket in here or there, but they don’t, the best example is Ronald Young, who’s become one of my great friends, and he’s probably the most famous, certainly the most famous implant surgeon in the world. And his University of Zurich, he’s a professor there same age as me, but I’ve watched him in clinic. He will cut a veneer prep, he will do a consultation for a patient. He will scale teeth if it’s necessary. He will do an extraordinary implant placement. He’ll restore it. He will be careful with the occlusion, and look at this, he’ll look at the patient holistically. That’s a dentist to me. That’s what a dentist is. So if you can’t, if you’re not a physician first and you’re not concerned about a patient’s health first, you’re not a dentist, in my view. So, and I think we lost that, and I think people chased a ticket because they thought it would generate them income. And that’s not true. And it shouldn’t be true either.  [Jaz]I see that and I see incredible value in being a good generalist and having array of skills, not just honed into one specific facet. However, some of the advice that we’ve spoken a lot about on the podcast previously is finding your niche. One thing I talk about is a niche kebab, right? For every one thing that you add on, you remove something else so that you refine to like two or three things that you love doing. Where does that fit into what you’ve just said just now?  [Colin]So one of the joys of my life previously before I became injured, was the triathlon. I would compete in triathlon and so I would swim and bike and run. And I was never really that good a swimmer, but I could swim. I could swim okay. So you can’t be a triathlete without being able to do all three. If you can’t swim, you can’t race. Now, you might get really, really good at running, and if you get really good at running, it doesn’t mean you’ve stopped to being able to swim. So if you learn how to take a tooth out, it doesn’t mean you forget how to take a tooth out. So my best example for you, I guess there’s two, if I could give you them, right? The first one is if I’m an endodontist, I’m a specialist, endodontist, and I open a tooth, right? And I look at it and it’s cracked, mesial, distal, then you can take it out. The endodontist goes, well, I don’t take teeth out. And the patient’s going, well, I’m here. I’ve traveled for an hour.  [Jaz]Numb. [Colin] I’m numb. I’ve paid for it. And they’re going, oh, that’s complete nonsense. Okay. And the other one that’s nonsense, I’m afraid is orthodontists who can’t take x-rays. So that is one of my greatest bugbears, right? I think we’re through that potentially, but I’ve had people like that that worked with me and they go, I don’t take bite wings. And what do you mean you don’t take bite wings? Right? You can’t? Have you? You don’t have, have you not got any hands? Why do you not take bite wings? And so I’ve seen some turnarounds, I’ve seen get-outs and bail-outs in dentistry based on the, I’m a specialist, right? And I’m sorry that, I can see whether if the tooth to be extracted is super complex and they go, it’s much better if somebody better takes it out. I get that. But not if it’s a central incisor. Right. And I can see that there are circumstances where the, where it’s better if someone who’s more experienced or more skilled in that area does it, totally get that. But there’s so many ways where the specialists go, I don’t do that. I don’t do that. And we need to just move away from that because we should all do our basic training. We should all learn how to cut, cut, access the tooth. We should all learn how to take a majority of teeth out, and then we can enhance our skills from there. And then of course we can become a GDP ortho, or a GDP implant, or a GDP Perio or a GDP. And they’re the really good guys. They’re the really good guys. ‘Cause they can do a lot of it and they can build relationships with patients.  [Jaz]Amazing. Well, I love that ’cause I agree with it so much. And there might be some facets which we disagree. And let’s see how this podcast goes. Let’s find, I love those moments. Colin, actually, so let’s try it. Okay. But there’s so much to learn from you, Colin, because what I wanna grasp from you today, the first theme is consent. And specifically, what you do is complicated in the sense that, it’s more specialized and complicated, sinus lifts or all our next potential. So things that are worth a lot of money. Things that a lot of take time to things that take a lot of surgical skill and training to be able to do. What I have seen from colleagues who are, similar, high level as you, is that the consent, the way I’ve seen consent being done, what my principles used to do that I work with in the past, and what I’ve seen from mentors is that sometimes consent is like this 30 page booklet almost, and it’s incredibly exhaustive. So I just wanna know, right? ‘Cause everyone’s got their own unique take on this. How do you see, what do you think it takes to be able to adequately consent someone to something that is a bit more refined or something that’s a bit more niche treatment. That’s quite a big deal, right? For these patients to receive surgically, like for example, let’s take an example of a wisdom tooth that’s impacted. You can do that in a one or two page consent form. The fact now that the treatment you’re doing is worth several times more than that, or several more nuances, how does that change how thick that pad of consent becomes? How long does it take to consent someone? What is the procedures that you do to make sure that you can look someone in the eye and say, you know what? I think I’ve adequately consented you. It’s a big question. It’s gonna take lots of pieces, but, I’d love to take your thoughts on that.  [Colin]That’s brilliant. Every question that you asked Jaz, is another podcast. It’s beautiful, right? But I will try my best to be as brief as I can, which is not one of my greatest talents, I’m afraid. But, first of all, you can talk about this in terms of the UK or you can talk about it in a broader scale, right? So the UK is quite a unique environment for consent in the world. And, I know that you have a big listener group that should outside of the UK that’s so I believe so, so perplexity tells me anyway. And so let’s do it genetically consent, right? If we can do that. And so certainly from a UK perspective, but genetically for the world consent is a relationship management exercise. That’s what it’s a hundred percent. And so in the United Kingdom, and not to go into too much detail, our consent was massively altered by, legally by a lady called Nadine Montgomery, who was an extraordinary woman. And I had the privilege of having dinner with Nadine Montgomery and to watch her speak and to learn all about her story and all about her son Sam. And they changed consent in medicine in the UK. But when you speak to this lady who was vilified by the profession, because she was the one that gave us, made us much harder, it was much more difficult for us to consent patients. This was gonna kill medicine. It’s not at all what she wanted. She wanted us to understand her. That’s it . so your job is to understand your patient. That’s it. Now you can put down-  [Jaz]Can you just explained, for those who don’t know about Montgomery, just to give us a little context background.  [Colin]I very Montgomery, was she- In the United Kingdom basically, we used to the test used to be, if a reasonable other practitioner said, that’s the way you should go, then you didn’t get sued. But what happened to Sam Montgomery, Nadine’s son. When Nadine was pregnant and she was a diabetic and she had pre-eclampsia, so she had high blood pressure and she asked for a section and she was denied a section by a female gynecologist. Because at that stage she didn’t like doing sections and Sam had an anoxic injury at both of was born cerebral palsy. And when they went back to it, she said, you didn’t listen to my concerns about this and had you to them. He might not, I might have had a section and that might not have happened, but she had to, she trained to be a solicitor to change the law. It took her 15 years right now. So what she said was, listen to me when I’m speaking to you please, because I need to tell you my concerns and what Montgomery- The philosophical part of Montgomery Consent basically says, know your patient in order to treat your patient. So you can’t treat your patient as if they were you. You have to treat them as if they are them. So anybody who practices the way you practice Jaz, totally gets that. So Montgomery consent is no threat to you. And the other side of this is that in countries where litigation is high, so for example, United States, UK, Israel, right? Those are three biggest ones. We’re terrified of being sued. So we defensively practice really heavily. That’s not the case everywhere at all. It’s not the case everywhere in Europe. So you would go to Spain and assume that people would consent like they do in Britain, and they don’t because they don’t need to, because the law protects them in a different way. And even in the United Kingdom, the law protects the dentist or the physician much better in Scotland than it does in England, than it does in Ireland. So that’s mental. So what you want me to give you is, I think I have it here. One second. I usually have it on. Oh, I usually have it on my notice board, but it’s gone somewhere else. I have a blank laminate, a piece of blank paper laminated, and I say, if you want to avoid getting sued, here’s your instructions, because there isn’t an instruction you can’t avoid. This is human interaction. You cannot systematize it, right? All you can do is do your best to understand your patient. And unfortunately, for a lot of practices of the United Kingdom, who still work either in the NHS or independent practice, who an enhanced version of the NHS, they’re time poor. Same for GPs. So you don’t have the time to spend a minute to get to know the person who you’re actually treating. And if you spend them, if you take a minute, then you can send patients. And of course we back that up with we, what we do now is we do everything based online. We have online booklets, which explains every procedure. We do a bespoke letter to the patient and we say, read your booklets and ask any question about the booklet that you want. But when you sign at the bottom, we’ve assumed you’ve read the booklet and you’ve answered all, I’ve answered all your questions, and we give them the headline potential complications. And that’s all we do. But we’ve done that in an environment where the patient trust us and we always, if we’ve done a say, an immediate, for large case for a patient, we’ll go to a patient, this is really complicated. There’s lots that can go wrong. So we don’t sell it on a false premise. And I think people get into a lot of trouble because they’re desperate for the work, so they downplay the good and the bad side. Taking all of someone’s teeth out and replacing ’em with implants is a huge, huge procedure. And it’s not to the same on the other side.  [Jaz]Colin, just want to add in, because I’m enjoying this, but I just wanted to add in one thing, very pertinent to what you just said there, is sometimes colleagues will say that I’m afraid of going to, making the conversation too negative a warning of all the risks. ‘Cause then I’ll lose the quote, unquote, I’ll lose the sale, I’ll lose the treatment acceptance, but I’ll lose the, that’s our point of consent. [Colin]But it’s also because you need so much emotional intelligence to be a healthcare practitioner. Clearly, that’s the thing. You can talk people out of any treatment you want. It’s dead easy to talk ’em out of treatment. Because you just say that, well, this could go catastrophically wrong. But it’s a pragmatism test with the patient. You’re gauging their level of pragmatism. If you’re unable to accept a certain degree of risk, do not have this treatment. And I, this year I became a surgical patient. I had a quite a big surgical procedure carried out at 10, 9, 10 weeks ago. And I went catapulted into the world of going and in medicine, in private medicine. I mean, they never consented me in writing hardly at all. It was ludicrous. Right. And I was totally cool with that because we had a chat about it and he said, look, there’s not a lot to go wrong with you, but it could, and in fact, something did go wrong. Right. But that’s the deal. Okay. And if you can get to that with the patient, I think there’s a word for it that we used to use in healthcare ages ago. Trust. That was the word, that’s what it was called. And so you’re trying to develop a trust relationship, right? But if you are a crook, it’s your trust is false. If you’re not, there’s nothing to worry about.  [Jaz]It’s bit of being your authentic self and allowing the human side, like emotional intelligence is the best way to do it. Having respect for the patient enough to give them an opportunity to back outta something that perhaps is not for them. And the only way you’ll know that is discovery of who the patient is in front of you.  [Colin]A hundred percent right. And there’s also just a final little of say to this, ’cause my daughter, who’s not a dentist, and none of my kids are in healthcare ’cause I’m a terrible example. Well my middle daughter is a physiotherapist, so I guess that counts as healthcare. But, my eldest officer is a biochemist, but when she was at, finally in school, she did a project at Cambridge University. She never went to Cambridge, but she did a project when she was at school. And it was a, it was psychology. It was assessing the degree of risk that practitioners applied to their patients or to their family as patients. Get it? So let’s say you’ve got two, however old your wife is. Let’s say she’s 25, Jaz, right? So your wife is 25 and you have a another 25-year-old patient. They both need a wisdom tooth out. You’re liable to push the one you don’t know away and take the risk on the one you do, which is mental because you believe in the treatment and you understand the risk benefit analysis, and you think you won’t get sued. And that’s an awful world to be in, right? So we actually will be happy to take greater risks on people that we love because we know the benefits are worth the risk than we are on patients that we’re concerned about because we didn’t get to know them in the first place. [Jaz]Well, that’s the epitome of defensive dentistry, isn’t it? Right there. The fact that you not willing to help someone who may benefit from that treatment overall, but because we’re afraid we’d rather push it to someone else or not offer it. And that really is defensive dentistry right there. [Colin]And of course, the ultimate sales tool, if you want a sales tool, is to explain two procedures to the patients and say, so let’s say you and my, how old, could I, Jaz? How old are you?  [Jaz]I’m 35.  [Colin]Okay, so you are genuinely young enough to be my son. So I’m gonna say, here’s the two options, Jaz. If you were my son, Callum, I promise you that’s the one I would do. And if you have developed a trust, nine times outta 10, the patient goes, that’s the one I would like. If you’re true, if that’s true, I’ll take it. But it comes to-  [Jaz]So that’s what you would say to your pa, I mean, this is something that you, this is how you communicate to a patient?  [Colin]Yeah.  [Jaz]I think I resonate with that and I I think that’s, ’cause patients often ask, what would you do? And so let’s tackle that, right? Because I’m sure you get that all the time. When a patient asks you, what would you do? How do you then make sure that you’re not giving them the answer? Because it’s not important what you would do, Colin. It’s important that you’ve understood them well enough to relay back to them that actually, based on what you’ve said so far and based on what’s important to you, this is what I would do based on you, not on me. But how do you have that discussion more elegantly?  [Colin]Yeah. So I would spin that back to the patient and say, I don’t think that’s the question. I think the question is, what would I do if you are my wife, brother, mother, daughter, son? And so I’d say what you want me to do is use the experience that I have to pigeonhole you as a member of my family and then to treat you accordingly. [Jaz]I love that. That’s great. That’s wonderful. I’m gonna keep that as a teaser at the beginning of the episode. That’s awesome.  [Colin]Yeah. Alright. Okay, cool. Wonderful.  [Jaz]So, with the consent, going back to it, so you said you have the pre online stuff that they do. So they already have some prior information they’ve kind of pre-qualify themselves. And then you have some discussion in the clinic where you get to know them and you decide, okay, is this dance for both of you or not? And then of course there’s the squiggle at the end, which people say it’s not worth the ink is printed on, et cetera. How are your consent forms like massive? And your treat plan letters, because, ’cause quite often I’ve heard is the treat plan letter is not really for the patient. Yes, it’s addressed to the patient, but that treat plan letter is for the lawyers.  [Colin]Yeah. Let me take you back a step to the process if I can do that. [Jaz]Yeah, please love that.  [Colin]Let you pick an implant. See a patient who is referred to me or refers the themselves to me for an implant consultation. First of all, it’s one hour, right? And people will say, well, it’s all right for you. Well, it’s not all right for me that it’s an hour. And that is what you would call in business a loss leader. I do not get in that hour enough money to pay that surgery running. Okay? So let’s be clear about that. But we still charge for that. And we charge what seems like a big number for that, but it doesn’t cover our costs. And one of my big areas of interest is the business of dentist. Right? And so, we see the patient for an hour, and I came on here and I’m not interested in punting anything that we do, Jaz. I just wanted to have a chat with you. But we do teach this formulaically, okay?  [Jaz]Yep.  [Colin]And there’s ways of doing this, and we divided the hour into four 15 minutes. So if you choose to do it as a 20 minute consultation, you can divide it into fives, but fives are not long enough. Right? But that’s fine. I get it. I get you might have to do that. Right? So the first 15 minutes is called building the bridge to trust. So the patient gets pre-qualified by a TCO, who are brilliantly trained to say, what do you need? What do you want? And we have 56 of us here. So they get put in the right place depending upon what it seems like they need. So there’s lots of people doing implant here. So often people will be, well, I call and treated my husband 10 years ago, or whatever it is, right? So they come and see me and they sit down and I go, it’s really nice to meet you. And the first 15 minutes is nothing to do with dentistry or anything. [Jaz]And the first 15 minutes is with the TCO or is with you? Sorry.  [Colin]No, no, no, no.  [Jaz]Does the TCO happens beforehand?  [Colin]But the TCOs talked to ’em on the phone, booked to appointments.  [Jaz]Okay.  [Colin]Got that information. That information is all set up for me before I see the patient. Any concerns the patient has, what they might be interested in, what the history is, that’s all done, right? So you are using the team, enhancing the team all the time, and then the patient comes in and then you say, let me tell you about this. And I go, no, no, no, no. I need to know about you for the reasons that we’ve just discussed. Only once I’ve ever had kickbacks from that where I gotta go. Why are you asking all these questions? And I’ll say to ’em, because I can’t decide what I think you might want unless I know who you are as a person. And so that we call that building the bridge to trust. And the purpose of that is A, to find out about the patient and B, to open the door to share personal information. Psychologically, if you allow me to share information about me, you will share information about you and we will trust each other. It’s basic human interaction. I will make myself vulnerable to show you that you can trust me. It’s really clear how we do that. The second 15 is the mechanics. We do that really quick. [Jaz]Can we break this down? ‘Cause obviously we can go in any way we want in this podcast, but this 15 minutes, like a lot of colleagues will be uncomfortable with this because they may be coming from a background where their entire consultation is 15 minutes. And now to spend 15 minutes to, to learn about someone, it seems like an awful long amount of time. ‘Cause I’ve experienced this before with colleagues who have moved from one type of practice and to another practice where we had to do much longer consultations. And you notice that patients are coming in, they’re booked in for an hour, but they’re leaving after 20 minutes because the clinician is just so used to doing everything so quickly. What kind of like in the whole interviewing sequence, like how do you encourage the patient to warm up and loosen up and talk about and what exactly do you wanna know? Do you wanna know about their cats and dogs names and what they do on the weekends? And like to what degree are you learning about them? [Colin]So I totally get that right. And it’s important that when you enter this world of practice, which is a different level of practice to that, which a lot of people are working at, and to quote the film Rocket Man, and I use this quote a lot of the time, you have to kill the person you were born to be, to become the person you wanna be. Okay? And that’s difficult. So you don’t get, this is not easy, nor is it supposed to be easy, right? You can learn it and you can practice it. And it’s been well proven that emotional intelligence is a developable skill. It’s a practicable skill. IQ is not, but EQ is, right? So what we’re looking for is a series of opening gambits, right? Conversational opening gambit to seek out a common ground with the patient. So if I was saying to you, do you have any children? What would you say to him?  [Jaz]I’ve got two boys, two young boys, six and two.  [Colin]How old are the boys? Six and two. Yeah, you said six and two. Yeah. What are they like, what is your 6-year-old like? What is he like?  [Jaz]Well, his sixth birthday is coming up. We’re doing a Marvel theme birthday party. He’s absolutely in love with Marvel. He plays cricket on Fridays and yes, it’s a great season of life to be a dad. [Colin]So I have a 17-year-old boy called Callum. So he used to be six. And during the ages of, between about six and 14, we were able to go do the whole of the Marvel Universe as it came out.  [Jaz]Nice.  [Colin]Up into, we saw a end game when it was just released. And so I can promise you that if you share that with your son now, the benefits you get when he’s 17 are extraordinary. Do you see what I just did?  [Jaz]Yes, absolutely. Yeah. You gave something a personal information about yourself.  [Colin]It took me one question to do that. Sometimes it takes more than one question, are you married? Do you have children? What do you do for work? Did you travel far when you got here? What was your last holiday? Do you read? Do you like books? Do you like movies? Whatever it is you want to share. And you’ll get to the point where, and the six degrees of separation, ancient research from the United States, if we got into this podcast for long enough, we would be able to find our six degree of separation. You’d be able to say, well, actually, my uncle lived in this part of Scotland for a little while and then he moved to here and I’d do, oh my God, my mom and dad lived there. And we would go, bang. And you almost always reach that moment in that 15 minutes where you go, bang, that’s us. To see how we are connected, shall we continue with dentistry? And it’s not difficult. It just takes a bit of explanation to do and a little bit of practice. Imagine that was your work. Imagine part of your work was to do that. What a beautiful job that is.  [Jaz]Well said, well said. To build that bridge is a truly wonderful thing. Now, I’ve seen some of your social media stuff and also in your lectures you talk about books and stuff. If someone, if a young dentist like is wanting to quite rightly develop their EQ, which is one of the most important things they could set themselves up for their career. Are there any resources, books, courses, anything that you could recommend to help develop their EQ?  [Colin]Well, first of all, they won’t read a book because they’re younger than me. And so if I recommend them or buy them a book, they never read it. So what they’ll want is an AI summary in about 250. So what I would suggest, the young person, let me bracket this in ages. If you’re under 25, go at GPT or Claude, whatever you like. And ask for a 250 word summary of emotional intelligence by Daniel Goldman and ask for another 250 word summary of talking to strangers by Malcolm Gladwell. Once you’ve taken the effort of reading that 500 words, you won’t be qualified, but you can use that as a platform for moving forward. If you’re older, if you’re between 25 and 40, listen to them on audiobook. And if you’re over 40, read them on a Sunday afternoon in your conservatory.  [Jaz]I love that. Okay. So yeah, at least you have two book recommendations and different media in which to consume in, depending on what phase of what seasonal life you’re in. The first 15 minutes, what are the second, third, and fourth, 15 minute segments of that implant consultation. [Colin]Second is the mechanics. So that is the absolutely standardized formulaic examination for a patient, which is, and I’m not, I promise I wouldn’t swear on this podcast. I promise I won’t. I nearly did. It’s absolutely cast iron, right? So if someone comes to get you, you’ve filled in all the stuff you were supposed to fill in — the complaint, your history of present complaint, your past medical history, your occlusal analysis, all of this stuff is done right. So just do that-  [Jaz]Data gathering.  [Colin]With an extraordinary nurse who does your notes and take your photographs and check if you need any radiographs. I don’t take a lot of radiographs nowadays at consultations, but that’s probably pattern recognition from experience. I’m cool if you take radiographs, if you want them. And sometimes I do, but usually I can formulate a plan provisionally for a patient and usually CBCT, everybody because it’s implant work. But actually I’ll do that if you accept a plan, but I’m not frying you if you don’t. And so that’s it. That’s that bit. And then the third part of it is the bit where you go, okay, let’s pull together what the possibilities are for you here. And so that is pulling the possibilities together, showing the patient what sort of options they might have for treatment and having that discussion initially. And that runs into the fourth part, which is then the after part of the consultation. So how do you follow that up? Who follows up and what do they get? And how do you consent a patient afterwards? So that you know what to tell you what happens in our place, and I can show anybody how to set this up, and it’s extraordinary is that TCO deals with a patient and we’ve got five TCOs here. They’re fantastic, but they’re so dialed into our philosophy of how to work, right? And our philosophy of sales are kinda hate sales, but we have to sell things. So they bring the patient in all the information. So generally speaking, they come in, we do the consultation. Generally they pick that person who’s already spoken to the patient, picks ’em up again, other side, right? Not on the day. I say to ’em, we’ll be in touch within a day or two. Now we also have an MDT here, which is a multidisciplinary team group, which discuss cases every Tuesday. A lot of the patients go to that, they love that. But it’s a huge thing now, different podcast, but if it’s straight, if it’s relatively straightforward, I dictate the plan. I fill the plan on my (PMS) which is Dentally, we use. And those plans are presented really well. They’re standardized in the presentation. Fantastic. I dictate a bespoke letter to the patient on Slack. That letter is then formulated and it’s put in a lovely package digitally with the treatment plans, and it goes out of dentally to the patient. Now it goes, we can tell when the patient opened it obviously ’cause dentally, you can tell from which what IP address it was opened on at what time. So if they ever tell us they haven’t read it, we’ll go, well, will you open it a few? There’s a few things happen. Then patient opens it and signs it. That happens. They haven’t even been back for a second consultation. The next thing that happens is the TCO phones them and says, are you happy with it? They say, I’ve got some questions. The TCO answers the questions, they sign it, and they all come for diagnostics with the nurse, not with me. So then the nurse does a diagnostic appointment for these guys into treatment. The next thing that happens is they have, if they don’t want to do it, they want more questions. They have a teleconference with me, right? They have a Zoom call recorded, and the final thing is they come back to talk to me again. But that used to be the standard format. First consultation, second consultation. I second consult. Now maybe 10% of cases. ‘Cause they go ahead with treatment because of the process. Or they have a zoom call at the end of treatment and the Zoom calls are much quicker than they’re recorded. And they’re much better. And I can show them all the photos and their x-rays on a Zoom call. So the process we have now is really good, but it’s based around the fact that they trusted it. And I can show you, we invented the treatment box. I don’t know if you’ve ever seen it. I haven’t got one here. And analog days, we did this with Chris Barrow and he took it around the country. We had this beautiful, it was like an iPad case. When it fell out, it had an SD card in it with Campbell clinic, SD card. It had a teabag, it had all our documents printed under here, but it had them all electronic here. And we put it through the post and that’s what arrived. We’ve done that digitally. Now we still do have that, but we do it more digitally now. So that part of the, how you present the plan, that’s kind of like a given, right? That’s like checking the patient’s occlusion after you do a composite. That’s gotta be right. And it has to be good depending upon what level of the market you’re at. But the key, the secret sauce, is at the start of the process.  [Jaz]Okay. So it’s all the data gathering that you’ve done beforehand. It’s the TCO involvement. And it reminds me of, sorry, you were gonna say.  [Colin]The trust. It’s the trust. It’s building the trust.  [Jaz]That first 15 minutes is absolutely golden. Without that, you can’t get to where you do eventually end up. And so go back to a little detail though. Like, imagine you’re doing this immediate, full-arch implant treatment and going back to what I said about making those treatment plan letters, like they as though they’re for the lawyers, right? Not so much for the patient, but the patient is the recipient. To what degree do you subscribe to that and to what degree in the digital sort of sending of these, Adobe sign or whatever you might use, would you say that compared to your co colleagues or people practicing a civil level as you, can you describe what your plans may be like compared to some other industry examples? [Colin]So I was an expert witness at quite a high level for 10 years. I am expert in criminal cases beyond civil cases as well. So I can tell you that the law is an ass, and effectively everything becomes a negotiation. So whatever you do to protect yourself, it’s not enough. So stop stressing about getting to a hundred percent and don’t. Now the way we do it is we have, in your consent letter, we have all these links. So we’ll say dental implant information, full arch reconstruction information, endodontic information, and we put those in if it’s appropriate for that treatment plan. And our admin support does that. So we say in the letter, make sure you read all that stuff. I’ve told you about it, but make sure you read it. It’s credit card, there’s credit card, Ts and Cs. When did you last read your credit card? T and Cs. And so, never ever. And did you ever say, well, I’m not having the credit card, because actually it remains their property at all times. Never. But you do get patients who want it. This is the spectrum. So, what we also do when we talk about consultations is, and we’re getting a bit deeper here, is there’s, we’ve got five types of personalities for consultations, right? Five types of personalities, right? So take my personality type, right? I’m a CEO personality. I’m not a CEO, but what I do is, so I can tell you that within about, we’ve never spoken before today. I’d never met you. Within about 30 seconds. You guys, I really like you and I trust you because that’s what the CEO personality does. But that’s what the CEO personality does, right? And so, if you stitch me up, the wrath will be terrible. So when you get the CEO personality, when I go for my, it was a knee operation I had, when I meet the surgeon in the waiting room, I had bought him, done. And he’s going to me, we’ll send you an estimate and I’m going, blah, blah. But it’s you. So the CEO personality, they trust really quickly, and so they’re never reading a word of what you sent. Never. They won’t sign it.  [Jaz]It reminds you of the book have you read, Surrounded By Idiots?  [Colin]Yes, yes.  [Jaz]So you are very much the red, dominant?  [Colin]A hundred percent. But the other personality types are the engineer. So the engineer goes, if you can’t get the engineer, I just wanna show you a prop, right? If you can’t get the engineer and tell him this is a fantastically clever printed crown that I’m not telling you about a podcast, but if you can’t tell him exactly what that’s made of and why you’ve lost. So the accountant personality, they don’t have to have these jobs. The detail about the detail and about the money and all of this stuff, and they have to be really clear. The teacher, they want to tell you. And then the worst one for ethical drag is the passive. That’s the 40, the 50, 60-year-old lady who’s lost her husband, who trusts you, who’s got plenty of money, and you go, oh, do you know what? I’m gonna spend your money? So you have to be really clear in your ethics for treating that patient. So that forms part of that process of building the bridge to trust, because those guys need a different calling. Each of them needs a different calling. And that’s emotional intelligence, right? And you can build on that and you do that. But we give you a framework because it seems complicated now and you have to practice it, and that’s serving patients for what they need. It’s not gaming the system. There’s nothing bent about it. It’s saying, as a professional, I’m prepared to be the person you need me to be, to look after you. [Jaz]And what I like about that is, in your communication, in your letters, you are making sure that all bases are covered so that they can go as deep as they want. For example, if someone wants to read the T’s and C’s for credit card is there, but a bit like me and you, I’m very similar to that. Like, I’m very quick to make decisions. I’m very slow to change them. And so I go by trust. My currency is trust. Maybe my principals who listen to the podcast as well, maybe they don’t wanna hear this, maybe they do wanna hear it. I don’t read the contract, but when I sign, I know lots of people get very deep into the associate contract. It’s not my personality type. I go by trust. I look John and Chris in the eye. I was like, do I trust these two? Well, John I went to dental school with is one of my best friends. I was like, yeah, I trust these guys and we buried the contract and the day need to pick it up is the day that we need to rip it up and and move on. [Colin]A hundred percent. I don’t look at it again.  [Jaz]Right, right. So that’s how I operate. But I appreciate that my patients are not reflection of me. They’re very different. And therefore the way I do it, Colin, is that I do a lot of Loom videos.  [Colin]Yeah, yeah. Loom video, we use a lot.  [Jaz]Exactly. But I know that for a lot of dentists, they struggle. They messaged me saying, Jaz, you talk about Loom, but my first one took me an hour to do. And so, whereas I can bash ’em out in five minutes, everyone again, it’s a exercise that you’ve gotta practice and practice and refine. [Colin]You have to systematize your process, whatever your process is. The phrase over the overriding phrase for our consent process is a sheep and wolf’s clothing. That’s what we are. So we are prepared to put on wolf’s clothing for our consent, but we are a sheep. So we are soft and kind, but as far as the consent is concerned, if you go into my consent, it’s as good as anybody’s, but it just doesn’t look like a 45 page massive document that that terrifies you. That’s the thing that terrifies you. And so I’ll say to the patients, these are the risks that you could get from this. But, I worked in head and neck cancer, so I see how people are consented. My wife works in children’s cancer, still people are consented for cancer operations on half a sheet of paper. We had a little bit vain and obsessed about ourselves, you know, a little bit. We’re not really that important Jaz, not really. And we should always not be too, we shouldn’t take ourselves too seriously.  [Jaz]Excellent. Well, I’m gonna move on to the next. I thoroughly enjoyed that. The next bit I wanna discuss is elective treatments and a common scenario, which we all face in our career at some stage probably early on, is like the patient who comes in. And just to make it relatable to most dentists who are, listen to this, so I don’t wanna talk about like full large implant stuff that you do. But let’s say a patient comes in and says, look, I’d like to have a gold crown on my front tooth. Okay. So that old scenario, which we’ve all faced before, maybe not, or we know a colleague who’s discussed it in the pub with you or on a Facebook group, more modeling. Where do you draw the line for yourself? Like, ’cause you might think that, hmm, is this really appropriate, but is this criminal? Like, can I do it, can I not? What decision making criteria and what kind of consent skills do we need to be able to consent someone for this kind of electric treatment? Which you don’t think that you would want in your mouth and you don’t believe in, but it may not be like too farfetched. [Colin]A lot of dentistry is philosophy and the law is applied philosophy. If you’re not, we don’t teach our children philosophy, which is a huge shame because it helps us to navigate this stuff and who we are and what we think. And so the analogies to this stuff that I’ve always used, so we have a principle in the practice that we use when we teach a lot. And if you saw me speak, you probably saw a slide that said prefix on it. Right? And it’s a linear analog scale. And as profit one end in ethics or the other, if we don’t make a profit, we die. We can’t treat anyone. But if we do that too much, we should be killed. Okay? And so we can’t be all ethics and no profit, but we can’t be all profit and no ethics. So we as a team talk about this a lot. Where do we strike? And that’s a philosophical decisions. Interestingly, and I’ll always like to reference this kind of thing, I’ve not been on social media for 10 years, right? Came off in 2015 and my last Instagram post was a picture of my breakfast in 2015. As a practice, as a business, we have a lot of that going on, but I don’t really see it. ‘Cause it wasn’t very good for me to be honest. And I knew that from early on. People do bring things to me and say, look at this. Have you seen this? And there’s a guy who was batting around recently who was comparing composite buildups to the price, we’re having a nails done. And he was just going like, if you have your nails done, you might as well have composite buildups. So to me, and let’s be clear about that, that’s abhorrent having composite buildups. And I’ve had composite buildups for wear recently, and my wife never noticed high, still hasn’t noticed. I’ve had ’em done, but my teeth were 50% worn down. So I had them for functional reasons and I’m delighted I had them. But to do it on a 22-year-old, we have to be really careful of that because that is not without significant long-term risk. Get it? To restore those teeth, to put on a plaque trap to in any way mechanically prep those teeth in any way is a huge problem. And so we have to be really clear with the patients and tell ’em that, but we don’t. We sell it as a fashion aid. It’s not like buying a top or a pair of shoes, and it shouldn’t nails like that. It’s not well, nails and nails. It’s not like nails. Right? ’cause your nails will grow back and so clearly we have a responsibility to position ourselves where we think the ethics sit for us. I always go back to do no harm. Part of my graduation, I was required to recite the Hippocratic Oath. Love it. Right? So first do no harm. I, as a practitioner, I will not harm you more than I help you. And so I still subscribe to that and I a hundred percent subscribe to fact to dentistry as a subspecialty of medicine. I a hundred percent subscribe to that. And that changes how you look after people. Composite buildups for aesthetic reasons. That’s not medicine. And so that’s hairdressing. Let’s be clear about that. That’s it. There’s no health benefit to that. Don’t tell me there’s a psychological benefit, there’s no health benefit to that. And so I won’t-  [Jaz]The first thing that comes to my mind, as, I mean, I agree, but there, there’ll be lots of listeners who are listening to this right now saying, no, no, no. They disagree. It’s a skill. It’s artistry. It’s giving confidence. It helps their mental health of the patient. And they’ll be thinking that. But then I would say that one of the things that was taught to me, I did a diploma in Ortho, and actually, I like the thing that the educator was saying was actually there are very few cases of ortho, which actually are functional and health ortho, the primary benefit orthodontics is aesthetics. [Colin]Yep. It absolutely is. Don’t get me started on ortho. I absolutely believe that. But I’m absolutely cool with straightening healthy teeth because I know that the long-term prognosis of those teeth is rarely. Not entirely, but really affected. I see plenty of resorption from ortho cases that we have to treat, right? So again, that’s not without its risks, which should be explained, but covering teeth in polymer right, is, that’s a totally different game. You’re doing that, not you’re doing it quick. You’re doing it to create an appearance, which is unnatural, fashionable. And so I know that people will disagree with this, but do you know what we have to say it like it is, right? And so I happily have that conversation with whoever you like. So the first treatment for someone like that is to straighten their teeth up. We don’t do aesthetic concept buildups where there’s minimal advantage to the patient. Not at all. We just don’t do it. We won’t do. I mean, just say the patient number. [Jaz]Colin? I know you don’t know anything about me in that regard in my clinical practice, but, I made this video, which again, got a lot of love, but also got a lot of hate because I said very much like what you’re saying now is like, I don’t like seeing teeth plastered with composite and I got a lot of pushback on social media from people who like doing so. But I’m with you and all of men or most of my orthodontic cases that I do like, aligners and stuff. Once I’ve got the teeth in enamel whitened. Yes. And looking great. I don’t wanna touch ’em, I don’t wanna have to put composite on them. Whereas I know people are quick to do that and then to build more volume. Give the wow effect. Give that shine with the composite. And I see lots of my colleagues do that. But, I’m not just saying this to agree with you, but I think just for those who are listening right now, that actually I think that’s a great point that, when you do that, it’s not as reversible as we’re saying. So the kind of language that’s being spoken on social media, Colin, I know you said you’re not on social media that much now, but like people are saying no injections, no drilling, no this, we’ll put eight, 10 composite veneers in three hours kind of thing. And that I think has got lifetime implications that probably are not lifetime discussed or make clear lifetime implications. [Colin]Lifetime implications. And you’ve not been doing it for that long, so you don’t know if it hasn’t got lifetime implications. The problem is, it’s a relatively new thing, but it’s not new. Jaz, in its principle because in the nineties we were doing Larry, Larry Rosenthal, veneeriology, and veneeriology was to protect. That’s all the same arguments were used there. And what we see now for the Larry Rosenthal veneeriology is terrible, right? So when we were using porcelain to do this, it was awful. And it’s not, I mean, we’re not prepping perhaps as much, but let’s be clear, you are sticking resin onto these teeth. You’re creating plaque traps, you’re creating ledges. And please don’t pretend that everybody that’s doing this is an artist. They’re not an artist, right? At the very top, two or 3%, they are an artist. But the guys that are doing it quick, down the bottom end, it’s garbage. Right? And we are seeing it coming through the door and they’re not finished properly. And they’re done cheap. It’s just, it’s really bad work, right? And it misrepresents the industry as a profession when it’s done badly like that. And I’m sorry, and I know people won’t like that, but you can’t please all the people all the time Jaz. And sometimes it’s important to say, so sometimes it’s important to say much. Would my kids have that? Absolutely, never would they have that.  [Jaz]Okay. No, and I’m glad we moved away from that gold crown scenario. ‘Cause actually what you are saying is far more relatable, which is the comp veneer wave that we are seeing. And this is a huge thing, like my social media, the algorithm is just constantly showing me this. And yes, I get it with, it’s a peg lateral. Okay. Like, the two actually that has got some space and size issues and stuff and I get it. But when you’re seeing, so what I’m seeing is lots of eight or nine out of 10 smiles being converted to the short term, 10 through the use of resin or veneers and stuff. And I think that’s where you’re saying that actually that’s the point. At which do we see the benefit and risk analysis a way up and what you are saying, the whole prefix thing that actually, that one probably maximizes on the profit and not so much on the ethics. So that was just a reflection, not so much a question. [Colin]So listen, it would be very easy for us Jaz, you and I to create an index for treatment for composite veneers and we would be able to look at the case aesthetically and say, is there a significant aesthetic detriment to this patient which could be causing a psychological upset objectively. And very few of those cases would qualify and you know that’s true. And so if we set up that we should do that, and if we set up that objective index and anybody who did it apart from that with clear clinical photographs before the treatment went to jail, then lots less people would do it. And I know that the good, the benefit of not being on social media is, it’s very difficult for the trolls to get to me. So I think that’s why it’s possible for me to speak about that. They still will though. Someone will, in a roundabout way, still manage.  [Jaz]I’m sure they will. But look, I think it’s important to discuss these and whilst I do host guests who are veneeriologists and do wonderful, beautiful work.  [Colin]And you should. [Jaz]Yeah. You definitely should get all perspectives. Yeah, yeah, yeah. But I like your perspective. And I agree with it in the sense that I’m not so prolific in the whole composite veneering. I think there’s a beauty to enamel. And so that is a level of elective treatment that everyone needs to decide, okay, where do they, which side of the line they’re on. And actually to have a, some sort of line somewhere. So what, before we move on to the final thing, which is about selling in dentistry, what’s the final piece of advice that you wanna give to a young dentist about elective treatments and staying safe and doing the right thing when it comes to elective? Yeah. So the Gold Crown was an extreme example. I’m glad we moved away from it. But composite veneer is a wonderful, real world example. What advice do you wanna give in terms of elective treatments?  [Colin]Okay. I think that, and this could take just a minute or two, but.  [Jaz]Yeah. Yeah.  [Colin]I’ve been talking to new graduates since 1998 and you’d asked me earlier on about a lecture that I did for dentinal tubules or something. I think I stopped counting lectures about 2000. Right. So I’ve done a lot of speaking, so I can’t quite remember everyone that I’ve done, but they, so I developed these approaches as we talked.  [Jaz]Can I remind you something that stuck from that lecture? I’ll remind you something, Colin. It was when you spoke about leadership and an example of leadership you gave is a patient comes in and they had like an amalgam tattoo or something, right? [Colin]And she was like, yeah, off the left. Left. I remember, yeah.  [Jaz]Is it, is this cancer? And you were like, well, actually everyone’s like bouncing around ’cause they’re afraid to say that it is not cancer. You’re like, it’s not cancer. Don’t worry. They having that leadership, that’s how, I remember that.  [Colin]That was a clinical leadership point. Yeah, I did use that for a while. But so we talked to guys and go, you know what, when I first five years of my career was in hospital service, right? So I was in five years, or the first five years, part of it was hospital service and MBT. When I added up my wage, I’d spent twice the amount of time working and I’d gained half the money of my mates that went into practice. But I exited with a fellowship in surgery and an insight into implant dentistry and various type of things. And I think for most of my friends, I’ve made far, far more money than anybody’s made that I graduated with. Right. And I’ve been so privileged and so lucky. And that’s the funny thing because I think a lot of the people have been brought into dentistry on a promise of what they’ll make. Yeah. And it’s harder and harder in dentistry now to make the money that they’ve been promised. And I’ve been telling that story for many years now. What I would like to say to the guys is, if you want to be really successful in dentistry, both in terms of financially and in terms of the respect you get from your peers and in terms of the satisfaction you get from your job, try and be good from the very get go. Just try and be good because there’s always a place for good in the market. If you get close to the top 10% of the market, you will be remunerated really well. You’ll be thought of really well. You’ll have a lot of colleagues that you trust and like, and your staff will stay with you because they respect you, all of that stuff. But if you start by trying to be rich. You’re unlikely to get good. So if you start good, you’ll probably be good and rich. But if you start trying to be rich, the likelihood is you’ll probably never be good. And what happens to guys at my age, and you’ll see it, is they get desperate to lecture or desperate to speak, or desperate to justify themselves because they’ve got enough money or a lot of money. And then they go, but I’m not, nobody thinks I’m in. They’re isolated in a position. And the guys who are speaking, they’re really brilliant world class guys that are speaking over here are doing that. But I’ve just spent 25 years trying to be really good at what I do. And so see the young guys buy a camera, right? Do the focus photography course, which is, I’ve got no link to that apart from it’s brilliant, isn’t it? And right. And do photography course and start photographing your work and be proud of it and realize that that building a career is building and it builds and builds and builds and don’t do anything to people that you wouldn’t do your own family. Straightforward. Brilliant.  Interjection:Hey guys, Jaz interjecting here. Listen to Colin. Colin is telling you, just like my mentors tell me all the time, when I was a new grad, the first thing I was taught was take photos. And it is shocking. Like obviously we see so many photos on social media, so I know lots of dentists are taking photos, but actually it’s still the minority. It’s shocking how few dentists overall are taking photos and no, I’m not including phone photos as photos. Okay? Phone photos are not proper photos You wanna take really beautiful photos, do what Colin says. Get yourself on a photography course. There’s a lot you can learn on a hands-on course, fancy shots, studio lighting, that kind of stuff. But if all you want is the foundations and to be able to take. A consistent series of photos, good occlusal photos, good frontal photos, wellex exposed, well framed, and I invite you to take on the 21 day photography challenge in just three weeks in videos that range from three minutes to 10 minutes, one video per day. You can learn photography to a very good level, and then you can fly. If you choose to go on a hands-on course, the 21 Day Challenge is available on the app. Protrusive Guidance, we just literally launched it last month. It’s been great to see your portrait photos and your engagement throughout the different lessons. I look forward to awarding you with your badges. Anyway, back to the episode.  [Jaz]Well, I think we’re gonna have to, I mean, I could speak to you for days and days, Colin. And, I think instead of going deep into the final thing about what is your view on selling in dentistry, but I think you have spoken about this for so long that I think you’re able to give us a post-it note version of your definition of sales in dentistry is selling. The whole thing about is selling a dirty word. So some dentists get very upset about this topic, whereas other dentists are very proactive in saying, Hey, we sell all the time. When we speak to our spouse, we are selling an idea. That kind of stuff. We all heard that before. So what is your take and what is your advice when it comes to, ’cause I think prefix is wonderful the way you described that. I really like that about the sort of the levels of profit versus ethics and how actually there should be a degree of balance. And I really, I’ve never heard of that. I love that. But what would you end the podcast in when it comes to sales in dentistry and have to think about it, how to approach it. [Colin]Well, first of all, sales is, it’s not a dirty word, but it has dirty connotations in certain places, right. So the last book that I’ll recommend if you’ve not seen it, which is a brilliant audio book, Daniel Pink ‘To Sell is Human’. Okay. It changed my world in sales because I exited the hospital service as a working in head and neck cancer going, I’m never selling to anybody. I’m not salesman. I mean, so there’s a famous story ’cause I’m very good friends with Chris Barrow. Chris coached me for years and paid him a lot of money, took over 18 months and stuff, and he transformed our business extraordinarily and was a big, big influence on us. But when we were at early stages, we were in Jamie’s Italian restaurant, which is not a thing anymore, and we were having a chat about sales and it was lunchtime and the restaurant behind us went quiet in a moment, just at the point where Chris shouted at me, you think sales is an STD? Right. And so I have Jaz, I’ve been on a journey, I promise, understanding that profit is oxygen for my business. Right. So use that as your intro by the way. Yeah. So profit is the profit. Profit is oxygen for my business. Get that. It’s essential for life, but it’s not the meaning of life. I do not wake up in the morning going, oh, I’m gonna get some oxygen today, but if I don’t breathe, I’m dead. Right? So we need to profit, right? But we don’t need profit to be our, our dream, our vision, our function. We don’t have that, right? But we, so what I want to do, if you or any of your family come to see me, is I want to be able to try and give you a really good solution to your problem. If I can. If I can’t, I want to be able to tell you that I’m sorry that I can’t, but I want to be able to try to find someone who can. That’s it. And so our business, my amazing business is expanded to the fact that so we can solution, manage a lot of scenarios, but not all of them, right? And so I want you to be able to choose a solution with us, or get the option to choose a solution with us. And I never ever want to let you down on service. So if you come to see me. You have a consultation, we will keep talking to you until you don’t want to talk to us anymore. Not in an obsessive way, not in an angry way, but we’ll say to you, do you wanna go ahead with treatment? You go, I can’t at the moment, Colin, ’cause my son, he wants a new cricket bar and it’s gonna cost me 50 million quid. So it’s gonna be about six months. We’ll go. Is it okay if we phone you in six months to check in? And if you go, oh, that’d be great. That’s the ideal thing. We will never miss that call. If you say to us, not just now, Colin, we’ll never call you again until you come back to us. That’s what sales is like. Never let people down because you’re too busy. Never break a promise. Never ever contact someone who does not want to be contacted. And so if you do that and you count it, if you follow the consultation process that I shared with you, right. My conversion rate is still, it’s about the only thing I’ve got left in the practice that I’m good at is still 80% or above. Right. If you come to me, if your wife fell off her bike tomorrow and she lost her upper central incisor and she has a large smile and that’s important to you, it’s close to 9,000 pounds for me to replace that tooth. And my conversion rate is 80%. The process works extraordinarily well, but that’s because we are trusted and we’ve developed trust over 27 years worth of practice in this area. [Jaz]As Raj Rattan, you say trust is something that you, you build in like drops or ounces and you can lose in bucket loads in a minute.  [Colin]So in a minute. People can’t understand if they talk about marketing Jaz and they can’t understand why they can’t attract patients because they don’t have a brand, because they don’t know what a brand is. [Jaz]Beautiful. Colin, I thoroughly, enjoy this. Part of my duties on the podcast is, I’ll give you some context, Colin. I’ve been doing this podcast since like 2018, 2019 now. So we’ve got, hundreds of hours and whatnot, and it’s been absolutely, one of my favorite things to do still is having these conversations, the most wonderful conversation we just had. But I have a responsibility that early on in my podcasting career, some people used to message me. It always stuck with me. What stuck with me, and they said like, Jaz, you are giving everything away for free. Like on the podcast, everything is being given away for free. And these course providers must hate you because you are literally giving away everything free. But actually that dentist, a dentist was wrong. Because what I’ve found is that actually through Protrusive, I have connected dentists and listeners to educators that they really resonated with and they never was on their radar before. Or, help them to connect with someone that, you know what, I like this chap. And I think there definitely, I think a lot of people would’ve resonated with you. Some people might hate your guts based on your views on composites. And that’s okay as well. But for those who resonated with you, can you tell us about the Colin, the Campbell Academy, I believe it’s called What You Teach. And I’ll definitely put the website and everything in the link as a thank you for giving up your time, but also to, as a responsibility, I have to help everyone grow because the podcast is one thing. And yes, we do CPD, but to be able to grow and do the kind of procedures is important for me to connect them with educators. [Colin]So listen, first of all, when I grow up, I want to be you, right? And so you are doing extraordinary, extraordinary work here, and it’s a brilliant thing you’re doing and never stop, right? And your enthusiasm’s fantastic. And it’s been a privilege to be asked to be here. I don’t need to promote anything, it’s just been a privilege to talk, right? [Jaz]Thank you.  [Colin]If you wanna find me, we are the Campbell Clinic Group, right? The Campbell Clinic is this, we purpose built a 7,000 square foot, specialist practice, whatever you call it. We educate, we research, we teach, the why of our business is we positive. We exist a positively influence a life of as many people as possible through the work that we do. In the example that we set, if you like that connect, go to Campbell Clinic, wherever you want on all your stuff, or go to the Campbell Academy. The Campbell Academy educates dental business and dental implants. And is, and is, is going like a rocket in lots of different places. And all of the chat that you get here is what you get. When we educate, we chat about this stuff all the time. What you get beyond our education is the philosophy, how to practice and what to do. And, and we have a tribe of people who subscribe to that. And we have a lot of people who probably hate it. The other place says, if you like the conversation, I write a blog. So my podcast is a blog. I have a podcast, but it’s stalled. But, I write a blog and I’m now at 4,250 posts. It’s been every single day for what? 15 years.  [Jaz]Wow. Well you’ve been blogging every single day?  [Colin]Yeah. And so if you go to Colin Campbell blog, you’ll find that subscribe. You’ll get it, it goes every single day. So there’s a business, a separate business one.  [Jaz]And I definitely will be. I’ll definitely put that link. That’s brilliant. And I’ll definitely put the link for the academy and promote all the good work you do.  [Colin]Yeah. Listen, honestly, I knew through the week I was looking forward to talking to you and that was a real privilege. I’m so glad I had the opportunity and thank you so much for your time.  [Jaz]It means so much to me. Thanks you so much, Colin. I appreciate your time. And we should do this again sometime.  [Colin]Whenever you’re like, gimme a shout. See you later. Cheers.  Jaz’s Outro:Well, there we have it guys. I told you it’s a saucy one. I told you it’s a little bit spicy, controversial. Sorry, but not sorry. I think you just did a brilliant job. Don’t you Just love Colin, and just before you think this couldn’t get any better, you can get CPD for this episode. Answer the quiz, get 80%, and you can get CPD. This is available for all our paying subscribers on Protrusive Guidance. And maybe now if you’re not already on the app, it is time to join us and upgrade. Head over to protrusive.co.uk/ultimate and unlock CPD. That’s enjoyable, inspiring, and actually we’ve got tons of masterclasses there as well. Protrusive education is a pace approved provider. I’m gonna take a moment to thank team Protrusive for all their hard work. And thank you once again. Dear listener, you joining me on this podcast just means so much. And if I can just ask you, just click that button, hit that subscribe button. Honestly, it would mean a lot. So please do that. And in doing so, I’ll catch you same time, same place next week. Bye for now.

Can and should Dentists carry out home sleep testing? It’s actually super easy and I have been doing it for 18 months! What happens after you screen them—do you know what to do next? This episode will teach you! Dr. Jaz Gulati shares his personal journey into incorporating sleep testing in practice—after 1.5 years of doing it, the impact has been nothing short of game-changing. https://youtu.be/H4rTkIuOHWI Watch PDP243 on Youtube Joined by clinical sleep scientist Max Thomas in this jam-packed episode, they deep dive into what it really means to go beyond awareness of sleep-disordered breathing. He breaks down the practical steps for dentists who want to do more than just refer—and start making a difference in their patients’ lives. You’ll learn how to bridge the gap between theory and action, how to screen effectively, and why you play a pivotal role in the patient’s journey to better sleep, more energy, and a healthier life. Protrusive Dental Pearl: If a patient has been seen gasping, choking, or stopping breathing during sleep — that’s pathognomonic for sleep-disordered breathing. 🛑 Don’t ignore it — they likely need a sleep study. Ask this in every history! Need to Read it? Check out the Full Episode Transcript below! Key Takeaways: Understanding obstructive sleep apnea is crucial for dentists. Dentists are in a unique position to screen for sleep disorders. The Malampati score is an easy tool for assessing airway obstruction. Sleep disorder breathing can significantly affect quality of life. Patient history is vital in diagnosing sleep apnea. Quality of sleep is more important than quantity. Dentists should ask specific questions to identify sleep issues. Sleep position can significantly affect sleep quality. Screening tools like Stop Bang and Epworth are essential for identifying sleep disorders. NHS sleep testing can vary greatly in wait times depending on location. Snoring is often a precursor to more serious sleep disorders. Dentists can play a crucial role in sleep disorder management. CPAP is the gold standard for treating sleep apnea. Understanding the legalities of sleep screening is vital for dental professionals. Remote monitoring became essential during COVID-19, shifting paradigms in sleep medicine.. Remote monitoring helps ensure patients are truthful about their usage of devices. Mandibular advancement devices may be more effective for certain patient profiles. Patient compliance is crucial, with many struggling to adapt to CPAP. Highlights of this episode: 00:00 Teaser 01:15 Intro 04:51  Protrusive Dental Pearl 05:52 Introducing the Expert: Max Thomas 09:39 Importance of Screening and Diagnosis 13:41 “Crowding” at the Back of the Mouth 14:46 Mallampati Score 18:54 Understanding Sleep-Disordered Breathing 25:35 Screening Tools and Techniques 32:09 Screening Questionnaires 37:24 Midroll 40:44 Screening Questionnaires 40:53 Athlete Sleep Screening and Marginal Gains 44: 20 Identifying Patients for Sleep Testing 46:15 Snoring: Risk Factor for OSA 51:44 Mandibular Advancement Devices and Legalities 55:33 Diagnostic and Treatment Options 56:57 CPAP: The Gold Standard for Sleep Apnea 01:08:33 Retesting Before MAD 01:14:41 Dentists Warning about DVLA Implications 01:17:18 Final Thoughts and Recommendations 01:19:19 Outro Resources for Screening Sleep Apnea S4S Pre-Screening Questionnaire Mallampati Score Epworth Sleepiness Scale STOP BANG Questionnaire Screening Tools The Acupebble Device  WatchPAT as an alternative Send your sleep test for reporting to Max Thomas – excellent service and affordable Max Thomas’ LinkedIn If you loved this episode, don’t miss Sleep Disordered Breathing and Dentistry – PDP139 #PDPMainEpisodes This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A, C, and D. AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Sleep Medicine) Aim: This episode is aimed at empowering general dentists with the knowledge and practical steps to actively participate in the screening and co-management of sleep-disordered breathing through the integration of home sleep testing in their clinical practice. Dentists will be able to – Understand the role of general dentists in identifying signs and symptoms of sleep-disordered breathing, particularly obstructive sleep apnea (OSA). Identify when and how to refer appropriately to sleep physicians or medical specialists after screening. Explore collaborative workflows between dentists, sleep scientists, and GPs to ensure effective patient management. Click below for full episode transcript: Teaser: When you think about the number they have per hour, less than five is normal, right? Less than five of these breath holds is normal. Between five and 15 is your mild category. 15 to 30 is moderate, and above 30 is severe. You see patients that have what we call an AHI Apnea-Hypopnea Index of 60, and sometimes these breath holds can be 30 seconds. Teaser:You end up looking at these studies and there’s actually more time spent not breathing than there is breathing. In some areas, you are six weeks away from a test because they’re not only on top of their list, but their numbers are lower. In other areas, you’ve got high population density and low service output. So you know, I have seen sleep departments that have got 60 week wait list just for the initial diagnostic tests. You already got the suspicion that they have obstructive sleep apnea. They’re already telling you that they’re struggling, and then they’re told to- Sleep apnea is one of those things that a patient may need to report and they may need to report it in the case where they have moderate or severe obstructive sleep apnea with sleepiness. And it’s really important that with sleepiness part is the main focus of the DVLA guidance. ’cause the sleepiness is the symptom that affects safety on the road. If the patient has sleep apnea, but they don’t wake up frequently from their breath holds, they don’t have the interruption to sleep, they don’t have the reduced cognitive function in the day. That sleepiness is what? This is all contingent on.  Jaz’s Introduction:Protruserati, I think this is one of the most profound episodes we’ve done to date. You see, the problem is that everyone’s telling us that sleep apnea is this huge thing and that as dentists we ought to know about it. And there’s plenty of podcasts now out there. Plenty of content out there, plenty of courses out there that are kind of filling that gap of knowledge. The issue is we’re still hungry. I’ll tell you what we’re hungry for. We’re hungry for the following. Okay, so now you know what sleep apnea is. Now you’ve asked your patient, you’ve done some screening questions to your patient, but then what? What happens then? Because if you’re not already actively in this space and you kind of refer and you lose that patient forever, what if you as a dentist want to do the sleep test? That’s what I do. I’ve incorporated sleep testing into my clinic for about 15 months now and it’s amazing the results we come back. Now, I just wanna start by saying that we as dentists, we cannot diagnose sleep disorder breathing. Okay, let me repeat. We as dentists cannot diagnose sleep disorder breathing, but we can screen and we play a pivotal role in its management. So what this episode will do is we’ll bridge that gap between actually knowing about sleep apnea and actually doing something about it as a dentist. And that is only achieved by those who are testing in their clinic. And let me tell you, it’s not mega expensive. It can be very convenient for your patients. And hey, even if you don’t start testing yourself, you ought to find someone near you or a center near you that can get your patient tested for sleep disorder breathing, such as obstructive sleep apnea. And correctly reported so that you can genuinely help your patients, help them live a healthier life with more energy, less dozing off during the day ’cause of sleepiness, better quality of sleep for them and their partners, and adding quality life to their years. Hello Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. If you’re new to the podcast, welcome, you picked a great one, and of course, if you’re a returner, thank you so much. Really means a lot. Your time is important to me, so I’m gonna make sure we absolutely smash it in this episode. This episode is a bit longer than usual, but let me tell you, it is full of gold, full of protrusive pearls when it comes to sleep apnea and actually doing something about it as a GDP being proactive, rather than just screening and then leaving it there and doing a big tick. Like, oh yeah, I’ve screened, I’ve done my job, actually helping your patients get the correct treatment. And the person who’s helping me today is a clinical sleep scientist. His name’s Max Thomas, and he’s such a knowledgeable guy and he explains things really well. The funny thing about this episode is we’re talking about sleep here, right? And I was recording this like 10:00 PM after my evening shift at clinic, and Max said this just come from Japan, suffering the most major jet lag ever. Yet, I still think we’ve created a piece of art, which I hope you will love and you may wish to listen to again as a reference. But most importantly, I think this is the one where the penny drops and things actually make sense in terms of how you can play a role to help and serve your patients. Let me tell you, the done for you notes of this episode are absolutely brilliant. You’re gonna absolutely love them because our premium notes, what we do with our premium notes is we ensure that you can actually retain the information. Look, I listen to podcasts, I listen to audio books. Sometimes you get home, you sleep and you forget so much of it. When you actually read a handout, that literally takes about 10 minutes to read. It really cements and reinforces your learning and it helps you take the next actions. So if you wanna download the premium notes, please head over to the Protrusive Guidance app. It’s all there for you. Head over to the Protrusive Guidance app. It’s all there for you in the Protrusive Vault section. It’s also under each episode we’ve got the transcript and the premium notes, which are like the done for you, revision notes. And yes, this episode is eligible for CE or CPD. We are a PACE approved provider. Dental Pearl Every PDP episode I give you a Protrusive Dental Pearl and this one’s very relevant to airway and sleep and it is the following. If in your patient’s history they have elicited that someone has observed them stop breathing or gasping or choking in their sleep, and that is pathognomonic, I hope I’m saying it right, pathognomonic. Let me just make sure I get that right pathognomonic, there we are. I said it correctly. Now what that means is that if someone says that they’ve been choking or they’ve been observed holding their breath or gasping in their sleep, that means they’ve pretty much have a sleep disorder breathing. You can, with a high degree of certainty, screen them as positive and probably will benefit from a sleep test. So it’s a helpful question to ask in your history. Now, of course, we cover that in good detail, but we cover about all the different questions we should be asking, all the different signs and symptoms and how exactly am I testing my patients and how Max report these, and then what happens when we get the patients some sort of treatment. This could be them having a CPAP. This could be a mandibular advancement splint, or a mandibular advancement device. So I hope you enjoy this deep dive and I’ll catch you in the outro. Main Episode:Max Thomas, welcome. A very warm welcome to the Protrusive Dental Podcast, my friend. I like to start the podcast in terms of how I came under someone’s radar or how I met someone virtually, or how someone came into my universe and it’s Mahmoud, right? My brother from another mother, Mahmoud, we’re both occlusion enthusiasts. We do courses together. We teach together, and he was like, oh, you know what? I play basketball and there’s this guy called Max, man. He’s really into the sleep stuff. I was like, man, I need a sleep guy. Put me in touch and I’m so, so glad that, I don’t know, a couple of years ago that he put us in touch. Man, it’s been so nice to learn from you to sort of manage these cases together, man, you’ve been pivotal in that. And so what I really want to do is today I want this to be the most tangible piece of content that dentists hear while they’re on the train, while they’re driving, whatever they’re doing on the treadmill, so that they can actually feel like, you know what? I’m actually gonna do something about sleep disordered breathing, because most lectures and most content you get out there is like, either come on my course or it’s like the basics and overview, but that nitty gritty detail of what do I actually do? Okay. Which you’ve helped me massively with. So Max, please tell us about yourself, my friend.  [Max]Thank you for the introduction. Yeah, so we met when I was still working up in Birmingham, actually. We haven’t met in person yet, but yeah, our link was Mahmoud. I’ve still got him saved as Mahmoud ‘Dent Baller’ because I never knew his surname. So shout out to Mahmoud.  [Jaz]Well, he’s still saved on my phone as Mahmoud Occlusion still.  [Max]Yeah, fair enough. I mean, I did that with all of my contacts, how I remember them. But yeah, so, I’d actually heard your podcast before I met you ’cause my wife is a, she’s a big fan, so shout out to Beth. She was playing one on a drive up between Birmingham and Bryson. And in order for me to get a Spurs podcast on, she also had to have a dental podcast. And it was a really nice episode. Where you had a physiotherapist on, and I still got something you mentioned tangible. I still got something that I use in my day-to-day practice from that, which is the best posture is the next posture. Keep moving around, particularly if you’ve got issues. And man, that stuck with me, so I appreciate the sort of yeah, keeping it tangible, making it, sure there’s nuggets to take away.  [Jaz]Excellent. And that episode, Sam, he actually came on again recently to talk about some more, the current concepts and the different types of loops that we have. So man, I’m so glad. That was a long time ago. That was like 270 episodes ago, so, wow. Like, we connected years ago, but tell us about you professionally. Like how do you define you? Because when Mahmoud was trying to explain your role, he was struggling.  [Max]Yeah, yeah, yeah. So-  [Jaz]He’s some sleep dude. [Max]Some sleep dude, I get called sleep man at some of the talks I do. I’m fine with either. I’m a clinical scientist that practices in clinical physiology and that is essentially the measurement of either lung function or sleep. And obstructive sleep apnea is where those things overlap. The airways and sleep and breathing is kind of our forte is measuring breathing whilst people are sleeping, looking at interruptions to those breath. And so our job really is about the diagnosis and management of conditions relevant to our practice. So for me, that’s obstructive sleep apnea, that’s insomnia and used to be a lot more sort of narcolepsy, really complex sort of sleep stuff. When we were first introduced, we’re in a big lab in Birmingham. Now I’m a smaller lab, but I deal more with obstructive sleep apnea, so probably, still doing quite a bit in the field that we were introduced in. I haven’t had any referrals from you recently.  [Jaz]Yeah, well I had my pneumothorax and that kind stuff. But, I get the same conversation with my lab technicians, right. It’s like, for me it’s like buses. Like patients, when they come to me, it is like two, three a pop and then suddenly nothing for a while. And very much, it depends on how many conversations I’m having with patients. So it really can vary week to week. But we’ll talk about, how I started to send my cases to you for reporting. ‘Cause I think that’s what dentists want to hear. How do you get started in your journey?  And when you talk about, just a little bit about you, about your day-to-day work, does that mean that you’re literally watching people sleep and you’ve got like, your clipboard or you’re just ticking things off and you are clicking things? Like do you do any element of that?  [Max]Yeah, so when you have these full polysomnograph where you’re doing, you’re measuring everything throughout a night’s sleep. You have them in as an inpatient, well, we don’t have that kind of lab anymore where I’m at actually, we had that in my old site. But you would have someone who was there observing them overnight, just making sure that all the readings were occurring. And if there was any issues, you’d be there to help. But the main job of a sleep scientist is to go through those data the next day and try and look at all of these different channels and work out what’s going on under the hood. If you’ve got a patient that’s complaining about the fact that they’re sleepy, well, you’re looking at the quality of their sleep overnight. You’re looking to see if there’s any interruptions that might be related to breathing, and if there are, you count how many of those sort of interruptions there are. We get this hourly rate out the other end.  [Jaz]Don’t you get the AI to do that though? You know what? There’s a list of jobs of where AI is gonna take over your job. Are you dangerously close to losing a job?  [Max]Yeah. So do you know what? I would say-  [Jaz]Sorry if I touched the nerve.  [Max]I would say no, you’re not, I would like it to be able to support us. ‘Cause a lot of the stuff with AI and healthcare is, we’re actually better with the device having some form of AI. But it’s to support clinicians and AI on its own can’t literally do the job and actually quite often need pointing in the right direction. But sometimes, people go to on holiday to Japan and then their body clock is the other side up and you’ve just got an AI to point you in the right direction and you kind of, it’s symbiotic in that sense. There’s a lot of work in the world of respiratory moving towards like automated interpretation of lung function tests and things like that. But actually in the world of sleep, we’re not quite there yet. We have assisted scoring, but then we go through and check it. We make sure it’s right. There’s quite a lot of nuance to the things that we do. And the traces are these tiny little squiggles and after years of experience you can interpret those squiggles, but quite often these interpretation algorithms, they get some of the big decisions wrong.  So we’re at a point, the only thing I’d say on the back of that is the uptake of technology in healthcare systems is so slow. We might have these AI technologies about, but then they’re not gonna be uptaken at a rate that will see me before I’m retired. I think.  [Jaz]Good, your job is safe then. And that makes me happy because guys, the way me and Max have been working together is, I screen my patients and we’ll talk about that, which questions I ask. And Max has been instrumental in helping me and I just wanna just go through his journey with you all and explore, okay, how did I detect, the first ever patient I sent you was like severe off the scale. I dunno if you remember this actually over a year ago.  And so it’s amazing, man, for me as a dentist, at dental school, they taught me that I can save someone’s life if I diagnose oral cancer or I see like lots of evidence of acid in the mouth and therefore they could have a Barrett’s esophagus and therefore. That’s a very indirect way. But no one mentioned at that stage, dental school, they didn’t say, we have a important role to play in the airway ’cause that’s another way to save someone’s life. And some of the studying I’ve done, some of the courses I’ve been on, were much like, we can add 10 quality years, not just 10 years, but 10 quality years in someone’s life. If you make such a diagnosis, if you help these patients. And you said something earlier that dentists are in the best position to do so. So just tell us why are we in such a great position to be able to help screen? Because we cannot diagnose, but we can screen and assist patients.  [Max]Yeah. So you are in a great position. You’re in a great position for a lot of reasons. The first reason is you are genuinely, truly general practitioners. As in everyone will come to a dentist and see you. Whereas actually at GPs, they have this sort of sample bias of people turning up when they’re super duper ill and they’ve got one thing that they need to talk about and that’s all they get. And sometimes GPs will catch other stuff and sometimes people will go to their GP saying that I’m very sleepy, my partner says I snore. That sort of thing. Whereas you kind of see everyone and you get this opportunity to have them sat in a chair and be still for a bit. And that’s when you start noticing symptoms. Another person who’s having a conversation with them might not. You’re in a very unique position, not only because of that, but also because you are looking, as you said at the start of the airway. And the main crux, or the main point that causes an issue in obstructed sleep apnea is the upper airway back of the throat, crowding at the back of the throat, causes obstructions when they go to sleep, and all those muscles relax and everything collapses across. [Jaz]When you say crowding dentist, think teeth being crowded, right? So, no, you’re right. But see, so let’s spell it out for a younger colleague. ‘Cause I know what you’re talking about now, but there was a stage where I’d be like, wait, crowding at the back of the mouth? Like posterior crossbites? What do you mean by crowding back of my, what are we looking at? [Max]Yeah, so that, I mean it’s almost all the structures in the jaw and the upper airway, the soft palate, the tissues at the back, all of that can contribute to crowding. So what you tend to see, your classic obstructive sleep apnea patient is someone that’s overweight, very thick neck, all the tissues that are in the back of their throat, there’s a lot of fat mass. And that’s taking up a lot of space whilst they’re awake and they’re operating their upper airways, muscles, the airway’s perfectly patient. It’s the moment they go to sleep. And when they get into the deeper stages of sleep, such as REM and all those muscles have really relaxed, they start getting obstructions that can’t be overcome by just trying to breathe in. And what they have to do is they have to wake themselves up periodically in order to be able to breathe. And they don’t always fully wake up, but they are having interruption to their sleep. It affects their sleep architecture and the next day they feel rotten. So you can see all those structures in the mouth. You could see retrognathia, you can see in a large tongue. You can see the soft palate is almost covering the entirety of the back. You can’t even see to the back of the throat. I don’t, I don’t dunno-  [Jaz]Let’s talk about that The Mallampati score. Let’s talk about-  [Max]That’s what I was about to say. [Jaz]So it’s good. So let’s talk about that ’cause I do that as part of my assessment, especially for my TMD patients. When I ask my series of questions, I’ll get the patient to open really big, as big as they can go and stick their tongue out all the way and just have a look. And there’s degrading from zero, is it zero or one? I forget the first.  [Max]I think it’s one to four.  [Jaz]Yeah, one to four.  [Max]It’s four different grades.  [Jaz]Mm. And so I think it was named after an anesthetist. Is that right?  [Max]The history of its loss to me. Sorry, I could have done some Googling. [Jaz]But anyway, the anesthetists, they are looking at, they are giving the score a lot because it is important for them for what they do, but actually for the dentist it’s important. But I won’t steal your thunder. You are the man of the knowledge. Please tell us about how easy it is for us to test Mallampati. I kind of gave a description of how to do it, but then how do you score it, and more importantly, what is the significance of that?  [Max]Yeah, so you actually knocked a memory loose when you said it was about anesthetist. ‘Cause it was talking about the risk of in, or the need of intubation or the difficulty intubating as a result of the crowding at the back of the airway. And actually I think the evidence was a little less clear for that than it is for obstructive sleep apnea. The higher your grade, the more sort of obstructed that area is the back of the throat. And for every step up in grading of the Mallampati, and I’ll talk about that in a second, but for every step up in grading, you almost double the risk of obstructed sleep apnea.  And the severity increase as it goes. And that’s sort of essentially those soft tissues contributing towards obstruction of the upper airway. A grade one, and now you’re testing me up. I should have had this up for me to look at, but a grade one is-  [Jaz]I mean, grade one you can see everything, right?  [Max]Yeah, you can see right through to the back. You can see beyond the uvula. The soft palate is way up and it’s all sort of in place. Grade two, you start getting the soft palate coming down. The uvula is still visible, but you can just about see through to the back of the throat. Grade three, it might be at the point where the uvula is even just. Sort of hiding behind the back of the tongue down, and then grade four, you literally can’t see beyond the soft palate. And yeah, it correlates quite well with the risk of obstructive sleep apnea. So your dental population are out there who are looking into the back of the throat, so their patient, you can spot this quite easily. You can see it without even telling them that I want to do an assessment here. You just pick this up as you’re going through your assessment.  [Jaz]But what I wouldn’t want people to do is just, fair enough. Some people, this might be the one thing that they take from this podcast. They might doing it. Yeah. But it’s just one piece of the puzzle. You also need the history. You also need the sleepiness, which we’ll get into obviously. But that is one important point. I’m glad we start with something quite actionable for dentists. Okay. So they actually realize, okay. There’s something to measure here, right? Dentist’s like to measure. So there’s something to measure. We like indices and scoring. So a Mallampati is such an easy one. I’ll just put you a word of caution actually for dentists is our patients with reduced mouth opening, right? They will bias towards a higher Mallampati score. But that would be a false positive, right? So my patient’s got TMD and they can only open 35, okay, on that day. And so I’m giving them a grade three, a grade four on the Mallampati, but actually they’re grade one, two because could they open 45, 47, right? They used to be that. So just take that with caution. But a really cool thing I like to ask my patients who are like, got normal mouth opening, but they’re still a Mallampati four is like, how did you find taking COVID tests? And they’re like, no, I can’t do COVID tests. I just never could get the damn swab to my tonsils. Have you thought about that?  [Max]Well, I dunno. So you say that and I think because their gag reflexes so much, I don’t think that is in any way related, or you might be telling me different, but I haven’t correlated that with our patients. Mainly because COVID absolutely slammed sleep as a medical science because obstructive sleep apnea is the coldest of things. It’s the last thing you sort out. If a patient’s got raring type two respiratory failure and all these other things going on, those services keep running lung cancer. Yeah, we’re gonna keep our two week weights going, but sleep was the first thing to get knocked on the head and yeah, it’s sort of been still recovering since, if I’m perfectly honest. There’s a lot of sleep services, the sleep service that in the department I joined recently that was absolutely, yeah, it was shut down. Its diagnostics are only just picking back up. We’re talking four years later.  [Jaz]I mean, everything’s been so slow, Max, and this is one of the reasons why I really wanted to just start helping my patients. So I started to do my own sleep tests and that that’s where you played such a huge role. And so we’ll talk about that. And I think we’ve jumped the gun. I mean, I’m so glad we talked about Mallampati score because most dentists that I speak to don’t know about it. They don’t look at it, they don’t know about it. And so I think it’s good that we covered that. But I know we’ve done it in previous podcasts, but this might be the first podcast someone might be listening to Protrusive. So what is sleep disorder breathing? What actually is sleep apnea? And you’ve kind of said that, yes, crowding in the back of the mouth will predispose someone. But as a condition, how do you define it?  [Max]Yeah, so obstructive sleep apnea or sleep disorder breathing, we should start with is about interruptions to respiratory function during sleep, quite simply. Now, the majority of cases we’ll see, or the majority of cases we are talking about here, are those where the upper airway is obstructed, usually by those soft tissues and crowding at the back of the mouth or enlarged tongue or something like that. They interrupt the airway. You can have other forms of sleep disorder breathing that are related to the central system, the drive to breathe, which can be affected by damage at the brain stem, brain damage affecting respiratory function, but also some heart disease can cause altered chemo sensitivity and they start breathing funny when they’re asleep. But putting that aside, ’cause that’s definitely outside of the remit of dentistry, the upper airway, you’ve got your obstructive sleep apnea. Now they have these breath hold events when they go to sleep, more common on their back often because of the way in which gravity affects those structures in the airway and they obstruct that airway during sleep, the more frequent these breath holds occur, which can be up to about, I’ve seen patients who have breath holds up to about a minute. A minute and a half. When they have, yeah, exactly. When you think about the number they have per hour, less than five is normal, right? Less than five of these breath holds is normal. Between five and 15 is your mild category. 15 to 30 is moderate and above 30 is severe. You see patients that have what we call an AHI, Apnea Hypopnea Index of 60, and sometimes these breath holds can be 30 seconds. You end up looking at these studies and there’s actually more time spent not breathing than there is breathing.  [Jaz]I’m trying to interject, but I just wanna just add a story and add some context into this. One of the reasons Max, I dunno if you know this, actually, I dunno if I may told you. One of the reasons that, you told me before we hit recording that oh, Jaz, you are quite proactive, whereas other people don’t care. You were proactive, but maybe it’s because my children were affected by this. So my 5-year-old had to have his tonsils. Was it? No, he had his adenoids. It’s not his tonsils, just his adenoids removed because he was diagnosed with sleep apnea. He had a sleep test. We had to literally tell him, he was like two and a half and we had to tell him, look, we’re gonna pretend to be Iron Man and we’re gonna put this like stuff up. I’ve got the video of him pretending to be Iron Man while he is kited up with his sleep stuff as a home sleep study. And so they found that, yeah, also the amazing thing is when I spoke to the surgeon afterwards, he said that, yeah, we removed this fat pad of adenoids, right? And we drained his ears and so much fluid came out. And so the next day I switched on the kettle and he was like, whoa, what is that sound?  [Max]No way.  [Jaz]And so like no wonder his speech was delayed. Like and I look back, he was always into Spider-Man since is like 18 months. But he would never say Spider-Man. He’d say Berman. He’d say Berman. And so we thought that was cute, but actually it’s because he wasn’t hearing properly. Okay. And so that made sense. Now that was my first born, right now he sleeps well it’s awesome that’s fine. My now nearly 2-year-old has it worse. So he also had a sleep test ’cause I pushed for it. ‘Cause I knew what I was looking for now. And he came back with a moderate sleep apnea. And so this actually took the doctors by surprise because a 1-year-old to get a diagnosis of moderate sleep apnea is almost like usually children with down syndrome or syndromic patients have this. So that was very concerning for me and my wife actually. Right. But anyway, so, he is a terrible sleeper. My almost 2-year-old. Okay. I talk about this regularly on the podcast, like, yeah. I had to get milk this many times to comfort him. I have to go get milk at night and he will hold his back to the main story. He holds his breath so much. He constantly is gasping in the middle of the night. He’s constantly like sleeping and suddenly you go and then he’ll wake up. And so just very distressing to see your child do this, but this is what adults are doing and they’re holding their breath. And these are the apnea hypopnea indices. The AHI. And so how well does that correlate that score? Like for example, you just made a really good example. You said someone could hold their breath for 60 seconds. That would come down as one event. Now someone doing that for one minute, 15 times as a AHI of 15. Right? But someone could be doing it shorter 45. Who’s gonna be worse off?  [Max]Yeah. So the minimum time that breath hold has got to be counted is 10 seconds. But you’re right, that number that we use at the other end, the AHI, breath holds per hour. It doesn’t always fully explain what’s going on under the hood. Those people with really long breath holds. They’re gonna have a large hypoxic burden. During those breath holds, obviously they’re not exchanging gases ’cause they’re holding their breath so their oxygen levels drop. It has a massive consequence physiologically down the line, and we think it’s associated, or that hypoxic burden is associated with later development of heart disease, high blood pressure, a whole profile of metabolic issues. Yeah. And to some degree cognitive function and all these things. So, the number that you get about severity is more about how frequently they’re holding their breath. But actually there’s other variables that you can get from more complex sleep studies that give you a bit more about, well, this kind of explains other aspects of their physiology. This explains the memory loss and all these things.  [Jaz]The reason I mention this is because I was always taught by someone, Jamison Spencer in the US who’s done some of the courses I’ve done is that, just ’cause someone’s AHI is 30 and someone else is 60 doesn’t mean that 31 is necessarily gonna be better in all the other metrics. Feeling less sleepy, et cetera doesn’t mean someone who’s in the moderate category can sometimes be really hit hard, right? Whereas someone could have an AHI of 80 and not really feel it as much. It was really, really fascinating when I was learning about how people’s physiology responds and you know you, that’s exactly what you study really. [Max]Yeah. Yeah. So another concept that we talk about is how quickly they react to these breath holds, something called loop gain. So some people can tolerate these breath holds and that their internal sort of regulatory systems don’t put them into action as quickly as somebody else. There’s some people that might not even reach that ten second threshold for breath hold, but it will cause an arousal, which is our term for waking up. And these arousals are what’s associated with your sort of interruption to your sleep quality. But some patients who desaturate, they don’t reach that arousal until it’s the point where you know, it is time to wake up. And often that could be the partner sticking an elbow in saying, you’ve held your breath for a minute now. Just like you were saying you were distressed, looking at the breath hold of your child. We often have patients that come into the lab. And they’re not bothered about their snoring. They’re not bothered about this. They’re bothered about it, my partner says that I hold my breath and I’m disturbing her. Is there anything we can do about that? And this is where the history taking and the conversation with the patient comes into it really, because what they want out of it isn’t always, fix my sleep apnea. I’m worried about my health. I’m snoring and it’s annoying my wife.  [Jaz]This is where AI hasn’t got shit on you, mate. You can see the whole patient, right? So, screw you, AI, Max is gonna keep his job. He’s gonna see the patient as a whole, listen to their concerns, yada, yada, yada. Dude, there’s so much to cover in this podcast. We’re just literally getting started here. Okay. So this is awesome so far. So, we talked a little bit about what sleep apnea is and there’s so many other dental lectures people can go to, but I actually wanna really get into okay, what our role is and how we can actually get started. So what kind of questions should we be asking our patients? So you said, yeah, no examination. We look into their mouth and we do a soft tissue exam anyway, so at that point I’ll do my Mallampati check. Okay. But a little bit before then I kind of look at ’em as they walk through. They look tired and sleepy. That first patient I ever picked up and my first sleep study I did using the AcuPebble device and I sent to you that the reason I sent it through, he was a TMD patient, but he literally yawned like eight times in a one hour consultation. And I was like, again, that is not to say that, I had another patient who yawned at similar times and I sent her a steep test view and she came back as normal. But for me there was a lot of things going on here. And I think with our, I dunno quote unquote my positive screening rate in terms of your clients, I think it’s good to get the data to help us to choose the best care for the patient.  [Max]I should have kept numbers on that. We could have seen what your hit rate was, but you are right. Do you know what it starts even before they walk in the room. ‘Cause you go out to the waiting area, don’t you? And you look at them sat in the chair and I mean, we’re in a sleep service so I see like, I see a lot of it, but the patients who are literally asleep when you go to get them and they’ve only been there 10. They think that’s normal though. Their whole life has been like that. And so sometimes when you’re asking questions, you say, look, do you feel sleepy? They’re like, ah, you know, I’ll sleep when I go home after work when I’m watching the television, and then I’ll be awake for a couple hours and I’ll go to sleep pretty much all night. And the questions you really need to ask are not so much about, do you feel sleepy? Do you wake feeling refreshed when you wake in the morning? Do you feel like you’ve had a good night’s sleep? And this can help lead the conversation to somewhere else that makes you think, ah, this is sleep apnea. Because sometimes I say, well, not in the morning, but when I sleep in the afternoon, I have a lovely sleep. And you say, okay, why is that? And that’s-  [Jaz]Someone said that to me literally yesterday, right? And she’s someone, I really strongly suggested a steep test and I’m not the first person. An ENT doctor in India also told her to get a steep test, but she never actioned it. And now I’m said, look. We can really help you. I’m convinced like she’s got Mallampati four TMD, which is obviously associated linked, but like, just exactly what you said, she struggles to sleep and then she has poor quality sleep. And every day when she has that nap at about 5:00 PM then she feels great.  [Max]Yeah. So, and where is that nap? [Jaz]It can be anywhere from what I asked her, like the kind of questions I ask as well is sofa or something. And then when you’re watching telly, do you those off?  [Max]That’s it. Yeah. So why I mention that is ’cause I always ask, the nap feels good, right? So your night sleep is in bed, where’s the nap? And they say, oh, it’s on a sofa. And that means they’re either set up right and they’ve fallen asleep like that and had a really good, their airway is not being obstructed by gravity or they’re on a sofa where they can’t turn on their back. And you’ve got somebody who probably has supine-predominant obstructive sleep apnea. It’s worse on their back. And then when they’re stuck on their side on a sofa, they do much better. So that exact situation has happened to you. That’s brilliant to hear. I’ve had plenty of patients like that who say, look, actually, I sleep all night on a sofa now because I get better sleep. And that I really just like to follow them up and see them afterwards and just say, look, are you now sleeping in your bed more comfortably now that you’ve got CPAP from us? [Jaz]But as a dentist, we can do this as well. The beautiful thing is that yes, we’re greatly, so I can tell you some stories, right? Whereby some patients, they couldn’t afford the sleep test that I usually send to you, for example, right? And therefore I send ’em to their GP, right? NHS GP and the GPs actually where I work, they’re pretty good. And like I kind of tell my patients what to say and whatnot. And they managed to get the steep test from the NHS and then they managed to get the CPAP from the NHS ’cause my suspicion was correct. And they come back and there’s one particular lady, she says that i’m dreaming again. I can now remember my dreams. I’m actually dreaming Jaz and so I thought about it for a minute, so correct me if I’m wrong, she’s dreaming because actually now she’s getting a better quality sleep and now she’s actually entering a proper REM cycle for her to actually get sleep. Am I right in my thinking with sleep?  [Max]Yeah. Well, it is possible to dream at any stage of sleep. You just have more vivid, probably emotional dreams in REM and they tend to stick with you. You can do, because I mean, sleepwalking happens in non-REM sleep and you can often remember what you’re doing in non-REM. But yeah, REM is your main sort of having highly emotional dreams that really stick with you. And you’re right, that’s the one that’s probably most interrupted as is slow wave sleep with obstructive sleep apnea. You sometimes get patients who present, actually they present with sleepwalking. And actually they have obstructive sleep apnea that’s causing the sleepwalking. And that’s because you’re not really supposed to wake straight up from deep sleep. You’re supposed to work your way down from light sleep to slightly deeper, but still light sleep into deep sleep and then REM to awake. If you wake up straight in the middle of slow wave sleep, you are likely to trigger or more likely to trigger a sleepwalking event. So you might have all sorts of what we call parasomnias behaviors during sleep that are actually related to obstructive sleep apnea. Yeah. Your group are in a fabulous position to try and not only identify it, but yeah, as you say, treat it, diagnoses the issue. [Jaz]And follow up and diagnosing and yeah, managing, but then also the ability to follow up. ‘Cause like you said, sometimes you don’t get that follow up, right. You guys have managed it and then you go and get to see them again maybe. Whereas we, every six months we see them. So it’s so rewarding to be able to be, I mean, sleep is a small percentage of my practice as you know, Max. I love my restorative dentistry. But I’m so glad I added sleep to my diagnosis set, my screening set, because I feel like I’m really helping these patients. I feel great about it. Whether I get a negative diagnosis or positive diagnosis, at the end of it, I feel happy that I screened, I help, and those who get a positive diagnosis and I’m able to get them a better quality of sleep. And I’m thinking, wow, I just might have added 10 years. Quality is this patient’s life that makes me feel so good. And so again, the whole follow up thing. I’ll tell you another story. Ricky, one of the dentists, one of the good buddies, he came to me because he won’t mind me saying this ’cause he was gonna post a video on Instagram about it. So I don’t think he’ll mind saying this Snoring, snoring is an issue. Okay? So he gets the elbow in the rib, right? So he said, Jaz, you gotta help me, you gotta save my marriage, et cetera, et cetera. Okay? So he comes to see me, I’m make a typical dentist. I listen, just skip the tea sleep test. Just sort me out mate. Okay? All like, fine, let’s just quickly do a mandibular advance splint. I think for him, I made a ProSomnus. And the cool thing is literally the next day, right, he sends me a screenshot from his phone. ‘Cause what I love nowadays, everyone’s got Apple watch, right? And so he send me a photo. Well done, or congrats. Your blood oxygen was 4% higher than ever recorded before last night.  [Max]Good stuff, man. In action. [Jaz]More importantly, I did save his marriage.  [Max]Yeah. Nice. Yeah, yeah. Like we honestly see patients in clinic who say, well, I haven’t been able to share a bed for the last 30 years. And if you are in a position to fix that and see them, you’re right about our follow up situation. It is a bit awkward. We would like to be able to see every patient every year as a minimum. We try and follow people up after we set them up on treatment, but trying to get patients back in year on, year out with the fact that once patients get on our list. They never go off. I suppose that’s true of dentists as well, actually. I’ve never really thought about that outside of sleep apnea services. But our services grow and grow and grow and grow and grow. And if healthcare leaders don’t allow us to add more staff, we have to either get AI to do some of the work, but we already know how that’s gonna go or, we have to be a bit more efficient in how we see them. [Jaz]So I just wanted to share those stories obviously, of patients and how we get to follow up. But again, there are lots of resources out there, like for example, indices or tests or screenings that we can do. So STOP-Bang, Epworth Sleepiness Scale, but for the general dentist who’s busy, like, but we also care about implementing this into our into actual service and care. Yes. You said the clinical exam, Mallampati, and then talking about are they sleeping in the waiting room? Ask ’em about their sleep quality. Are they a sleepy person? Do they wake up refreshed? All these questions are important, but where can we find some structure? Where can we find checklist? So yes, STOP-Bang is one, is that highly rated? [Max]I think STOP-Bang is the best for identifying the risk of sleep apnea. Epworth is more about having a quantitative measure of how sleepy they are during the day, and it’s important if you think you’re diagnosing, obstruct sleep apnea, to ask the Epworth, you need this quantitative assessment because this conversation that then happens later on around driving and sleepiness the DVLA. Now this can be, there’s nothing that is more of a rapport killer than telling somebody that your condition may affect your ability to drive or you might need to be monitored a bit more closely.  [Jaz]I mean, I definitely wanna talk about this Max, but this is one of my last questions because there’s so much I wanna cover before we get to that. And yes, we’re gonna talk about the DVLA, ’cause it is obviously linked to Epworth. But what we should be checking for is STOP-Bang, Epworth. Do you think as dentists we should be asking for this or not?  [Max]Yeah, well mainly because most of the stuff that you’re gonna do for your sleep studies will have incorporated questionnaires that you can stick in. So-  [Jaz]But it’s more about figuring out, for example, I’m in practice, right? And so I’m using AcuPebble , I have a fee for that. That fee, or outta that fee, I also pay your fee for the report, for example, right? And so it needs to work in care, so you gotta be in an ideal world, yeah, everyone should get screened. [Max]Oh, I see.  [Jaz]It’s a wonderful health thing to do, but how do we pick it so that it’s a good worthwhile punt. So how do we pick the patient that, okay, actually this patient, I think the patient, I think you will actually benefit. I’m hoping it’s negative, but you might actually come up with a positive. How do we pick the patients who are gonna spend money? Do you see what I mean?  [Max]Yeah. So I think that you have some very high risk stuff that you see on clinical history. If somebody tells you that they have been observed holding their breath, witness apnea, do whatever questionnaires you need to do, get ’em the sleep study, because that’s quite uncommon, that’s limited almost exclusively to sleep apnea, sleep disorder breathing. If they tell you they wake choking and gasping regularly. So not everyone has a bed partner to see, but if they say they wake up choking and gasping, and then still quite high risk, but less specific is unrefreshing sleep. Now if you’ve got any of those things, add a STOP-Bang. And if that’s even slightly towards the end of the scale, give them the information. Just say, look, I suspect that it may be worth screening you for obstructive sleep apnea. Now these new screening technologies are quite uninvasive. We give you this thing to take home, you slap it on, you either have an app on your phone or you bring the device back and it gets downloaded and that is analyzed for you and we come and sit back and have a conversation with you about the results. I think if you’ve got any of those high risk symptoms or you’ve got real suspicions based on their sleepiness, their neck size, they look like there’s crowding, bruxism is something.  [Jaz]So you mentioned neck size. So basically the form that I really like to use right, is there’s a lab in the US, S4S Solutions for snoring. Good lab. I know the guys that own it really well and they have a fantastic form on their website, which I really like and all my delegates on my TMD course, I said listen for airway screening, use this form for your patients because for those who come as high risk, it’s actually got a pre-written letter to send to the GP. Like it’s just done all the work for the dentist for them. And I love this form, so I’ll put it in the show notes. I’m sure S4S will be very happy about that, but essentially it does Epworth, it does questions about like do you fall asleep? How sleepy did you get during driving? How sleepy did you get sat on the house, how likely you go sleep while you’re sat on the sofa. Got really great questions in there. And also the impact on their life. Like because of this snoring, are you sleeping in a different room? Like you get to understand that aspect as well in that form. And then Flemon’s, it gets the patient to actually measure their neck circumference. So how significant you think Flemon’s score is to all this?  [Max]I don’t think I’ve ever heard that phrase before.  [Jaz]Well, on the form, so Flemon’s basically is that you measure the neck circumference and you measure it. So it’s like, 43 centimeters or whatever. And there’s a certain, I think it is 43 or 48, there’s a certain cutoff, which puts you more high risk, low risk.  [Max]Yeah. So is that 17 inches? ‘Cause the STOP-Bang is very US-centric. Actually a lot of our sleep medicine is because we follow the guidance of the AASM, the American academy for sleep medicine. So a lot of it is sort of, yeah, more US-centric. 17 inches, I think the one. So what’s that conversion probably about.  [Jaz]Alright, lemme do it right now. Right. So on the podcast, just doing this guy 17 inch, good old Google, 17 inch to cm, 43. There we are. 43 centimeters.  [Max]Yeah. So yeah, that, I mean, that’s just the cutoff for adding a point on that STOP-Bang. But it makes sense. So this doesn’t have to just be fat mass. We have rugby players. Enormous thick necks, muscle and fat both still obstruct the airways when they’re fully relaxed. And that’s what happens when you sleep.  [Jaz]I didn’t appreciate that. I just thought it was fat. But no, if it is muscle. That’s interesting.  [Max]Yeah, we have a lot of rugby players that have, I think there’s screening in, at least in the, I dunno, anything about positions in rugby, but where the larger players play, they screen those chaps ’cause they just have enormous mass in the neck. And so when they go to sleep, that just relaxes and contributes to obstruction of that upper airway. [Jaz]Now you said you’re a Spurs fan, so firstly I’m very sorry about that. Secondly, like some of these, documentaries that you see, like for example, like, not that I’d ever watch such a rude thing, but the whole documentary on Man City and their successes and whatnot. And how I know, right? So how every athlete, like they have their, each player will have their special drink with their special formulations specifically for their biology. I wonder. And maybe if you know this, do these professional level highest football teams, do they do sleep screening for all and sleep tests? I just think why wouldn’t you? Why wouldn’t you for the highest performing athletes?  [Max]Yeah. So in general, it’s all about marginal gains at that sort of level. Everyone’s elite, right? So how do you get that extra 1%? Cycling was the first sport to do that, and they did everything. And they started having people take maybe their own mattress, but, or a mattress they know that they get very good night’s sleep on. When they go and do the Tour de France, they take this around. They have teams that are responsible for that. I mean, I’ve gone and done a talk for a premier league football club. I did one for knocking Forest and that was at the start of last season. [Jaz]So they’re having a cracking season this year.  [Max]Ah, I’m not gonna say it’s cause and effect, but I think what they were doing is they were no way, I can’t say that, but what they doing-  [Jaz]The Max effect.  [Max]Yeah, the Max effect. I came in bush, but what they were doing is that they were demonstrating that they were an organization that is concerned with marginal gains and sleep is one of those. They do a lot of going on the road. They do a lot of late games and the recovery benefit from a good night’s sleep. You have patients who have been woken up by their own airways 30 times an hour for their entire life. Their entire adult life as much as they remember. Imagine how grumpy you’d be if you were poked awake 30 times an hour every night.  [Jaz]Totally.  [Max]You’d be really grumpy, you’d be forgetful. You would be really, really not your best self. And then I have patients come back to me in clinic and they’re like, this has absolutely changed my life. And you know your listeners can be part of that process. They can be the people that do that on the-  [Jaz]It’s magic. [Max]Honestly, when you find a patient who is really badly affected and they don’t realize quite how badly affected they were, and they start treatment, that is a very special feeling when they come back in and they’re like, you have saved my marriage. I can actually remember the things that are happening to me in the day time. It’s remarkable how important sleep is.  [Jaz]I think what this episode’s gonna do is that, we’ve set the scene in terms of trying to find that patient, that winning horse, if you like, so that you know it’s worth it for them. Because you can’t just sleep test everyone. The healthcare facility is just, that’s not how healthcare works. You’ve gotta no have a suspicion, a hypothesis or preliminary diagnosis or a screening that okay, this patient would benefit from screening. So that’s what we’re talking about. But I just wanted to mention this. As a parent of two young kids, one who just does not like sleeping, ’cause you’ve got moderate sleep apnea, like sometimes you have to really look at their entire history and don’t think that someone is not sleeping well because sleep quality is not good because of sleep apnea. It could be that their baby’s crying every hour and waking up. So you really look at that social history, like I sleep tested myself as well, right? Using the AcuPebble as well as one of the first patients. I did my own self, right? Just to test the tech out. And I was really curious ’cause obviously I wasn’t sleeping very much. I felt like not very good at all. But I was thinking, hmm, is it because I’ve actually got a small mandible. I have actually got retrognathia-  [Max]Hidden behind.  [Jaz]Exactly that. Why do you think I have such a voluptuous beard is to make me look class one and normal, right? So anyway, so I thought, wait, what if I do right? And no, I didn’t. My AHI was like two or something, right? So I’m golden in that regard, but it’s because I’m not getting great steep ’cause of the kids. So you gotta really look at a patient’s social history. So we talked about, you mentioned some great things there. I’ll attach the form so that people can start using this form with their patients. And then, so now we’re getting into the real meat and potatoes of it, right? Okay, so we’ve just identified a patient who would likely benefit, and you’ve already said what you could say to a patient that, look, it’s a non-invasive thing to do. You can have it done and if you’re in private practice like me and your patient can’t afford it, whatever, that’s fine. You fill in that form like S4S one and send ’em to their GP and maybe even a cover letter and some GPs will hopefully help. The problem is there’s big waiting lists in the an chest. Now you are probably in a great position to tell us about that. Obviously this podcast goes out around the world, but for those in the UK, how long do you think that they’re waiting typically to get assessed and then seen?  [Max]So the unfortunate answer to this question is that that is essentially a postcode lottery. It depends on where you are. It honestly depends on where you are. In some areas you are six weeks away from a test because they’re not only on top of their list, but their numbers are lower. In other areas, you’ve got high population density and low service output. So, I have seen sleep departments that have got 60 week wait lists just for the initial diagnostic tests. You already got the suspicion that they have obstructive sleep apnea. They’re already telling you that they’re struggling and then they’re told they’re gonna have to wait a year for a test that, at the moment can be in the range of just over a hundred quid. Most people would pay for that level of diagnostics. I wish they didn’t have to, to be honest. But I think we’re in a situation where the options now are for people to be diagnosed that in the community, in the comfort of their own home with these devices sent out to them. I won’t talk about any specifics. You’ve got one that you use, but the whole paradigm has shifted a bit for sleep apnea detection. We’ve got these screening tools that we can use to see the bulk of patients.  [Jaz]I mean, we’ll talk about the other options now then I guess. So yes, you could refer, but depending on where you are in the world and also depending where you’re on in the UK for example, for those in the UK it’s a postcode lottery and so there are some devices available to dentists to help assist get the screening. Now let’s talk about the legality of that. Now, before we do, there’s one thing, annoying. I’m so sorry about this to go back now, but we need to address it. ‘Cause otherwise it’s not gonna flow. It’s snoring because in the dental sector, when they market to dentists, they’re like, hey, you can help with someone snoring. And that’s how dentists might get into it, rather than you can help with someone’s obstructive sleep apnea kind of thing, right? ‘Cause very much, we can’t really treat obstructive sleep apnea. We can under the instruction of a sleep physician consider it kind of thing. But the snoring, we can do our screening and then go straight to a mandibular advancement device for their storing, right, providing you have some level of training. So is snoring a risk factor for obstructive sleep apnea firstly?  [Max]Yeah. So if you snore you’re more likely to have obstructive sleep apnea and that’s a pretty clear relationship, but not everyone that snores that.  [Jaz]And we have like a spectrum, right? Can you explain it as a spectrum? ‘Cause I’ve heard this term simple snoring. So you either, you’re a simple snorer and then you have this upper airway resistance syndrome and then you have full fledge obstructive sleep apnea and it’s all sleep disordered breathing as like a spectrum. But I have some colleagues, Max, and tell me what you think about this. Have some colleagues, very intelligent colleagues, and they believe there’s no such thing as simple snoring. Like if you are snoring, then potentially there’s something going on and that should be looked into. What do you think about that?  [Max]So I just think in general, what you’ve got with that noise is you’ve got an indication that there is a reduced size of that airway. Those structures are vibrating ’cause the air is squeezing between them and they’re rattling as that air goes through. That means that they’re closer than they were when you were awake. Doesn’t necessarily mean that you’ll get obstruction that interferes with sleep, but you can have what we call hypopnea, which is where the H and AHI comes from. And that’s not necessarily breath holds, but that’s a reduction in flow so much that it’s interrupted oxygenation, it’s probably caused an arousal. It’s not necessarily a complete blockage. You’re not having a complete apnea. And yeah, I dunno whether or not I agree that there is or isn’t simple snoring, but for me, I’ve got a very different sort of, you know, the bias that I get is that people come to me because they’re sleepy, because they’re in a situation where somebody suspects, they have obstructed sleep apnea and very rarely, for me it’s simple snoring. Just snoring. It’s almost always obstructive sleep apnea by the time they’ve reached secondary care. So I think maybe to you out in the community, it might be a little bit more difficult to unpick, but that’s where these screening tools come in.  [Jaz]Well, yeah. It’s one more thing, you know, are they storing, are they sleepy? What’s their Mallampati score? You bring it all together and then, what’s the patient’s values? Are they also on, two different, three different types of blood pressure medicines? And we know that actually sleep apnea is what’s driving up the blood pressure. And then despite the medicine, it’s still not coming down. And so we know that already as well. Are they bruxist? Like you mentioned that, and I didn’t wanna cut you off at that point, so I apologize about that. But you’ve rightly made the link between sleep disordered breathing, and bruxism. And so let’s say that you really want to help your patients and that pathway in wherever you’re working is not fluid enough. It’s not good enough. So what I did was I got in touch with AcuPebble and I paid for my AcuPebble device. And then it was basically like bulk buying, like 15 tests. And now I pay per test basically right now as a dentist who does that, my missing link was you, Max. ‘Cause they kept telling me, oh, you can’t just screen. Although the metric will give you kind of like a diagnosis, it doesn’t mean anything until someone with the power can actually sign off on it and report it. Right? And so that’s you. And so I’m so glad to have found you so that you can do that. For a lot of people who they go to is like a sleep physician who’s actually like consultant, sleep physician. And so correct me if I’m wrong, legally as dentists, if we’re doing some screening, not diagnosis screening tests like the AcuPebble or the WatchPAT, these are two leading brands which dentists are using. We still need to get someone to report. So how do you find someone who reports, I found you by accident. I’m so glad I did.  [Max]Yeah. Well, I mean, what you could do is you can put my contact details in your description of the podcast.  [Jaz]Of course. I’d love to.  [Max]Yeah. So for sure. But you are right in saying at the moment it’s not really set up for dentists to be involved in a diagnosis, and I think that’s mainly from your regulatory body. I think it’s not like the GDC will come and get your first born, but I’ve heard that they’re pretty quick to act and they want you to act within your scope of practice. And I think Aditi Desai put something out in just saying, look, you should have a sleep physiologist or a sleep consultant report your sleep study because-  [Jaz]And I agree with that because I’m looking at those metrics. You are picking up things which I’m just looking at the AHI and stuff, but you are really going deep and I love the reports that you make and I totally respect that.  [Max]Yeah, yeah. So we’re so used to seeing all these patterns that we can see sort of like a shape of a squiggle and we realize that actually, well this might be a bit more than just obstructive sleep apnea. This might be something central and actually this needs referring on to a center where they can do a bit more. ‘Cause you can’t just treat central sleep apnea in the same way and not all daytime sleepiness with an AHI of six can be explained just by sleep apnea. They might have something else and you get concurrent other sleep disorders. So yeah, I think in order for you more from a governance perspective and compliance with your regulatory body, having someone else just chip in to that point of diagnosis, you can do all the management. And what you can do is you can retest them once you’ve developed an appliance or you can ask the patient to take that screener study and go to a sleep service or go back to their GP and get referred on and they’ll be taken a bit more seriously because you’ve got some concrete proof that there’s sleep disorder breathing. [Jaz]Yep. And so what I’m gonna do also in the show notes, guys, is like, yes, I use AcuPebble, but I’m not tied with them. There are other brands available. So I also spoke to WatchPAT. I’ll put their links below and that’s how you screen. I’ll put your link below as well so that if they want someone a very reasonable rate to do some reporting, then Max can do that for you as well. And so now we have something that whereby you can actually do a very high quality screening for someone very quickly in the comfort of their own home. And you’re really, helping ’em now. One thing is dentists, when we get taught from the trade, we are taught that, okay, you can treat a snorer the way that we’re taught. And so tell me what you think about this Max, if you agree with this. The way dentists are taught is when you have someone whose main complaint is snoring, like, I don’t like the fact that I’m snoring. Okay. And then you do all the Epworth, you do the Mallampati, do the clinical exam and sleepiness and everything, and they’re coming up as low risk. So based on those algorithms, everything they’re saying suggests they’re low risk of obstructive sleep apnea. But their concern is snoring. We can go straight to a mandibular advancement device providing we’ve done some sort of basic training. So this could be like some sort of CPD you’ve done. Do you agree with that?  [Max]So do I agree that you can go ahead and try and treat snoring without assessing for sleep apnea and doing the whole diagnostic shebang? Is that the question?  [Jaz]Well, we have screened with the using the algorithm and then if they are low risk, then we are not needing to get an official sleep report before treating just the snoring. And it’s kind of like the disclaimer there is like, by the way, we are just treating snoring. We’re not actually dealing with any sort of obstruct sleep apnea. That’s kind of like the consent disclaimer that we have. What do you think about that?  [Max]I don’t see a risk with that. You told me once that the reason why you started doing the sleep diagnostics was also to do with something with the airways. I don’t know. You wanted to screen for another- It is an indication I’d not really come across before, mainly because I’m trying to diagnose and treat obstructive sleep apnea. But weren’t you trying to identify if there was issues with the upper airway when you were treating for another splinting or something? [Jaz]Yeah. Yeah. So, okay. I’m so glad you mentioned this, Max. Okay. So guys, the American College of Prosthodontists suggest that before you raise someone’s vertical dimension, so before you open their bite, okay? And so the way the jaw opens, right, is like when you open someone’s bite, the jaw goes protrudes a bit, it goes back a bit, right? And so we are potentially making someone’s airway worse.  [Max]Right. Yeah.  [Jaz]And so if I have someone who’s already like borderline or on, they’re giving me like the radars going off that, okay, actually they could have a sleep disordered breathing and I’m potentially gonna be giving them an appliance to open their bite or doing some serious dentistry to open their bite. Could I be doing a disservice or injustice to their airway. And so sometimes I will send a patient for a steep test to see where they are before I commit them to an appliance basically. Or before I commit them to opening the vertical dimension. Right? So that was the rationale there. And I still stand by following the American College of Prosthodontic advice, that that was the first piece of literature I saw that and really made me think about it. And then this has been shown by lectures and stuff that look, if you open this patient’s bite or if you use something called centric relation, and their jaw goes back a whole 15 millimeters, then you may have made their airway worse. And so you raised a wonderful point there. But in a case of just snoring only, right? And then everything else, all the other parameters are good. Like what are your options? Like if the patient generally doesn’t wanna do it and they’re low risk anyway, and then you are letting them suffer the psychological and the social disadvantages of the snoring. At least you can help them with their snoring. And even if they have an underlying sleep issue that is not being picked up, you’re probably helping that anyway.  [Max]The only problem I would see with that is if you’d managed to identify daytime somnolence and weren’t then seeking a diagnosis. I think if they’re not sleepy and they’re just telling you they’ve got a problem with snoring and their main concern with snoring is it’s a social problem. I hate going on planes. It’s something I hear from my patients that snort and I’m like, why do you hate going on planes? Then he said, well, because it’s really embarrassing. ‘Cause when I fall asleep, you know, I snore the whole place down. I wake up and everyone’s looking at me and you know that, I mean, you are treating with your dentistry a psychological conditions there, aren’t you? I honestly, I don’t see an issue. Someone raised this with you as something that they thought, actually-  [Jaz]I’m not even raising.  [Max]Oh, I see.  [Jaz]It’s just I’m not raising it, this is what we’re taught and I just want to hear your perspective and what you thought, in case I was putting masala and some spice into the conversation kind of thing. Just me kind of thing. But I’m glad you don’t see an issue with that ’cause that’s kind of what we’re doing. And that’s fine. Just to let you know. So I want to cover what options exist. So these like WatchPAT or AcuPebble and then you get it reported. Okay. And then based on that, you kind of are guided as how to manage this patient. ‘Cause in your, the person who reports it, they’ll kind of give you, this patient may benefit from a CPAP or this patient may benefit from a mandibular advancement device. So what are the guidelines that you guys follow suggest the different pathways-  [Max]Treatment modality. [Jaz]That’s it.  [Max]Yeah, so I mean the main guidance we follow is nice. The nice guidance is related to severity. So the more severe end of the spectrum, we start with CPAP.  [Jaz]Can, you just, what it stands for, what it is because dentist dunno.  [Max]So it’s essentially, sort of single level ventilation device. It’s called continuous positive airway pressure. It acts like a pneumatic stent. You’ve got air pushed into the airways that keeps the airways apart. ‘Cause with the obstructions and obstructive sleep apnea, it’s kinda like a whoopie cushion. I dunno if the current generation is gonna recognize what Whoopi cushion is really, to be honest. But the way in which we generate force to breathe in is by making that lung larger. Your chest wall moves out, the diaphragm comes down, the lung gets larger. But if there’s a closed top as if the whoopi cushion’s closed, you don’t get any air in. What you have to do is you have to open the upper airway. And so that’s what CPAP is doing. It’s acting like a pneumatic stent that’s pushing that airway open so that anytime you open and close or move the chest wall and push out air, it can freely pass. And so CPAP is the absolute gold standard of treatment because it pretty much treats almost any level of sleep apnea. A mild, moderate, severe, very severe. There are some cases where so overweight, so obese that the pressures they need require more complex machines, but I’m sure that you are not gonna be screening those patients. They’re gonna be picked up before. So yeah, that’s how CPAP works, and honestly, it was a game changer developed in Australia and has been a mainstay of sleep apnea treatment. [Jaz]Tell me this Max, because that patient, I told you who I sent to the GP and my suspicion was correct, and then she’s telling me she’s dreaming better, she’s sleeping better. She’s ever so grateful. Her health is just looking way better, which is awesome, right? Everything we want out of healthcare. But interesting she’s told me that they’re able to dial into a CPAP and change it remotely. Tell me about that.  [Max]Yeah, yeah, yeah. Yeah. So remote monitoring was, it was a thing before COVID, but it became a necessity during, so that was the one good thing about COVID. We had this massive paradigm shift to using all these remote technologies. This is where we first started sending sleep studies out to patients rather than them coming into hospital, being set up and shown how to use the device. We were doing all these things remotely, but most of the CPAP devices that are made now, in fact, all of them, unless it’s the absolute budget versions, will have like a sim card in it. And that will send a signal back to our servers after it’s been used. Typically, sort of they use it for the night, they leave it plugged in, but off and then it sends a message back to us and we can see their usage, but also we can read other things off it. We can read off if the machine suspects they’ve got any breath hold events. So it gives you an AHI quite crude the way it’s measured, but it’s still quite helpful in managing patients. So I can get this series of days of usage. I can see how many hours they used it for. I can see when they turned it on and off and all this stuff. And it really helps us to manage patients. ‘Cause back in the day before we had that, I’d have patients come in and be like, yeah, I’m using it all the time. It’s fine. I’m brilliant. Yeah. Great. And then you actually go and download their software and they didn’t know, they download their usage. They didn’t know you could do that. And you come back with this report and you’re like, you haven’t even used it in the past month. And then they start telling you the truth. So this remote monitoring is almost like, yeah, it prevents the conversation from some drifting away from fact.  [Jaz]The question I have based on CPAP then is, and the reason I ask about remote monitoring is appliances. I do a lot of appliances for my TMD patients, right. And so when I give an appliance again, I worry about their airway getting worse. Okay. And so the question I have is when they’re wearing something in their mouth, like an appliance that opens their bite. Would that then mess up how their mask fits? Do I need to be worrying about how effective the CPAP is? What type of delivery of air? Is it through the nose? Is it through the mouth? How is the air actually going in?  [Max]Yeah, good question. So both. So you can have a full face mask. And a full face mask isn’t like that. Although we do have masks like that called shields. A full face mask sits over the nose. I’m pointing to my face for those listeners who are just well done listening on. [Jaz]Yeah, it’s like a Guedel airway kind of thing, right? Like?  [Max]Yeah. So exactly. Your bag valve mask that front. Exactly right. So that’s a full face mask. It goes around the nose from the bridge of the nose and then it sits just above the chin, but around the mouth. So that’s the most common style of mask, although we are having more of a shift to-  [Jaz]But the air is actually going through your nostrils, right? It’s going through your nostrils and open the airway like that?  [Max]Yeah. Or if you’re someone that sleeps with your mouth open, we would recommend using a full face mask. ‘Cause the moment that you’ve got, you have nasal masks as well, but the moment you’ve got a nasal mask, in a mouth breather, you sometimes have the most uncomfortable sensation of the air just being pumped from the back of the nostrils out of the mouth. And the CPAP’s obviously not doing its job at maintaining airway pressure there. So you can have nose masks, you can have full face, you can have these combination masks that do a bit of the mouth and the nose, but they fit slightly differently. So there’s a load of different styles of masks. All I’d say to your patient is, if you’re gonna try one of these devices, is there to stop their TMD, you would want them to just be very aware if they’re getting increased leak, if they’ve got a sleep team just to say, reach out to them first and say, look, I’m trying this new mouth guard and over the next couple of nights, can you just tell me whether or not, my leak has gone up? ‘Cause we can see that stuff from a remote monitor.  [Jaz]See that’s the magic of it. That’s why remote monitoring really piqued my interest is that, now as long as you give your sleep team a heads up, like, hey, can you just watch me closely over the next couple of weeks I’m gonna outta this appliance and is my AHI getting worse? Because the thing is, look, if you’re opening the bite a bit and maybe the airway is getting smaller and then you guys titrate it, you guys will just pump up more air. But once you have that data from the other side of the country, you guys can just lift up the air pressure, right?  [Max]Even better. AI is our friend. So you can have automatic machines that titrate the air as it detects an obstruction. ‘Cause it sounds like it’s all just one pressure, but actually it starts at a very low pressure when they put the mask on ’cause going to sleep, it’s like having your head out of a moving car window. You know that feeling of the air rushing. It can sort of take your breath. You get very used to it after a while. But we start off with low pressures and then we ramp it up. We build it up. But during light sleep, you might not need as much pressure. Then they turn on their back and they hit deep sleep. Suddenly they’re getting more obstructions. The machine can drill in a bit more pressure.  [Jaz]Wow.  [Max]So most of the devices from a CPAP perspective, now we’ll be auto titrating and therefore, you know that concern of yours will be alleviated if they tell you they’ve got an auto trading machine. Or if they don’t know, they could ask their sleep team. But I think that would be less of an issue. It’s more if it causes a leak ’cause those machines. They aim to try and deliver a certain pressure at the back of the throat. And so sometimes if you introduce a leak, what happens is the machine overshoots because it thinks there’s air leaking out. I need to try and maintain pressure at the back of the throat, and patients can get quite uncomfortable when their mask leaks as a result of that sort of cycle. [Jaz]Well, there we are. So tangible advice there guys. If you are doing appliance work for patient who may already have a CPAP, just give them a heads up to speak their sleep team and tell the patient to be wary or hypervigilant about a leak. Now, CPAP is the gold standard. But if someone’s got AHI of five and someone’s got an AHI of a hundred, then are they both getting CPAP or is the modality changing to a mandibular advancement device or the lower AHI? [Max]Yeah. Well, so I suppose the question in that is, where is mandibular advancement more effective or where is CPA more effective? And so there’s quite a lot of work on this and actually really the tourist out, there’s some signal coming from the noise, which is generally if you’ve got a patient in front of you who is thinner, their sleep apnea is not a result of extreme obesity. They’re younger, they’re retrognathic, and there’s other sort of structures and features that are related to that lower jaw and the the crowding at the back of the throat rather than body mass, then it’s more likely our mandibular advancement will be beneficial. CPAP is always gonna win this war ’cause it just treats everything. [Jaz]So why not just treat everyone with CPA? Is that what happens in this country? Or is it ’cause of cost saving measure to give a mandibular advancement advice then?  [Max]In all honesty, the pathways and what the NHS has done to dentistry in general has been our own downfall. Other countries have got really well integrated, mandibular advancement device pathways that are integrated. America’s way ahead of all of that stuff. But everything in there is private. So the cost is immaterial to the patient at the point where they’re unsure, but over here you’ve only got mandibular advancement services in specifically commissioned services that have applied for that and got funding from their ICBs. It’s not just a given, like with CPAP, if a patients got moderate or severe obstructive sleep apnea and they’re sleepy, they’ll get CPAP.  [Jaz]What about if they’re milder?  [Max]Yeah, so you can opt to choose to give CPAP and it will treat the obstructive sleep apnea. But the thing about CPAP is it’s really quite comfortable. I’ve just said, it’s like having your head out of a window when your car’s driving. But also, I struggle to have anything on me when I’m sleeping, you know? And it could be really unsettling. Patients get insomnia from the treatment now where-  [Jaz]It’s not very sexy either.  [Max]Oh, it’s certainly not sexy unless you’re into – [Jaz]Darth Vader, right?  [Max]We’re selling it now. But yeah, you see a sort of cost benefit, pay off more in CPAP when people are very obstructed and very sleepy because they’re so tired they could fall asleep. Mid conversation, they put this mask on and they wake up in the morning like this has been a godsend. This is amazing. And they get this big benefit. The cost seems like nothing to them. You’ve got someone who’s got an AHI of six, they only have six breath holds an hour, and it doesn’t really disturb them as much as it does. This chap that has 30, they don’t get as big payoff. And actually the disturbance from the machine may be more than their sleep apnea in the first place, you know? But sleep medicine is about trying to reduce the amount of interruptions to sleep, not increase it. So that’s where it comes in. Also, patients who are a 28-year-old coming to my clinic, a 28-year-old man, still single, you’ve mentioned it’s not sexy. They don’t want to have to wear CPAP in front of new partners. They don’t want to have to wear CPAP for the rest of their life. It’s not a cure. This is a for maintenance of their airway. So yeah, usually a patient who’s younger-  [Jaz]Small mandible. [Max]Severe disease. Yeah, small mandible, that sort of thing. But also not super severe disease. Mandible advancement might do a great job of treating severe disease, but the evidence is kind of out there. If a patient is intolerant, a CPAP, I would almost always want ’em to try something else. If they’ve got proven sleep apnea, they can’t use CPAP, have a go at something because it might not cure all my understanding.  [Jaz]That’s 50% though, isn’t it? 50% of people. Am I right in saying that they don’t tolerate CPAP? [Max]Yeah. I mean if not more.  [Jaz]That’s huge. It is really, really uncomfortable. And some patients have both, right? Because they have their CPAP at home and when they go abroad or they go on flights, they have their mandibular advancement.  [Max]Yeah. And more portable there’s, yeah, exactly. And you can use those both at the same time. If you’ve got really severe disease and you’ve got somebody who’s super obese and they’ve also got retrognathia and things that are causing crowding, you can do lots to create space, but also you still need that pressure going in and you can buy treat. I don’t think that’s gonna affect most of the people in that listen to your podcast, but it’s worth mentioning, you can have both to treat it just, most people, they do struggle. We are getting better with getting patients on CPAP when we’re employing skills like motivational interviewing. I don’t want healthcare to be sales. Actually, I’m talking to dentists and you are put in a weird situation where actually sometimes healthcare and sales overlap. For me, they don’t. But actually a lot of the skills we use are sales skills. I’m trying to convince someone to do a thing that is in their interest, but not really what they want.  [Jaz]That’s dentistry, man.  [Max]Yeah, yeah, mate. It takes a lot of energy. You have to be enthusiastic and you have to really be saying, look, you are gonna get something outta this, but you have to try and it’s not gonna be easy. I always tell them, when you first put a CPAP mask on, you are gonna remember my face and be really annoyed at me. And next time you see me will be after a period of a few nights of it, and then you’ll be happy to see me. And that’s only if you’ve persevered. If you’re annoyed the first time and you didn’t put it back on, I’ll see you again. You’re annoyed again. I know that you haven’t really tried your machine on. Yeah, it is very tricky and I wish we just had pathways that were a bit more integrated. I wish we had dentists that could come into hospital, see our patients and fit them for mandibular advancement when they can’t tolerate CPAP, that’s half of our patients. [Jaz]I mean, that’s the dream man, Max. That’s the dream that we can work together better. But again, so it’s great to have you, and I’ll put your link in the show notes for those who want to get their sleep test reported by you. But I guess what I want to do in this episode is just share my journey in terms of getting a sleep clinician like yourself and sleep scientists on board to help report, but also my own journey of learning and just share out loud kind of the key things that we’re looking for, which I think we’ve done. So talk about CPAP, we talked about mandibular advancement. The big worry with mandibular advancement devices is the bite change risk, which there are some things that can be done to mitigate it, like AM aligners and that kind of stuff. But what you know while in the short few minutes I have left with you is should patients have a retest after? So actually no, this was more relevant before you told me about remote monitoring. So my question was, when patients start a mandibular advancement device, do they get a retest to see if it’s working because they don’t have a CPAP at that point, therefore they can’t be measured remotely. So actually our patients, should they be getting retested? ‘Cause it costs ’em money. So for example, if I give them mandibular advancement device, right? I often debate myself, hang on a minute, they’re saying to me they’re feeling better, their snoring is getting better. Is that enough? Or do I legally need to get this retested in the private sector where it all began for them as well? [Max]Yeah. Legally, no, we haven’t really talked about the DVLA, but that’s where the legal stuff comes in. But you don’t need to retest them if you suspect if their symptoms have resolved. Can we come back to this question after? We’ll do the DVLA stuff first because-  [Jaz]Yes, actually yes, just because that’s the last question actually. So, DVLA guys around world-  [Max]Well, the answer to that is contingent on the way it works for the DVLA is-  [Jaz]Can I just say for those around the world, DVLA is like the governing body for driving, who can drive, who can’t drive in the UK. So basically, if your patients are too sleepy to drive, it ain’t happening. [Max]Something vehicle licensing authority.  [Jaz]Something like that.  [Max]I guess it’s driving, but yeah, so they’re the ones that hold people’s licenses and they have rules about all sorts of medical conditions when it comes to driving. Vision is obviously a clear one, but sleepiness and things that contribute to increased sleepiness such as diseases that affect sleep, but also drugs that cause drowsiness. You know, you have to report some of these things. Sleep apnea is one of those things that a patient may need to report and they may need to report it in the case where they have moderate or severe obstructive sleep apnea with sleepiness. And it’s really important that with sleepiness part is the main focus of the DVLA guidance. ‘Cause the sleepiness is the symptom that affects safety on the road if the patient has sleep apnea but they don’t wake up frequently from their breath holds. They don’t have the interruptions to sleep. They don’t have the reduced cognitive function in the day that sleepiness is what this is all contingent on. And then you can have mild sleep apnea where they’ve been sleepy and it’s been three months or so. So they’ve had that for a long period of time. Moderate or severe obstructive sleep apnea with sleepiness. They need to report to DVLA. They should stop driving until their symptoms have yeah, ceased and they need to have been on treatment. At that point, so it gets-  [Jaz]But then you know there was an answer. Okay? So if they self claim that, oh, my symptoms are better, and they’re wearing a mandibular advancement device, they can just drive again and just tell the DVLA, hey guys, I’m feeling better now. I’ve got a mandibular advancement, or I’ve got a CPAP. Or they need to send in a test result saying, hey, actually I am better.  [Max]So they do the first, and then the DVLA will write to their sleep clinician and say, we need a review of this patient because we know that they’ve been diagnosed with obstructive sleep apnea. We need you to tell us what treatment they’re on. We need you to tell us whether or not it’s effective. And there’s some other questions in that form that’s sent to us as clinicians to fill out. And at that point, you may need to ask for a retest. That’s the only reason. If your patient is still sleepy and you are treating them, it might be worth retesting. And the reason why it might be worth retesting is because you haven’t fully treated it. If you’ve now got no AHI and you’ve still got sleepiness, it comes down to probably refer them onto a sleep service. There’s a lot of things that can cause somnolence. There’s a lot of drugs. There are other health conditions, but also you need to take quite a detailed sleep history because patients often conflate sleepy for fatigue, and there’s lots and lots of conditions that cause fatigue. The one thing I’ll say about the Epworth, we hadn’t talked about this. At one point, but you mentioned that patients that struggle to fully open their mouth might have a raised Mallampati score, for instance. Well, the Epworth really hyper selects, sleepiness and people that are night shift. So if they work night shifts, all the questions are about, you know, if you’re in a meeting, are you likely to fall asleep? Well, when do meetings occur? If you’re in a theater, are you likely to fall asleep? All these things happen when they’re usually asleep. And so if you’ve got someone who’s doing night shifts, the Epworth, pinch a salt with that one and also pinch a salt with your professional drivers. Talking about professional drivers, the DVLA guidance is very different for bus drivers and lorry drivers. They need yearly review and they need special monitoring, so I would recommend that dentists don’t try and. If they find out that the patient in front of them is they suspect has sleep apnea and is also a bus or lorry driver or a professional, like a taxi cab driver or something, they really need to be sent onto their GP. They need to be managed.  [Jaz]I’m so glad you’re saying that because that could affect someone and I think it’s better. They’re a special case and they need special considerations.  [Max]Yeah. Yeah, and usually as in taxi firms, we’ll have screening services and they’ll go to, either they’ll have an agreement with a local hospital or they’ll have a agreement with the private sector and they’ll screen their own. They do their sort of health checks yearly. Bus companies.  [Jaz]Well, I promise. Then last question then, right. As the dentist who may be recommending a sleep test in their best interest, right? Because you are onto something, you’re thinking, okay, I can help this patient, right? And you give them the form, or in my case, when they get AcuPebble, they fit in the Epworth on the device, right? And they do the sleep test. Is it my responsibility to warn them that, hey, by the way, if you do score sleepy and you come with a high AHI, then we’re gonna have to tell the DVLA, because that’s jumping five steps ahead and potentially, and definitely biasing them because then now, they’re gonna be thinking about that and they’re gonna be scoring lower on the Epworth, which we had a chat about that privately. So what do you think?  [Max]Yeah, I think it’s a really awkward place for us to be put. I think it’s something, as you say, biases the outcome. Your professional drivers will know exactly what’s happening when they fill out an ES. They’re the only people I ever see score zero. Have you ever done your own E Ss? [Jaz]Yeah, yeah, yeah. You always own sort of score.  [Max]Yeah. So eight questions with a maximum of three points per question, and therefore 24 is the highest score above 10. We start thinking there’s excessive daytime sleepiness. And most people, I’ll score an eight consistently, even when I’m doing well because it’s like, if you lay down in the afternoon, would you dose? I’m like, well, yeah.  [Jaz]And a night shift worker, like you said, might score 15, but that’s ’cause the nature of the questions, which absolutely are biased against the night shift worker.  [Max]Absolutely. And only people that are willfully trying to obscure their sleepiness score zero. Or you know, the complete nutters that you get come into your clinic. I’m sure you have them, every single field of medicine has them, but they come in and they either score 24 or 0, 24 or zero. You are pretty sure that less likely to be accurate.  [Jaz]And so what do you think then, do you think, I know you said it’s awkward for us to, is there a legal requirement firstly for dentists to warn someone that, hey, by the way, if you score too high, you know you can’t drive. You gotta be careful kind of thing. So because that’s happened with us, with a patient who is upset about not being able to drive and I understood that, but I just worry about them biasing it because they suddenly change their scores.  [Max]So you’ve got this balance, you have this balance between doing what’s right for the public and the people that need to be protected from sleepy drivers.  [Jaz]And the patient themselves. A sleepy driver is a-  [Max]Yeah, and themselves, but also not adequately informing them. But in our sleep clinics, the DVLA conversation. The DVLA conversation comes towards the end. So we’ve gone through the whole, I’ve asked ’em questions about their sleep. They filled out their Epworth when they were in the waiting area. We’ve done all the stuff. I have as accurate a measure of their actual sleep history, what their main presenting complaint is. How often it occurs and all this stuff, none of that’s been biased by the later conversations. And then I bring up the DVLA conversation towards the end, but with enough time for them to ask questions, which they guarantee they will have. And that’s kind of how we do it. And I feel bad for those of private sector or, you crossing over between cosmetic dentistry and other things where you, the rapport is so important for what you’re doing. They have to trust you and you are doing what they want and you are getting them on a treatment pathway. That’s exactly what they wanted and what they needed. But at the moment they see you as the face of taking your license. All the other avenues feel like they might get closed off. And so yeah, it is one of those situations and I quite often, during my consultation at the start, I will just make sure that I understand what they value, what they’d like, what, you are sleepy now, would you like to not be sleepy? How do you feel you would be in 10 years having treated your sleepiness and really get ’em focused on other things before you say like, by the way, you’ll need to treat this if it’s very severe because you’re quite sleepy and the DVLA might want you to stop driving. It’s not your job to go and directly, if I’m correct, it is for a GP. They can go to the DVLA and report the patient themselves, but we in secondary care tell the patient to report to the DVLA. Because there’s penalty for not doing so. That’s kind of how it works. They’re told that if, if they haven’t reported their moderate or severe sleep apnea or sleepiness. There’s a thousand pound fine and then if they’re found at fault, it is talking about criminal proceedings at that point.  [Jaz]Well, I’m glad we talked about that and I think it talks about the rapport building and the ethical dilemmas and there’s no, it’s a gray area, but I think we need to be careful. I think the great advice you shared was that if someone is, they do driving for their money, you know they’re living, then you definitely need to refer that patient. So that’s great. Any final points? Yes, please.  [Max]I think I probably wouldn’t let it, hang on it being a gray area. I think you’ve got a responsibility to make sure that they’re safe, but their conversation doesn’t have to be like, by the way, you are at risk of using your license through, through going through this diagnostic process. The conversation is about, you’ve actually got the opportunity to identify and treat a condition that could be life limiting, not just the quality of your life, but also the length of your life. And these are all the avenues that are available to you. But actually just know that, sleepiness whilst driving is, and I won’t labor that point anymore. I struggled not to have that conversation at the end of it ’cause you know, the what if. That kind of thing.  [Jaz]Mm-hmm. Okay. Great point. I’m happy with that. Max, you’ve gone beyond the call of duty. You’ve been here for an hour and a half now and you must be so tired, man. You’re jet lag. You’re gonna hate me tomorrow, man. I’m sorry, but thank you. Honestly, thank you so much. And guys, honestly, if anyone wants a service from Max whereby you can do your sleep reporting for your tests, if you are at that level in your journey into sleep disordered breathing as a dentist for screening, then I’ll heavily recommend Max. I’ll put everything in the show notes below so you can reach out to Max. And I just wanna thank you Max, for helping me be a better clinician like in a big way.  [Max]I really appreciate you.  [Jaz]Any final points that you wanna give to dentists out there?  [Max]Honestly, I said this at the start, no, you’re in a very unique position because you get to see literally every kind of patient you are seeing mostly this general population and you can pick out something we’ve diagnosed 5% to 10% of sleep apnea and you could be there absolutely reaping up the rest of that population that we haven’t managed to diagnose at this point. [Jaz]So you’re saying that you are diagnosing 5% to 10% of the sleep apnea in the nation. So really there’s 90% of people out there with sleep apnea that are undiagnosed. Is that what you mean?  [Max]Yeah. So that from the sleep apnea trust, those numbers. They think that we’ve diagnosed about, yeah. I mean, I believe it. Yeah, I believe it. The incidents about that.  [Jaz]Totally. Yeah. I mean, I think we have a great role and Max, thank you for supporting me in that role. For everything you do, and guys you’re listening, I hope you enjoy this one. Thank you so much, Max. I appreciate.  [Max]All the best. Cheers, mate. Jaz’s Outro:Well, there we have it guys. Thank you so much for listening all the way to the end. I know it was a longer one than usual, so maybe you had a couple of commutes to listen to. Do not miss the premium notes for this one. The Protrusive Guidance subscription is a paid subscription for all this premium stuff, but the teamwork really hard to put this together. And let me tell you, if you love the podcast, you’re gonna love our premium subscription and the PDF transcripts, the premium notes, and the ability to get CPD just like you can for this episode. We are a PACE approved provider. If you feel that this episode has helped you and advanced you in your understanding of sleep disordered breathing, and what on earth you should do next, then please do send this to your practice. Your WhatsApp group with the all your principals and associates and everything. Send it to them. This is something that I think the entire team should listen to. And you know what? We all know someone who’s affected by this in our lives. This could be a parent, a spouse, an uncle, or even like me. My children have been affected by sleep disorder breathing. My eldest had his adenoids out, and my youngest is on the list to have his adenoids out. Honestly, cannot wait to have them out. So all these teams are very close to home for me. But of course, now that I’ve been developing in the airway space for a small amount of time, but I just want to share my experiences so far. I hope you found that useful. Thank you again for listening to the end. I’ll catch you same time, same place next week. Bye for now. Oh, and make sure you comment below. Tell me what you thought.

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

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

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

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

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

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