Protrusive Dental Podcast

Jaz Gulati

The Forward Thinking Dental Podcast

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Jul 4, 2023 • 14min

The ‘Anti-Biomimetic Dentist’ – Restorative Lessons from Pasquale Venuti Part 1 – PDP152

In this thought-provoking episode, Dr. Pasquale Venuti represents Tomorrow Tooth aka ‘the other voice of Dentistry’. He is a renowned dentist who is not afraid to express his controversial views. While he may challenge the modern techniques taught in dental schools today, he brings attention to the shortcomings in current practices and encourages critical thinking. Dr. Jaz and Dr. Pasquale explore various topics that challenge traditional dental practices, including subgingival caries, flat onlays, post crowns, and cement selection. By raising practical and applicable questions, they encourage dentists to question established norms and seek better solutions for their patients. https://youtu.be/tZp4s0Wj2zY Watch PDP152 on Youtube Protrusive Dental Pearl: New Restoration Needed and the Patient has an existing occlusal appliance. What can you do? Imagine a Stabilisation Splint – For patients who rely on an occlusal appliance – how do you manage the scenario if they need a restoration? Do you need to make a new occlusal appliance? ? Not really. You just have to gouge out the acrylic where the new restoration was placed (intaglio surface of splint). If the splint fits well, no further adjustments are needed otherwise additional acrylic can be added to provide retention (like a partial reline of the splint over your new restoration. Don’t forget that vaseline!) Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 02:36 The Protrusive Dental Pearl05:25 Pasquales introduction16:53 Subgingival Caries and Gingivectomy22:10 ‘TableTop Onlays’ – Where is the limit?28:30 Pasquale on C-Factor31:12 What are the Limits of Adhesive Dentistry?36:55 Guideline for Adhesive vs Mechanical If you enjoyed this episode, check this another episode by Dr. Taylor Paton: Biomimetic Dentistry – What Actually Is It? Click below for full episode transcript: Jaz's Introduction: In this episode, we're gonna talk about the other voice of dentistry. It's a very provocative episode title, right? Jaz’s Introduction:IThe Anti Biomimetic Dentist, well, for those of you who know the Italian Stallion, Dr. Pasquale Venuti, he’s just amazing. And he’s not shy to express his views. He’s very controversial, and he won’t mind me saying this right? And it’s not like he’s like completely in the fringe. He’s not like, ozone. He’s not removing people’s amalgams to cure them of their erectile dysfunction or whatever. Whatever, he is not fringe. He’s just on the other side of what we get taught at dental school nowadays. The adhesive approach, but what Pasquale is great at is, is pointing out the shortcomings in the modern techniques, right? What’s wrong with fiber posts? What’s wrong with blindly following adhesive dentistry? So, what tomorrow tooth, the group, that Pasquale is part of is so good at just expressing the other voice of dentistry, take nothing at face value. So I think you’re gonna really enjoy this episode. I’ve been sitting on this episode for a couple of years now for various reasons, mostly because the amount of interjections and the amount of additional content this episode required me to do is why it took so long. But hope you enjoy this episode and learn a lot with Pasquale Venuti. Some different views of thinking, some slightly controversial areas will be covered in this episode. So get those onions ready because there’s gonna be lots of onion chopping during this episode. Hello, Protruserati. I’m Jaz Gulati. Welcome back to another episode of Protrusive Dental Podcast. It is your first time listening. Wow. You’ve chosen an interesting one to join us. And if you are a usual listener, like I said, man, this is the one for the onions. We’re gonna do a two-part episode. In this episode we’re gonna cover sub gingival caries. We’re gonna cover flat onlays. Like when can you get away with it and when is it a bad idea? Is it ever a good idea? How about post crowns? We’re gonna get really deep in part two when it comes to post grounds and find out why Pasquale Venuti absolutely hates fiber posts. And lastly, some considerations of looting cement. When is it a decent cement? When is it a looting cement? These kind of real world questions, applicable questions that need to be asked, right? So Pasquale does a fantastic job, and I’ll not waffle on any longer. Let’s do the Protrusive Dental Pearl and then hit the main episode. Protrusive Dental PearlThe Protrusive Dental Pearl today is inspired by a question from our splint course delegate support groups. Those of you who enroll on splint course learn more about different occlusal appliances as a GDP. These are permissive splints that don’t necessarily move the jaw in certain positions. A bit safer for GDPs getting started into the management of bruxism with appliances, the management of some types of pain with his appliances. A little bit controversial there, but the question was, when we are dealing with a patient who absolutely loves their occlusal appliance and relying on it for many years and is doing this job, is protecting the restorations, protecting the teeth. But now this patient needs a restoration. So let’s just take a stabilization appliance, right? Acrylic stabilization appliance, AKA, Michigan, AKA, Tanner. And now you replace a crown on a lower molar, for example. And so now your splint’s not gonna fit anymore. So the question is, what should we do? How do we manage this scenario? Do we have to make a new appliance? Not really. You just have to gauge out the acrylic, intaglio surface best word ever in dentistry. The intaglio surface of the splint where the tooth is and then seat it back on. And so now, there’s no parts of that splint binding on that restoration from that crown anymore. And then you assess, right? Do you need to realign it or do you not? Like if the appliance is perfect, how it is and it’s no rocking and it fills retentive and it just as it was before then I’m gonna suggest you don’t need to pull the acrylic out and start realigning that one tooth, because as soon as the patient takes off the splint and starts functioning again, the tooth’s not gonna over-erupt. And we are keeping it simple. But if you find that by losing that one additional tooth of retention of the splint, basically, that now the splint is rocking, or the retention’s been affected, then yes, you gauge out a little bit more, make some space for a decent amount of acrylic. You put some Vaseline on the restoration, the crown, for example. You air abrade the inside of the splint. You put some liquid monomer, acrylic monomer and then you mix the doughy acrylic. You put it inside the intaglio surface of a splint where you’ve just gauged out the old acrylic, right? So you’re essentially relining the splint. You then put it over the restoration, and then you just wait a little while, but then start inserting, removing, inserting, removing, inserting, removing. Because if you don’t do this bit, the acrylic will lock in all the undercuts, and then you’ll have a very sad patient. So once you’ve done that, then you can just meet it up. Essentially, you’ve just picked up that tooth in acrylic so that now, It’s gonna be perfectly seated over that crown. Now it might be binding too much, a little bit too tight in the area, so it might just need a bit of relief. But essentially it’s a good way not to have to make a brand new occlusal appliance for someone just because we’ve changed one restoration. So the ability to realign acrylic splint is a good thing, and I feel like a lot of time, general dentists are afraid to use it because we’re perhaps not so experienced with using acrylic. Acrylics are a great thing to use, whether you use it for lucia jigs, crowns, temporary crowns, or just like I showed you, relining areas of splints. I even use it for more advanced cases, converting my B splints, for example, to have a degree of protrusion. So I’m bringing the jaw forward, right? So I’m adding some acrylic there. Getting the patient to bite into it in a protrusive position, and then that’s like an anterior repositioning splint. So you are converting the kind of occlusal appliance you have to a different type using acrylic. So don’t be afraid to get out the acrylic, but just make sure you don’t let it set in the mouth. You insert, you remove, you insert your remove so it doesn’t lock in. That’s the biggest mistake that you could make. Anyway, we’d like to learn more about appliances for GDPs, head to splintcourse.com. Otherwise, let’s join in the main episode with Dr. Pasquale Venuti. Main Episode:Pasquale Venuti, the real, the original Italian stallion. Welcome to the Protrusive Dental Podcast, my friend. How are you? [Pasquale]I’m so fine. Thank you for the invitation. I’m proud to join your podcast. [Jaz]Dude, I am so, so happy you came and accepted my invitation. You are someone I respect so much and I’ve learned so much from over the years, and I’ll describe to the Protruserati who listened my experiences with you in the past. And when I told the Protruserati that you were coming on, so many people were really interested to hear your views which I know you’re gonna really help a lot of dentists understand your perspectives which some people with some dentists think are controversial and that’s totally cool. We love controversy on this podcast. It’s all about learning from each other. My first experience with you was also a controversial one, Pasquale. I saw some images that you posted on social media around about 9, 10 years ago where you were treating these deep carious lesions, and then you would be destroying these papillas. And I say that as a joke, you were destroying these papillas and you were restoring these teeth beautifully, but just the fact that you’d actually blazed through the papilla for me at the time, as a young dentist, I was like, what the hell’s going on? You are invading the biological width. I even commented, you are invading the biological width. And then you commented back saying, I did not invade the biological width, the caries did. And that was the first of our many interactions going forward. And I learned so much from you. And I saw you in Sydney. You were with Lincoln Harrison in Sydney, then again in Stockholm when I see Michael Melkers so I’ve learned so much from you now doing your vertical course online, which I’d love to sing and praise about. But Pasquale, just for those people who don’t know who you are, tell us a little about you as a dentist, your philosophy, your views. Where does that come from? [Pasquale]We have the same path in dentistry. We were trained at more or less the same way, with the same university dogmas. Well, when I jumped to dental arena, I jumped with the typical overconfidence of the new graduate, a classic Dunning- Kruger effect. I felt smarter and more competent than any other dentist competitor. And of course, more confident than my father. My father was a family doctor and he never had a formal training in dentistry. He was doing some dentistry just for his passion as family doctor. [Jaz]Wow. [Pasquale]Yeah, because at that time there were no dentist in the village. I live in a village of 8,000 souls in 80. There was a shortage of dentist in Italy. So many family doctor did some rudimental dentistry, especially caries you mean, endodontic treatments. Some mobile prosthesis ole bridge. So, my father just read three books in his life. One of N2 endodontics, a very controversial way of doing endodontics nowadays. A book of fixed prosthodontics of the famous Bible from Herbert Shillingburg, and another book of endodontics from Wayne. They’re now are my library. So it’s not surprising. During this podcast, I’m going to show you some slides. One of the most interesting part of dentistry, you don’t need so much formal education to do good dentistry. So imagine that Greene Vardiman Black the famous GV Black, the best dentist ever. So he degree around 19 or 20 years old in Illinois. And then, he decided to do some dentist. So he went to follow a dentist of Mount Sterling in Illinois. The. So in this office, he spent three months, he read the only book of dentistry the daughter spare owned at the time, a book of 100 pages. So GV Black was able to perform and to write and to teach the best dentistry ever, just with two months of formal education. Just one book or 100 pages. So, let’s imagine myself, I had read coming from university, hundreds of books, thousand of literature, of dental papers. So I was very overconfident. So, the problem in coming out from university, you have not right skills and not the right mindset for facing the real dentistry. So anyway, as soon as I jumped in the office of my father, my father left because he went to do family dentistry. So, I had a fortune to never co live with my father, so I never fight with my father. So, but anyway, I put in the basement every stuff for my father. The dentatus post dental pins. Plastic post for cast post prosthetic bars for vertical prep, amalgam. And then I put in the new office fiber post of course, glass fiber post. At the time, I was using big shoulder bars for doing horizontal prep because I was taught at university that vertical pep was very dangerous. [Jaz]Hey guys, I’m gonna start interjecting now and again in this podcast to make it more tangible at various points. So for the young dentist, for the student, Pasquale just mentioned horizontal, vertical, like what does that even mean? Right? It’s a confusing term if you’ve never been exposed to it this way. Well, horizontal just means kind of like a normal crown prep that you were taught at dent school, right? You sink your bur into the tooth and now you have a margin. Okay, you have a normal margin. This could be a chamfer, this could be a shoulder. So that is a horizontal margin. So for those of you who are watching on the app or the video, you’ll see an image of a normal cramp prep that I’ve done. But then what is different about a vertical prep is that it kind of doesn’t have a margin that is completely straight into the gingiva. And you can kind of think of it like a knife edge. Now this might be offensive to some groups, but if you think of it as a knife edge, it gives you some degree of understanding. And there’s lots of different types of verti prep. There’s BOPT, there’s shoulders, and we’ll come onto that in little bit of a education that’ll be setting up on protrusive premium called Verti Prep for Plunkers. So that’s coming soon. But essentially, horizontal prep is like a normal cramp prep. Your shoulder and your chamfer and your verti preps are kind of like knife edge, but that’s quite an oversimplification. But at least now you know what he meant by horizontal and vertical. [Pasquale]So my dentistry started with this kind of dogmas coming from my formal education. Some cognitive dissonance starts to happen in my mind after two, three years of practice because I was following up a lot of patients from my father practice with therapies done by my father with 20, 30 years follow up now. [Jaz]And these are root canal treatments, right? You’re talking about root canal treatments? [Pasquale]Yeah. They were root canal treatments. They were fillings with so-called the kite tissue underneath crowns on vertical prep with overhangs everywhere. But anyway, they were clearly successful after 20, 30 years. And my dentistry have just a track of two, three years. And my cognitive dissonance started to reach the peak. [Jaz]Okay, so I’m just gonna interject again about cognitive dissonance. It’s a big word. And for me it can be confusing sometimes. So I just thought I’d make it a bit more tangible, right? What this means, like, cognitive dissonance is that uncomfortable feeling you have in yourself when your thoughts and your beliefs don’t align with your actions. So if I was to give you a dental analogy, example is that maybe you believe or maybe you’ve come to believe from the literature that you’re reading, that actually we don’t need to do total caries removal, that it’s okay to make sure we got nice clear peripheral zone. The ADJ area must be super clean and so that we don’t exposed, we should be happy to leave some caries over the pulpal area so that we don’t expose and we’re not doing root canals where we shouldn’t be doing them right? But then this is what you believe. But when you come to actually removing the caries, you can’t stop yourself. You can’t hold back and you end up chasing that carries pulpally and you might be exposing more often than you should. So that’s an example of cognitive dissonance made into a real world dental example. [Pasquale]When in 2000 I perform an endodontic treatment on a central incisors, and then I placed my fiber post, and then I did my horizontal prep, a big generous shoulder, and I did an horizontal crown on it. After two years, in 2002, the patient came back with the crown with a post in the hand. So I was shocked because I never saw before a dentatus post or a cast post of my father in the hand of the patient. So something was not working and I didn’t know why. Anyway, after 10 minutes of shock, so I decided to go in the basement, use my first plastic post, and duralay for doing a cast post, so I redid the post doing a cast post this time I redid the crown, and yet the crown is in the mouth of the patient after 18 years now. [Jaz]So Pasquale just referred to using something called Duralay which is like this red colored acrylic. And what we can do with this Duralay along with a plastic post is if you put it inside the canal and then we can literally use some bits of Duralay and start building a post and core. So you are kind of like directly chairside building a post and core as the acrylic setting. You are inserting, you’re removing, you’re inserting and removing, just like the Protrusive dental pearl I gave you earlier. And it’s a handy way of communicating to the lab exactly the shape of the canal and how you want the core to be. Cuz then the lab sends you back a metal replica of this acrylic resin, basically this duralay acrylic resin. Now, I did this once and only once have I done this in my career and it was as a dental student, and this was with an old school tutor. But I was grateful to just gain those skills at the time. So if you’re not familiar with duralay or he didn’t really know what he meant by fabricating a metal post core using the duralay that’s what he meant. You actually adding little bits of acrylic on to build this bigger piece of acrylic, which essentially is like a post and core in your hand. A tiny little version basically. But then that gets sent to the lab to get processed into metal. Now this is relevant because Pasquale in the rest of this episode, he’s remembering this time where he was challenging what he was taught eg the use of fiber posts and the use of heavy preps, right? Which is completely the opposite what he does now, by the time he had this doubt, he thought that he knew it all after dental school, but he’s finding that his results weren’t as good as his fathers who was using more traditional techniques. What Pasquale now goes on to talk about is sub gingival caries and removing the gingiva to allow you to reach the caries, cuz sometimes the gingiva’s in the way and you can’t actually seat your matrix. But what he believes in is removing that inflamed gingiva, which is really crazy when you first get exposed to this. It’s like, whoa, how does this even make sense? But I’ve been doing this for years. And you know what? These papillae do grow back and it’s an absolute game changer for me in my restorative dentistry. And some groups, people do get offended by these techniques, but I think they’ve been absolutely brilliant for my restorative dentistry. So he’ll now talk about that. [Pasquale]So what I was seeing was in strident contrast with what was published at the Dental literature my patients were not a patient of dental literature. My patients were an average with low income, with very better oral hygiene, and most of the decay were underneath the level of soft tissue. That’s why my first need is to become free of gingiva when doing some fillings. That’s why I start to cut soft tissue. So I know after cutting hundreds of papilla, so I start to see back the papilla in a few weeks. So I realized that it was not a big problem. The big problem was not cutting the papilla because at the beginning, for example, I did not cut the papilla, papilla was like a religion to me. So what happened then? I placed my matrix because I had the impediment of the papilla. My wooden wedge was too occlusal and crushed the matrix inside the cavity. So my feeling was very bad with a very strange profile. But if you got the papilla, you are able to do a perfect proximal profile and papilla will grow up again, a guess. [Jaz]And this is so simple, Pasquale, cuz this is why I learned from you initially, because the traditional ways that I was taught to manage that would be, oh, this patient needs crown lengthening. That’s what I was taught. And when I saw you doing such a simple thing like that, and then now having done it hundreds of times, myself, seeing the Pilla come back, seeing year on year, how good the tissues look when they have been educated properly how to clean it. And the fact that I was able to now restore these teeth without surgery and everything’s fine is just mind blowing. Why the only other option was suggested to be crown lengthening? [Pasquale]Yeah, I started with crown lengthening. I mean we started with the same path. So, my patient had very bad oral hygiene. So after crowd lengthening, they ended up with a big black triangle. They didn’t clean. So the situation is even worse for them. So, and after some years I get also new decay on the root because with crown lengthening you expose the roots, so the situation is worse and worse and worse. So crowning is a viable treatment in a patient with perfect oral hygiene. But honestly, in my humble opinion, there is no need of surgical crown lengthening in restorative dentistry. For aesthetic reason in anterior area for increasing the hate of the grounds. If you need federal, you can do auto extrusion, but if you don’t need federal effect, it’s not a problem because you cannot impinge in biology width because if caries is down there, it means that the biology width is reshaping underneath the decay. So you have not a possibility to impinge it. So it’s fake problem in my opinion. I mean, 20 years ago there was a problem, how to get a isolation in very deep caries lesions because rubber dam sometimes is not enough. But with Teflon nowadays, we can easily manage a very deep margin. That’s why you need such a crown lengthening just if you’re not able to isolate the tooth. But nowadays, thanks to Teflon, we have almost infinite possibilities to reach every margin, even underneath the level of the bone. [Jaz]And for those listening right now, if you wanna see examples of these teeth being treated, Pasquale is so good at posting so many cases and also so many follow ups, nine years later, 12 years later, three years later, all over. So join the Tomorrow Tooth group where Pasquale posts a lot of cases, and I encourage everyone to do that. And I love already how we are getting into the clinical details and stuff, but like, there’s so many things I could ask you and share from the lessons that you’ve taught me to the Protruserati, but we’re gonna focus on a few different tangents we’re gonna go on now. Firstly, I just wanna mention for the purpose of the podcast, that there is some tension, there is some friction. There is, I don’t wanna say war. War is a harsh term. There is some friction, let’s call it, between the biomimetic dental group and tomorrow tooth principles and that kind of stuff. And I just wanna say that, look today it’s about listening to your views and your experiences. And then I will also have some biomimetic group on and they will share their experiences. And it’s all about learning from each other and sharing our views. We’re not gonna come at it as an attack. Let’s collaborate, let’s listen to each other’s views. That’s very much the angle this podcast is coming from. So the theme of what we’re gonna cover in this podcast is we’re gonna talk about traditional retention, resistance form versus adhesive versus completely flat adhesive, and where you think on that. Then we’ll talk about the limits of adhesive, and I know you have some really amazing cases of how you manage these very deep caries lesions, yet still doing adhesive dentistry. We’re gonna talk about the concept of post crowns and where they lie. And then also go deeper into fiber post versus cast metal coast, cast metal post, which is something that a lot of the listeners have requested for almost a year now. Your views on the C- factor when it comes to indirect restorations. And finally at the end we’ll talk a little bit about the use, this surge in use in fibers. And I don’t mean fiber posts, I actually mean fibers in composite. So, if you wanna listen to that, you have to wait all the way to the end. So, first question, Pasquale is, and just from my experience, there’s traditional dentistry that the horizontal margins, whatnot. And then of course, nowadays replacing more and more vertical for those who are enlightened and stuff. And most of my crowns where I don’t have enamel all day round, I will be doing vertical crowns. That’s my philosophy. For me to go adhesive, I want at least 90% enamel for me. And I don’t want to overzealously use deep margin elevation, especially in someone who has poor oral hygiene. That’s my view at the moment. And that’s very much I think, echoes what you’ve taught me as well. And correct me if I’m wrong later, but I see more and more on social media, the use of a very flat platform for a adhesive onlay, i.e. a tabletop onlay. Whereas whenever I prepare for an onlay, I still like to follow the angles of the tooth and get some form of resistance form. Even a small degree is better than going completely flat, but I see more and more flatter and flatter adhesive indirect restorations. So what do you think? What is the limit in terms of how flat do we go? Because I saw you post a case recently where you were saying, you know what? You’ve lost faith in these flat preparations and you need to still build in some resistance form. Can you enlighten us on that? [Pasquale]Yeah. I’ve been practicing dentistry since 20 years now and many of the people that collaborate with tomorrow two, like Roberto Magallanes Ramos John Khademi Dev Clark. So they were practiced dentistry then since fourth years. So we tried during our path, both strategies. The so-called classic strategies with retention and resistance form and the new way of doing adhesion on unretentive and unresistive preparation, the prep, there are completely flat. So, those preps are proposed by people that self proclaim ourself, biomimetic dentist. I don’t know, what does it mean. Anyway, this kind of dentistry, the flat dentistry, they unretentive and unresistive dentistry has two main problems in my opinion. The first problem is operative problem, so trying and only with no form of resistance is an nightmare because it slips everywhere. For example, how you check the contact areas on a flat onlay. So we have not a possibility. It’s a circus. The other problem you have not a univocal position of the onlay. So what happens that areas can move and slip a bit or shift eventually the onlay from the decided position. So, but there is another biggest problem there is not operative it’s a rational problem because we have no literature about the longevity of this kind of unretentive and unresistive. Always. We have just some case. Some follow up study at one, two years old. You mean we do dentistry for serving the patient for 10, 20, 30 years. But with this background of just one, two years follow up, I would not be so confident to serve my patient with this kind of preps. Anyway, I had the possibility to experiment on my patient this kind of dentistry since 2013. And the rate of failure on my experience at seven years is almost 40% of the bonding. [Jaz]I just wanna say Pasquale, for those listening who don’t know who you are, like I can guarantee you guys it is nothing to do with Pasquale’s hands not being good enough for this type dentistry. Like, if you see his adhesive dentistry, his isolation’s always meticulous. Pasquale can do any procedure he wants in my mouth. I trust him. So it’s not to say that, Pasquale is not bonding correctly, not isolating correctly, not using air abrasion, et cetera, et cetera. He’s doing the beautiful dentistry. So this, it speaks volumes when Pasquale is saying that something, at seven years, he’s noticed a 40% failure rate. [Pasquale]I mean, I will show you later in the presentation some cases, okay? Some tough cases, okay? Tougher than every case has been published in the dental literature so I tried this kind of prep in many ways. But the biggest problem, especially for a young dentist is how to locate the onlay because we have no index. When you have a flat policy, you have no index. And restorative dentistry in indirect restorative dentist index is paramount. Because you have to have a unical position of your restoration. [Jaz]So what does Pasquale mean by indexing? Let’s make it tangible. Sometimes to understand something, you must understand what it isn’t. So if you have a flat onlay prep, right? And you imagine trying to seat an onlay on this flat prep, and it’s kind of like moving around. Like you can twist it, you can seat it many different ways, and maybe it’s slipping. A bit, right? Maybe you’ve experienced this firsthand with your fingers. Now the opposite of that would be a crown preparation with lots of slots and grooves, and it fits in really snugly in that one position. That’s a highly indexed restoration. So what Pasquale means that we should move away from completely flat preps and have a degree of anatomy inside the in taglio surface of the onlay, for example, that’s gonna seat in and not be slipping. The contacts won’t be slipping. The onlays not slipping off. And this is called indexing. Not only is it but good for your technician, it makes it easier for a technician to make you a good restoration. It makes it easier for you at the time of your cementation or your bonding procedure to make sure that you get that one path of insertion. So indexing is a good thing to have. [Pasquale]And with flat onlays you have it now. So what we did, at some point, we start to do some hole into the center in order to locate, because it’s not all your problem, it’s all the problem of the technician that cannot have a exact location. So sometimes if the hole is not so deep, the former resistance is not enough. But there are a lot of problems, eh? I will show you better. One of the biggest misunderstanding in the dentistry nowadays is about C- factor, because the people that proclaim that flat onlay has a very low C- factor, okay, are completely wrong because they do not understand the basis of C factor. Because if they studied the work of Carol Davidson, the inventor of C factor, C factor is called in this way because the name of Carol Davidson. So they will see that in 1985, Carl Davidson studies the flat onlays. Flat onlays have infinite C factor. C factor is extremely high because you have one surface, there is the tooth surface and the onlay. So, and the cement has to compete with two surfaces opposing each other during shrinking. So you will end up with a lot of crack inside the cement. So if you have no form of resistance, what happens that under the true load, especially the parafunction, the crack will start to move and to continue inside the mass of the cement you have the bonding at some point, so it works very fine if you have a patient with no parafunction. But if you have a patient with parafunction, you will end up with the only hand in a few years. [Jaz]As you taught me Pasquale it’s a good way to say it is the biomechanical risk of a patient. And there’s a difference as you taught me many years ago about these. A patient who has low biomechanical demands and high biomechanical demands, and it’s important to appreciate who you’re dealing with. So maybe what you’re suggesting is maybe those 40% of cases where you found that these flat preparations, would you say that a lot of those were in patients with high biomechanical needs? [Pasquale]Of course. Of course. Most of the patients, this is for every therapy in dentistry so a filling lasts 30 years in a simple patient, in a patient with lower biomechanical demand. That’s why sometimes you see gold filling, lasting 30 years, but if you check those mouths, you will see that in that mouth there is no wear. It’s not about gold, it’s about the mouth because all also composite filling can last 30, 40 years. [Jaz]Wow. Even amalgams do 40, 50 years and we see all the time and everyone says amalgams causes cracks and stuff. I’ve got plenty of patients with 30 years amalgams not a single crack. [Pasquale]How many cracks you see in a patient with virgin teeth? A lot? [Jaz]Mm-hmm. [Pasquale]So you mean the crack is about the force, the vectors, the muzzle vectors. It’s not about what you pull inside a cavity. Anyway, I will show you many cases about cracks just for giving you a better idea. [Jaz]Brilliant. We’ve talked a little bit about the importance of having a degree of resistance, especially in this patients with a higher biomechanical demand. What is the limits of a decent dentistry? Because I’ve seen you do some really tough cases and go on really over and beyond with your skills to try and isolate and try and to achieve all the adhesive principles. But where do we draw the line? Where is it for you personally, Pasquale, that you say, okay, this will be adhesive, this will be non-adhesive. Where is the limit? [Pasquale]A couple of years ago, I had a discussion with my friend Marlene Payman from Luve University because I challenged her to define what does it mean, adhesion? So, for example, if I ask you is an adhesive or not? In your opinion? [Jaz]I would say that GIC would come into the category of an adhesive cement. [Pasquale]So how do you cut the threshold between an adhesive cement and nonadhesive cement? [Jaz]Well, actually now I’m thinking about it for me. Now you say adhesive should have some sort of degree of resin. So if it’s glass or iron cement, that’s a chemical setting, whereas a resin modified glass man would have at least common. So actually now I’m gonna revise my answer and say if I’m using something like a Fuji plus, which is a GIC ba base cement, that would be for me. I use it for my non-adhesive crowns for like my verti preps for example, vertical crowns I would use Fuji Plus or something. So I would say no, it’s not adhesive. [Pasquale]I mean, when you talk about adhesion from the chemical point of view, you have adhesion when you have some chemical bonding between two structures, okay? Instead we are using the word adhesion for defining some cement they have no chemical bonding, but micro mechanical interlocking. [Jaz]Yes. Yes. [Pasquale]Because the hybrid layer is just a mechanical interlocking. So the only cement that we can use adhesively in then is glass ionomer not the resin cements anyway. We tend to classify a cement been adhesive. Just if you get 20 giga pascal in adhesion. For example, if you are under 20 giga pascal, you tend to see the, to say that it is not adhesive cement anyway. The problem is that how long is the micro mechanical bonding, how longevous it is, what can damage the micro mechanical interface? So that’s the question. You can have some giga pascal of adhesion at the beginning. It is longevous or not so, and what we have found over time that this bonding is very longevous on the enamel, but it’s not so longevous onto the dentine. Because, the problem, the biggest problem with dentine that we have no dentine. We have what I call the 50 shades of yellow just for no, when a dentine is decay is attacked by dec. It change structures, and when you bond that dentine, it’s not easy to have longevity’s bond, in my opinion. This is my experience. After 10 years, if you start to remove a filling done well, you have a very trouble to remove from the enamel. But then after you have removed the addition onto the enamel, you can remove the filling with an excavator because the adhesion to the end is completely lost. You can do an experiment. Everybody should do this experiment. You have a deep filling, you have a deep decay. You have to do a deep marginal elevation of this dentine. If you just do a bonding of two millimeter of denting of this deep margin, okay? After the light curing, you can remove within excavator that little piece of composite. That’s why when you do a deep marginal elevation, I highly suggest to create some mechanical interlocking with the enamel. So you have to extend the platform because if the deep marginal elevation is very minimal, it’ll detach easily because that then is not prone to the bonding procedure. [Jaz]I mean that makes sense, Pasquale in terms of how deep you are and you’re purely on dentine, but to extend it onto enamel, you mean we should also go a bit more buccal and a bit more lingual. [Pasquale]Buccally- [Jaz]So that it’s fine. Understood. [Pasquale]Yeah. You have to extend the platform at least three, four millimeter inside a tooth, because if you limit yourself a deep little margin, the bonding is quite poor. It’s almost zero, so, but why enamel? The enamel is quite stable. It’s a rock, so it doesn’t change. It’s the same from the first day of the patient to the last day of the patient. Dentine change over time, change color, change structure. So enamel offer another advantage. It make the tooth very stiff. If you have a lot of enamel, so the tooth cannot bend easily, but if you have lost most of enamel, the residual dentine under the chewing stresses can bend if it bends, the mechanical interlocking with composite will us teach very easily. So that’s why if you have a lot of enamel go with adhesion, even with the flat surface. But if you have not so much enamel, honestly, it’s better to project and design is something that is re resistive and resistant in my opinion. [Jaz]Brilliant. So, Pasquale, just to wrap that up, and I told you one of my guidelines for adhesive versus non-adhesive is at least 90% enamel. Would you like to offer some sort of mathematical or rigid guidelines in terms of that, if that helps the young dentists understand about when to go adhesive and when to go non-adhesive, mechanical. [Pasquale]So many people will, it’s not about how many enamel you have all around, because some teeth have a lot of enamel around about the surface, but the thickness of enamel is very minimal because, for example, is an erosive patient. So erosive patient is not easy to treat because you have enamel at 360 degree, okay? But you have adjusted 0 3 0 4 millimeter of enamel. And 0 3 0 4 millimeters is not enough for me adhesion, you need enamel, almost a 360 degree. You can accept 250 degrees of enamel around and at least a thickness of enamel of 1.5 millimeters. If I have less than 1.5 in thickness, I will not do any adhesion. Anyway I will present later in the presentation some cases that are very paradigmatic. What happens when you do a filling in an erosive patients, so you have enamel, but you have a very teen enamel, and you will see what happens to the fillings in a few months. Jaz’s Outro:Amazing. We’d love to see that. Yeah. Brilliant. So then, and the next thing we wanna talk about Pasquale is the whole concept of no post, no crown. So this concept of we want to avoid placing posts as much as possible, and we want to avoid doing crowns and instead do onlays to maintain the gingival third of tooth structure where which is responsible for the strength of the tooth. Now, my own personal views on post is that I haven’t placed a post for like, maybe two years now, because for me, if I have enough feal, then I think almost I don’t need a post. I can just rely on my composite and the crown will be engaged in a feal. If I don’t have any feal then I’m thinking, why are we even using a post here? So for me that tooth is for the bin or needs some crown lengthening or something like that. Or even if I can’t get that fair ferrule from a vertical preparation for example, we can gives you a little bit more ferrule to play with. For me, that tooth is unrestorable. So I’d love to hear your views on this mantra of no post, no crown and find out how much you in your daily dentistry are using posts at the moment. Well, there we have it guys. I’m sorry I left you on a bit of a cliffhanger there, but we’re gonna cover the big bad topic of post next time. We covered a lot of ground, we covered a lot of breadth, but in the next episode we go a little bit deeper into some of these areas, especially when it comes to posts and why in this world where everyone seems to be anti post, he is pro post. And even then it’s like a class post that he favors. And we’ll find out a bit more about his philosophies in restorative dentistry. If you’d like to gain some CPD, just head over to the app protrusive.app or on your device like Android, iOS, you can actually download the native app. And just by answering a few questions, you get some CPD for this episode. There’s also monthly premium content that I add all the time. But I do wanna thank you for listening all the way to the end of this episode, and I hope you look forward to part two with Dr. Pasquale Venuti, same time, same place next week. See you there.

9 snips

Jun 6, 2023 • 45min

Prescribing Antifungals as a GDP – Diagnosis and Management – PDP151

Download our Prescribing Antifungals for Dentists Cheat Sheet! Miconazole? Nystatin? Amphotericin B? What dose? When should you refer, and to who? How often do we prescribe antifungals as a GDP? I always need to brush up on the guidelines and best management of oral fungal infections whenever I make a diagnosis – which is why brought on Oral Medicine Specialist Dr. Amanda Phoon Nguyen to make diagnosing and managing oral fungal infections less painful! Dr. Phoon Nguyen shared her experience and insights into diagnosing and treating oral fungal infections. Here’s a glimpse of what we covered: Primary Oral Candidosis: Explore the three types: pseudomembranous candidosis, chronic hyperplastic candidosis, and erythematous candidosis. Learn how to identify each type and when further investigation may be necessary. Candida-Associated Lesions: Understand the different candida-associated lesions, including denture stomatitis, angular cheilitis, median rhomboid glossitis, and linear gingival erythema. Discover the significance of these lesions in relation to systemic health. Treatment Approaches: Gain insights into effective antifungal medications, such as miconazole oral gel (Daktarin), amphotericin B lozenges (Fungilin), and fluconazole mouthwashes. Consider interactions and precautions when prescribing antifungals for patients on specific medications. Denture Hygiene: Explore the role of dentures in oral candidosis and the importance of proper denture hygiene. Learn practical tips for denture maintenance to prevent candida colonization. https://youtu.be/-RqoVZVVnsI Watch PDP151 on Youtube The Protrusive Dental Pearl: What are you Waiting for? If there’s something you’ve been putting off (meditation, exercise, diet, work, etc.), the best time to start was years ago. The second-best time is today! Write it down, tell someone, keep yourself accountable and start right now. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 01:31 The Protrusive Dental Pearl02:47 Dr. Amanda Phoon Nguyen06:43 Candida Albicans08:37 Primary Oral Candidosis14:48 Modifiable Factors18:40 GP vs. Oral Medicine – Where to Refer?21:44 To Prescribe or Not to Prescribe?24:10 Antifungal Medication31:44 Interactions35:48 Angular Cheilitis39:06 Median Rhomboid Glossitis and Denture Stomatitis39:57 Denture Hygiene If you enjoyed this episode, check this another episode by Dr. Ben Pollock and Dr. Samuel Cope, Got Your Back – Physios and Dentists. Click below for full episode transcript: Jaz's Introduction: If you've diagnosed a fungal infection in your patient, perhaps oral thrush or a denture dermatitis, should you prescribe antifungals straight away? Or is it a good idea to improve the oral hygiene, the denture hygiene first? Should you always be sending for a blood test or is it okay just to go straight for the antifungals? Jaz’s Introduction:Look, if you’re anything like me and every time you even suspect fungal infection your patient, you are thinking, whoa. When I even begin what I prescribe, I haven’t done this in ages because you see this is something that, unlike a lot of other things in dental school, this is probably actually taught well, but the frequency of how often you actually see patients with fungal infections is not very common. Therefore, we kind of forget what is the best to prescribe at the best time. So unless you’ve done it a few times, you’re probably going to gain a lot from this episode like I did with our guest all medicine specialist, Dr. Amanda again from Perth, Australia. Now Protruserati, I know you’re going to love Amanda because she is so straight talking. I know you love our straight talking guests and she’s just absolutely brilliant. We have a fantastic infographic for you to download as well. And a lovely episode summary for you to sink your teeth into. Hello, Protruserati. I’m Jaz Gulati and welcome back to another episode of Protrusive Dental Podcast. If you’re new to the podcast, hello. Thanks for joining us on this oral medicine topic. Very rare for an oral medicine podcast. Perhaps we should do more. I don’t know. Let me know in the comments if you think I should be doing more of these. It’s maybe not as sexy as composites and adhesion. That is bloody well important, isn’t it? Every episode I give you a Protrusive Dental Pearl, and today is like a philosophical motivational one. If there’s something in your life that you’ve been holding off, that you’ve been putting off, right? This could be like adding meditation to your life. This could be exercise. This could be improving your diet. This could be something business related, something, or even work related, a habit that you want to pick up. Remember that the best time to do it was some years ago, right? The best time to do it was some years ago. But you know what? The second best time is today. And I’m saying this, even if it helps one person, then this Protrusive Dental Pearl was well worth it, right? So if there’s something they’ve been holding it off, what are you waiting for? Right? Today is the best day. Yesterday was a better day, but that’s not going to happen. So why not do it today? Why not write down right now? Write on a piece of paper, write on one of those apps, write on Google Docs, WhatsApp, someone, voice note your spouse, what it is that you’re going to do, starting from today, that you should have started yesterday or many years ago, but today is a damn good day to do it. So you go ahead and do it. And if you want to message me on Instagram to let me know what that thing was, @protrusivedental, I’d like to hear. It’d be cool. Anyway, I’ll catch you in the outro. Enjoy this episode. Now, there’s a lot going on, right? You’ll get lots of helpful advice about what to prescribe, the different conditions, so it’s going to lend itself, like I said, very well to the notes and the infographic, and I’ll let you know how to get your hands on those. But I’ll catch you in the outro. Main Episode:Dr. Amanda Phoon Nguyen and welcome to the Protrusive Dental Podcast. How are you? [Amanda]I’m great, thank you. Thank you so much for having me. I’m very excited. [Jaz]I’m stoked to have an oral medicine guest finally on the podcast. This will be some new stuff for the Protruserati and something that’s really relevant for all general dentists. Now, before we dive into antifungals, what to look for, what to prescribe, just tell us about yourself. Why did you fall in love with oral medicine? How bizarre is that? [Amanda]To be honest, when I was going through dental school, I, A, didn’t think I would ever specialize. I thought like why would anyone ever want to narrow themselves to one field? But then I think as I became a dentist and I had more and more experience, I actually found general dentistry quite overwhelming because there was so much to know about so much. And then I started to think about specializing. I did some further study and the two that I actually was very interested in was pediatric dentistry, because I quite enjoyed, like treating kids and then oral medicine and in the end oral medicine one out. And I’ve been a oral medicine specialist for a while now and I love it. I think the bit that is so interesting about oral medicine is that every patient that walks through the door, Is something different. Like there’s a lot of like differential diagnoses, diagnostic sieve trying to put together like puzzle pieces almost to get to the right diagnosis and treatment plan. And I think that is what I find the best part about oral medicine is that it’s so interesting. [Jaz]It reminds me of, I treat a lot of TMD, and the more I read about TMD, TMD is a thinker’s game. Right. It’s very much thinker’s game. Oral medicine is very much a thinker’s game. And just like you said, like yes, you do lots of investigations as a general dentist, but general dentistry, you’re getting your handpiece out, you’re doing something, whereas you are working with your mind and really trying to nail that diagnosis, which sometimes probably can be one of the most challenging parts, I imagine. [Amanda]Yes, I think so. So, sometimes when I talk about oral medicine or I speak to people about oral medicine, sometimes even with patients, there’s very much a tendency to jump into how do we manage this? But actually, the main goal is to actually get the right diagnosis first, and I think that’s where a lot of the art and sciences of oral medicine comes into play. [Jaz]Well, in the UK, Amanda, I might be wrong, but I think in the UK you have to do medicine. You have to be duly qualified to then become an oral medicine specialist. Is that the case in Australia as well? [Amanda]Yes. So in the UK, you had to be dually qualified, I think, until very recently. And in oral medicine in Australia it’s a dental specialization. In oral medicine, I think you have to be dual qualified. So there’s a couple of places that are still dual qualified, but most places now are moving towards singly qualified. [Jaz]Fine. And so the topic, I mean, there’s so much we could talk about in all medicine, but just a little bit more about you. Where do you actually practice you? Are you in a hospital setting? Are you in a private practice setting? How does it work there? [Amanda]Yes. So I work in a bunch of different places actually. Cause I quite like the variety. So I work in private practice three to four days a week. And then I am at the university. So I’m an adjunct senior lecturer, at the University of Western Australia. And I also have a consultant’s position at the Perth Children’s Hospital. So I do a mix of public and private. [Jaz]Brilliant, brilliant. So it keeps you busy. Very busy. It seems so amazing. Well, thanks for making time for this podcast episode on fungal infections and antifungals so we could start anywhere. Now I’m going to help get your advice on terms of which is the best way to lead the show. But one idea I had was to break it down in terms of sometimes patients come in without any symptoms and it’s the signs that we spot, and then sometimes they come in with symptoms, which helps us. I think the best way to start would be perhaps the symptomatic patient who’s prompting us, oh, I have an issue with my tongue. Oh, I’ve got some white flecks or whatever. And then it’s up to us and use that information, the symptoms and the signs to come up with a diagnosis, and then we can get our prescription pad out. So maybe the first half, let’s talk about diagnosis, signs, symptoms, diagnoses, and then we can talk about the management. So perhaps you can tell us what are the most common fungal issues that a dentist might encounter and how to even begin diagnosing them. [Amanda] Yeah, so fungal infections is a very broad category of infections that may occur in the oral cavity. By far and large, the most common causative organism is Candida. So that’s a group of yeast so Candida albicans is actually the one that is most commonly implicated. And the reason why I’m sort of bringing that up is that we can’t look at it as a broad thing, we need to think about, are we just talking about candidosis, which in this case we are. Because there’s a bunch of other infections that can occur in the mouth that are fungally caused. But the one that a general dentist, or that a dentist would most commonly see would be one that was caused by oral, that it’s caused by Candida. Actually this brings me to my first point. Do you call it candidiasis or candidosis? Because in Australia we, some people say candidiasis, I think it should be candidosis. And I think sometimes getting that out of the way is probably the best thing for us. What do you guys do over there? [Jaz]From my lectures in Sheffield, we had Candidosis. [Amanda]Very good. So I say Candidosis too because that is more in line with all the other fungal infections, which actually end with ‘Osis’. So, candidiasis kind of doesn’t make too much sense. But anyway. So let’s say we’re talking about oral candidosis. It’s important to recognize, aswell that it is actually a commensal. So if you look at the studies, it exists on us, in a large percentage. So between 40 and 80% of people actually have Candida on them already. And then some of the newer studies can say that it is as high as a hundred percent. So when we are talking about candidosis, is it actually the presence of the fungus that we are concerned about? Does that actually need treating or is it actually when it becomes an infection and causes a problem and that’s when we should treat it? And that will come down to how we actually diagnose it. So, First of all, looking at clinical signs and symptoms, I think it’s fairly reasonable to diagnose based on a clinical appearance, and that is what I would do most of the time. So when we talk about primary oral candidosis, we can have the pseudomembranous candidosis, chronic hyperplastic candidosis, and erythematous candidosis. Now, a pseudomembranous candidosis is the easiest one to recognize. Pardon this. If you are having your dinner or if you’re listening to this while you’re eating, it looks like cottage cheese in the mouth, basically, right? So you look at it, it looks like cottage cheese. Now, when I tell people about doing a head and neck examination, I always talk about palpating and feeding lesions as well. So the first thing you should do if you see cream cheese in the mouth or cottage cheese in the mouth, give it a little bit of a wipe. Is it food debris? In infants is very common. Sometimes they have milk debris as well and people start to worry is that actually candidosis. So give it a little bit of a wipe first. See what is left behind. If there is a very erythematous base behind, then you probably do have pseudomembranous candidosis. Do you need to do any additional testing to diagnose it? I don’t really think so. So in most cases, if that is what I see that looks at pseudomembranous candidosis and I will proceed to treat that. Now, the other ones that we talked about, chronic hyperplastic candidosis actually looks a lot like leukoplakia, so it can be non homogenous or homogenous. It’s basically a white patch in the oral cavity, most common locations, buccal commissures, ventral tongue Now, if you see a white patch that cannot be wiped away and you don’t really know what it is and you don’t think that it is related to trauma, I think that should be further investigated. There are some studies out there that show that upon biopsy, chronic hyperplastic candidosis lesions ahead of a higher degree of dysplasia and things like that. So I think those ones should be treated with suspicion and you may want to consider maybe referring it to someone who could manage the patient long term if it does turn out to be dysplastic. Erythema can- [Jaz]So pseudomembranous, which is the cottage cheese one and the chronic hyperplastic, they can both be wiped away. Is that correct? Yeah? [Amanda]No. So chronic hyperplastic cannot be wiped away, but pseudomembranous can. Yes. [Jaz]Okay. [Amanda]Yes. And then erythematous candidosis, which is the other one, you can get the acute or chronic forms of it. But the first thing that I do when I look in a patient’s mouth is very red. Acute erythematous candidosis is actually usually painful and actually it’s usually most associated with someone who has recently been on a broad spectrum antibiotic. So if they’ve been on antibiotic, their mouth is suddenly red and pretty painful. I will be happy to treat that as well as candidosis. So I think candidosis, there are a lot of different presentations, but if it’s a fairly classical form and it fits, I think having a clinical diagnosis and in considering management, I think is adequate. Where we would do like further investigations like biopsies or swabs or things like that? I think the role- [Jaz]Oh, blood tests even? [Amanda]Oh, blood tests even. Yeah. So I think the role for that comes, so blood test is more to see if there’s an underlying systemic contributor. So we can talk about that when we come into management. But say you see a patient with all of these clinical signs and symptoms and you think that it is oral candidosis, I think it is reasonable to go ahead and manage the patient. And we can talk about management in the- [Jaz]But sounds like the second one, the chronic hyperplastic sounds like the advice here is because it is a patch that can’t be rubbed away, that as a general dentist perhaps you are good. You’re correct to refer,. [Amanda]Yeah. [Jaz]As a rule of thumb. [Amanda]Yeah, that’s it. [Jaz]Okay. [Amanda]So because chronic hyperplastic candidosis, I would say that most people will not be able to differentiate it from a leukoplakia just by looking at it. So I think in this case, when I say you can go ahead and treat, I will be thinking more about the erythematous candidosis or the pseudomembranous candidosis, because- [Jaz]Very helpful. [Amanda]Like realistically, if you see a white patch on the side of the tongue, on the ventral surface of the tongue, that doesn’t wipe away. A patient doesn’t know how long it’s been there. That’s pretty much a referral I think in most Australian dental professional books [Jaz]As a general dentist and a restorative dentist, I treat patients with their denture dermatitis. And that is often linked to fungal infections candida now, does that fall into either of those categories, or is that an entirely new category? [Amanda]Yes, that’s an excellent question. So the three that we just talked about there, pseudomembranous, chronic hyperplastic, and erythematous candidosis, they are your primary oral candidosis. Now you do have, Candidal associated lesions, which is a different category. And the reason why there is a different category of these, of which denture dermatitis fits into there is that it is usually thought to be a polymicrobial infection. So not only related to Candida or the evidence isn’t strong and Candida is the only causative fact. So those ones would be your angular cheilitis. And we can talk about that because that’s very common. A lot of people have that. Median Rhomboid Glossitis, where you have a deep populated area in the dorsal surface. So the tongue looks a little bit like a diamond. And then you have sometimes called Linear Gingival Erythema, where you get basically a red band along the interdental papilla. Now if you do see a patient with linear gingival erythema, not to say that it doesn’t happen in people who don’t have an underlying medical problem, but it’s seen in a lot higher numbers in people who do have HIV. And then the denture stomatitis. [Jaz]But that must be so difficult to diagnose Amanda, because it just, you might think that that’s just gingivitis. [Amanda]Yes. So the hallmark feature of that actually is something that is not responsive to plaque management. So if you see a patient and you think that they’ve got gingivitis, you do plaque control, you do debridement, scaling cleans. You increase the oral hygiene, but it still remains, and I think that’s when it’s worthwhile considering referral either to a oral medicine or a periodontist. [Jaz]Okay, so if you’re enjoying this episode and you know about the different conditions, and we’re going to get into what to prescribe if you want it all nicely and neatly presented to you in an infographic, so it’s easy for you know what to prescribe when, and the different diagnoses, like a cheat sheet, right? An antifungal dentistry cheat sheet that you wish. Then school have given to you or you wish was in a textbook somewhere. But don’t worry, I got you covered. If you want this, you head over to protrusive.co.uk/antifungals. That’s protrusive.co.uk/antifungals and I will email to you personally. So back to the episode. Got it. So in terms of you break it up, because now we branching into two areas. Let’s finish up and wrap up the first part, the three primary diagnosis we make. [Amanda]Yeah. [Jaz]And we talk about their management before we talk about the denture and the angular cheilitis, which I think I’d like to because it’s just so common that we see it actually. [Amanda]Yes, yes. So with all of the candidal presentations, if you suspect a fungal infection, and we’ve talked about how the most likely ones that you will probably suspect is the pseudomembranous and the erythematous candidosis, the general treatment will be with via an antifungal medication. And there are different types of antifungal medications that we can consider for patients. Equally as important as starting your patient on these medications is considering what are the modifiable factors there are. Because we’ve talked about how candida is something that is present in a large percentage of patients. There is something that has changed. So something in the environment that has changed or something in the host factor that has changed, that has caused the candida to become more active and more invasive and basically start to cause a problem. So classy things will be, have they recently started a new medication? Have they recently got a denture? Have they recently changed their diet? If they do have things like diabetes and stuff like that, it’s always worthwhile, I think, to ask the patient, how because we see lots of patients with diabetes, how well controlled is it? When did you last check? Are they checking themselves at home? Did their doctors check it? How their denture hygiene is as well, I mean, It’s not uncommon that I have patients come to see me with these types of candidal infections, but they are not aware of denture hygiene or they have been told, but they just don’t listen to it. So reinforcing all of that’s important. If they have anemia, that’s a pretty common one as well. So that’s where the blood test will come in. So if I see a patient and they have a history of anemia or anything like that, or if they’re sometimes they’re female or they’ve been bit rundown, I would generally do a general blood screen. So I would do a full blood count. I would do vitamin b12, folate, and iron studies cuz these are the things that sometimes are well, that are used for mucosal healing. So if there’s any sort of deficiency in them, there’s a defect in the mucosa and that’s how candida can sometimes be a little bit more active as well. We don’t see this as much as anymore, but back to dental school days, up to the people who are listening. You might remember like hearing about red, beefy tongue where the tongue looks very red and very smooth and things like that. So if you see any of those sort of signs, I think is a good idea to investigate what’s underlying it because- [Jaz]What about dry mouth xerostomia is that a cause as well? [Amanda]Definitely, yeah. So that would be one of the things that can alter the, is a host factor that has altered so I think paying attention to all of these factors is quite important as well. Steroid puffers as well. If you do have patients that are using steroid asthma puffers, reminding them that they should rinse their mouth out after using it. It’s also important because sometimes they sort of were told by their dentist or they read it on the packet, but then they forgot all about it and they’re wondering why they’re getting this candidal infection in their mouth. So I think spending a little bit of time seeing if the patient’s systemically well, if anything has changed oral appliance wise, checking their saliva. Checking the control of their systemic conditions. I think it’s basically really important because in the past, candida used to be called like, the disease of the disease. That’s actually what they used to call it. So, that’s like the hallmark sign. Like you’ve got to check out if anything else is going on, if they are immunocompromised, if they’re on long-term corticosteroids, that’s another one as well. See if maybe that is something that they are doing if they recently had antibiotics. [Jaz]This is what, I mean you mentioned the antibiotics and you’re quite right. That’s a common one. But what becomes difficult for the general dentist, and one of the reason I got you on is that you’re a general dentist. You busy list and suddenly you have to switch on your oral medicine hat on and become this investigator, quite rightly so, but this is where general dentistry struggle because you’ve got a queue of waiting patients, you just diagnosed fungal infection and now to do the entire medical history so exhaustively to figure out exactly what’s changed the environment. That can be a tricky thing. So hopefully we’re going to give you a few tips to make it more efficient and better. So, two questions I have based on when all the wonderful said you said that is, let’s talk about anemia being either suspected or in the medical history. Would you expect the general dentist to refer to oral medicine or to the GP to get bloods? You think? [Amanda]That is an excellent question. And you know, to be honest, I don’t really know the answer. Like, okay. I know what my answer would be, but I don’t think it is always correct. I think it depends on the patient’s general practitioner, because I’ve had multiple cases where the patient is sent to the doctor and the doctor hasn’t really known what blood test to order, or they’re unsure about potential systemic contributors to oral candidosis. And then the patient just ends up going round and round in circles for a little bit. I think this will have to be up to the person that is listening to like whoever’s listening to the podcast to maybe have a chat with their patients about, do they have a regular GP, has their GP been pretty thorough. Because a good GP I think would be very adequate at managing this. But then at the same time, GPs are also very busy, so they need to know a little bit about everything. So it’s sometimes very difficult to expect them to know how to manage oral candidosis systemic conditions. They may not know necessarily what to look for when they start to order blood tests, and then even then they may not know what to prescribe. And actually, one really big thing that we’ve not really talked about as well is that I’ve set the cases where Oral Candidosis is very obvious. Pseudomembranous Candidosis being the example. But there are many times where these signs and symptoms are sort of nebulous or not very obvious, and then the patients are misdiagnosed and they’re sort of going to a merry-go-round. So a classic example will be burning mouth syndrome, which is otherwise known as oral dysesthesia. I’ve recently just done a lecture on that as well, and and I looked at this paper that was done in Italy. And the number of burning mouth syndrome cases that were misdiagnosed as oral candidosis is actually quite high. So, would you necessarily expect a patient’s GP to be able to know the differential diagnoses of oral burning or potential oral infections? I think that is really difficult as well. Because GPs are very busy, so they may not know. [Jaz]Are they always segregated, the burning? I mean, is any evidence that everyone in burning mouth syndrome has a candle infection same time or vice versa? The candidate is what set off the BMS, is there anything linked or are they very much different entities? [Amanda]Yeah, so there have been a couple of studies that looked at Candidal carriage in people who do have burning mouth syndrome. But unfortunately I don’t think we can put much stock into that because Candidal carriage is something that we know doesn’t necessarily mean infection. So I think it’s probably easier to think of it as being separate because burning mouth syndrome is meant to be a diagnosis of exclusion, where we’ve wrote everything out. Then we diagnose the patient with burning mouth syndrome. So, If they do have signs of oral candidal infection, then we would diagnose them as having a oral candidal infections first, and then see how they respond to management. And if we are sure that there’s no longer any other infection or any other problem, and we think it’s burning mouth, like, it’s a diagnosis of exclusion essentially. So I think it’s easier to think of it separately. [Jaz]Okay. Well the second question I wasn’t asked then is, let’s say we’ve looked for the signs and we’ve either diagnosed the cottage cheese appearance or the chronic hyperplastic when get a referral out to get it investigated because of the risk of dysplasia or we’ve got the erythematous one and from this podcast, we think, okay, I think I’ve diagnosed a fungal infection. Now something as you said, quite beautifully, something has changed in the host and we’re going to discuss and have a chat with the patient, look at their medical history, take a close look. What is the recommended pathway? Is there a school of thought that actually we shouldn’t pick up the referral pad? How about we listen to the patient, we’ll figure out what’s changed, and try and see if possible if within our powers we reverse that. Or should we also prescribe antifungals and investigate what’s changed. So what I’m trying to say is, a pans off approach, no prescription, but let’s just drink more water, stay more hydrated, figure out what’s causing the xerostomia speak to your GP about changing that medicine, clean your denture better, and not giving the antifungals. Is there a place for that? [Amanda]So I have to caveat this by saying that you have to look at the therapeutic guidelines of your own country, where you’re from, who are wherever. Cuz I know people from all around the world listen to this podcast. But what I would do in Australia is that with the people that I work with, I would actually encourage doing both. So if you have a reasonable suspicion that it is an oral fungal infection, like oral candidosis, modify any risk factors that is possible or densely related, or talk to the patient’s GP if there’s anything there. Manage the patient with their oral fungal infection. And then if it doesn’t get any better or something’s a little bit unusual, or if you think it is chronic hyperplastic is a leukoplakia, you don’t know if it’s leukoplakia or not. Those ones I think you should refer, but if not, if it’s a fungal infection, I think dentists should be able to manage that. And certainly I think it’s a good idea because I’m sure in the UK as well, in the same is same here in Australia. The wait list for an oral medicine specialist or like a specialist is quite long. You don’t necessarily need- [Jaz]Massive. [Amanda]Yeah. [Jaz]And they’re few and far between. The oral medicine specialists only work in certain tertiary centers if you like. So, usually the only option we have is to refer to Max Fax, which may, which is similar, but not the same. [Amanda]Mm-hmm. Yeah, no, I agree. So I think it, I think general dentists or dental professionals are well within their capability to manage this. And then if it’s recalcitrant or anything’s a little bit unusual, then I think that is worth a referral. [Jaz]Okay. Brilliant. Well, let’s talk about my medicines, I guess. The management as a general dentist that is accepted before we then talk about the angular cheilitis and median rhomboid glossitis. Yes. So please tell us. [Amanda]Yes. So there are different types of antifungals. So the earlier ones are actually the polyenes which is the Nystatin and the amphoterecin. Now Nystatin in Australia comes in Nils stat oral drop form. And I think when I looked it up online, what they had it in the UK, I think it comes in a suspension. Some places may have it in pastels. Nystatin is something that has been shown to be not particularly effective in the oral cavity. Now obviously the efficacy depends on which formulation you’re using. But in general, they’re not amazing. In Australia it is a little bit of an issue because that seems to be very widely prescribed, and I don’t know why the most weak one is the most commonly prescribed, probably for ease of use. But the problem with the nilstat that oral drops or the suspensions, is that we have issues with making sure that they stay in the mouth for long enough. Because if it’s an oral drop or suspension, it kind of doesn’t really hang in there that much. And also it doesn’t taste very nice or in some formulations they don’t taste very nice and it actually increases salvation in which further dilutes the Nystatin so I think a Nystatin is probably one that I wouldn’t recommend because it’s not particularly effective unless for some reason you decide to get it compounded at a compound chemist and they can do different things, like different suspensions, different coating agents to make it stay in the oral cavity a little bit longer. But why would you do that when there are other things? So the most common one would be miconazole oral gel. The brand name here in Australia is Daktarin Oral Gel. That is- [Jaz]Yes. Same. [Amanda]Yes. Yeah. So that’s pretty easy to find. You can get it from the pharmacy and then that is what I would get patients to apply in their mouth four times daily for about four weeks. It is generally well tolerated. There are a few significant interactions which we will get into that I think people should be aware about. But in general, it’s- [Jaz]Can you just describe the general dentist, when they’re explaining to their patients maybe the first time they’re prescribing this, and yes, you can read it, but how should they instruct their patients to wear it and how might it differ if the patient’s got a denture? [Amanda]Yes. So I get this question all the time, so I actually even made a video about it. So with the Daktarin oral gel in Australia, you don’t need a script for it. So I write the name down on a piece of paper, and I give it to the patients, and I tell them that they can buy it from the pharmacy. Now, Daktarin Oral Gel here comes with a spoon. I tell them that the spoon is actually too much. All they really need to do is apply a pea size amount into their oral cavity. So depending on where I think the infection is the worst, I will tell them to put it on there. But generally I always tell them to put it on the dorsal tongue because that’s where the IT candida likes to hide. So I tell them to apply a pea size amount in their four times daily, for about four weeks. Now, the official guidelines is that they should be doing it for seven to 14 days and then continue for another seven days after the infection has cleared up. Now, I don’t know about you, but there are not many patients I know that can accurately identify when the infection is cleared up and continue for another seven days after. So just at ease. I usually tell them just do it for about four weeks. Now when they put the gel in their mouth, I tell them to leave the gel in there for their mouth as long as possible. I tell them not to eat, drink, or rinse or swallow for about 30 minutes after. So I generally tell them- [Jaz]No swallowing for 30 minutes? How? How do they do that? [Amanda]So if you have like a little bit you can, but I try to get them, cuz some people would try to get rid of the gel taste and things like that. I’ll be like, no, it should stay in there for as long as possible. A little bit of swallowing is fine, but they shouldn’t like try and actively swallow all of the gel. So I explained- [Jaz]Should they try and keep their tongue out? Like should they try and keep, stick their tongue out and leave it there? Or just, close their mouth. Okay. [Amanda]Yeah. So what I tell them to do is that, when you wake up in the morning, have your breakfast, brush your teeth, or whatever order you want to do that in, put a piece ice in your mouth, put it rub it around your oral cavity, and then just go about your day. Don’t worry about rinsing it out, leave it alone for about 30 minutes and you should be fine. Now, sometimes you may have patients who do struggle with doing it four times a day, but I sort of explained to them that candida is pretty good at hiding. You need to keep using it long enough. You need to apply it often enough for it to actually work. And most patients are fairly compliant. Now, if they do have a denture, I tell them to put it to the fitting surface of the denture. As well as a little bit on their tongue. And then at night when they sleep, because we’ve talked to them about denture hygiene already, they take it out at night so they can just apply it directly into the oral cavity. So that’s typically how- [Jaz] So just before you sleep is a good time to also apply. Maybe that fourth time should be just before they sleep. [Amanda]Mm-hmm. Yep. So dinner, brush your teeth, apply, you can go to bed if you want. [Jaz]And do other, there any studies looking at their efficacy of Daktarin? I mean, how effective is it in terms of as a medicine? [Amanda]Yep. So Daktarin Oral Gel is actually pretty good. So there are other ones that we can talk about, which will include the fluconazole mouth washes and the amphotericin B lozenges. Those ones are actually better for adults, but Fluconazole mouth washes in Australia has to be compounded, so that’s quite a bit of an expense to get a compounded fluconazole mouthwash. The amphotericin B lozenges is great, however, so amphotericin B is a lozenge. Amphotericin B is called Fungilin 10 milligrams and it comes in a little pastel that the patients suck on, and they do that again four times a day. I usually tell them to do it for about four weeks. It can leave a bit of a yellow stain on the teeth, but it’s temporary that will come out. And amphotericin B is my choice. If cost is not an issue because it’s only covered partially here by the government, so in terms of costs, I generally will go Daktarin oral gel unless there’s a reason for them to go to amphotericin B. The other thing as well, which sometimes patients don’t, like it’s obvious to us, but not really to the patient. They don’t take their denture out when they’re sucking the Fungilin lozenge. So you have to make sure that they are happy to actually have their denture out when they’re sucking it, cuz the lozenge takes about 30 minutes to dissolve. So we all have our those patients who won’t sleep without their dentures. Their partners have never seen them without their dentures. Sometimes it’s a bit of a big ass to get them to take it out so often during the day. So in those cases, I’ll just do Daktarin Oral Gel cuz they will be a little bit more compliant for it. In infants though, in studies, the Miconazole Oral Gel is actually shown to be the most effective. [Jaz]Is that concern is, you say that Candida is a disease of the diseased and a child having it and diagnosing it. Is that a reason for referrals of GP to get investigated for a child? I mean, I’m thinking like leukemia, I’m thinking things like that, or is it a common thing that it’s not worth worrying about too much? [Amanda]I think it’s worthwhile to treat first and see how they respond. If it’s recurrent or coming very frequently, then definitely investigation is needed. But they used to call it the disease of the diseased, but we know that it happens in higher numbers in the very young and the very old as well. So I think if it’s just a once off or not happening too often, I don’t think it’s too bad, but if it keeps coming back, then it needs to be investigated. [Jaz]Okay. Any other medicines that you think are worth mentioning for GDPs? Like the fluconazole you said is a mouthwash, right? [Amanda]Mm-hmm. [Jaz]But you has to be compounded, you mentioned that one already. So it’s a bit trickier if, are those all in terms of GDPs needing to know? [Amanda]You can do fluconazole capsules, so you can give them 50 milligrams of fluconazole that they can swallow and they can do that for up to a week. I think if you’re getting to the stage where giving them systemic fluconazole. I think that one you’ll have to do a little bit of reading up. Like I still think it’s fine for general dentists to prescribe it, but obviously giving something systemic versus giving something topical, there will be more interactions. Actually, we need to talk about the interactions for miconazole and I suppose for fluconazole as well. Mm. [Jaz]Let’s do that. [Amanda]Because one of the things before you give the patient Daktarin Oral Gel and this is the time where it is definitely worth spending going through their medical history with a fine tooth comb as well. So if they are on a statin, you need to be a little bit wary. And if they are on warfarin or even some of the newer anticoagulants, you have to be a bit wary as well. So, miconazole can potentiate the action of warfarin. So patients can actually bleed a lot more even with the newer noac. So Rivaroxaban also has that action. Sometimes there is a little bit of a concern in the hospital department if you need to treat the patient with an antifungal, are you able to give them miconazole or itroconazole or fluconazole, or do you need to change them on their blood thinning medication? So I think that’s something that needs to be considered. Not to say that if I have a patient with Warfarin, I would never put them on Daktarin. But I think that’s something that should be done at specialist level. So Warfarin- [Jaz]I think, yeah, as a general dentist, I think as a rule of thumb, as a general dentist, anything that ends in -azole if they’re at risk of bleeding or on that kind of medication that makes ’em bleed more, or as you said, they’re on a statin. Is it a rule of thumb? Say avoid miconazole avoid fluconazol? [Amanda]Yeah, and also probably your benzodiazepine, cuz it can lead to long lasting sedation. [Jaz]Okay. [Amanda]So those are probably the ones that I will avoid if the patients is, if you want to put them on Fluconazole or Miconazole or the azoles basically. [Jaz]And so maybe go for the Nystatin suspension in that case. [Amanda]I would probably go for the amphotericin B lozenges first because I think that they are still more, they are more effective. One of the big issues with Nilstat oral drops, if that’s the formulation that’s available to you, that there were a couple of studies done and it’s about 50% sugar. So some patients can run into an issue. So say if they have salivary gland, hyper function, maybe they’ve had neck radiotherapy, they need to be on long-term antifungals. And you give them Nilstat oral drops that they use every single day, they’re going to get ringbark caries. They’re very high risk of dental caries. So generally on the whole, I would prefer amphoterecin B rather than your Nystatin oral drops. [Jaz]Amazing. We’re going to now do a segment of the podcast where it’s going to be about roughly a minute long, so good luck. Okay. We’re going to make an Instagram reel out of this. Okay? So, I’m going to get you to summarize everything you said. Okay. If the patient has this, you’re going to prescribe miconazole, but weary of this, this, this. Second choice is this, but then watch out for this. So try your best. It’ll be a very fun Instagram reel to make. So, Amanda, over to you for the real guideline for GDPs prescribing antifungals. [Amanda]So this is not exhaustive if a patient has oral candidosis. You can put them on Daktarin oral gel, otherwise known as miconazole oral gel. You do have to be careful if the patient’s on a statin. You do have to be careful if the patient’s on Warfarin or Rivaroxaban or if they are on a benzodiazepine. Second option, you can put them on Fungilin 10 milligram lozenges, otherwise known amphotericin B lozenges. You do have to be where it can cost temporary staining and it’s not safe in pregnancy. And also for denture wearers, they have to take off their denture. Yes, don’t forget to reinforce denture hygiene and keep an eye out of any systemic contributors. [Jaz]And then third choice would be the Nystatin but generally you think with the first two, the azoles and the amphotericin B generally we’re going to be okay. [Amanda]Yeah, I would put near step pretty low. I don’t know. Can you splice that together into a minute? I hope so. [Jaz]Yes. Yes. That was way shorter than a minute. That was perfect. [Amanda]Oh, very good. [Jaz]That was really good. That was really, that was brilliant, Amanda. I love straight talking guests like you. I love guests like you, who’s like, duh, this is what you need to know. Boom, boom, boom. You’re like an encyclopedia of all medicine. I’m so glad I’ve connected with you. This is amazing. So, I guess the final part then let’s tell the GDPs about a common thing that I see, well, I say common, but like probably like in the scale of commonality, like more common than a dental trauma, like more common than evulsion coming in, but less common than a lot of the other things we see. So angular cheilitis and median rhomboid glossitis, what is the thinking? Any difference in terms of what you explained so far when we’re coming across these issues? [Amanda]Yeah. So first off, let’s start with angular cheilitis. Cause I think that’s probably going to be the most common one that people see. If you see angular colitis, you need to consider why that has happened. And so I think- [Jaz]Can you just describe for the student maybe what it actually is? [Amanda]Yes, sorry. So, angular cheilitis is usually crusting erythema or ulceration involving the bilateral commissures of the lip. So you can actually see that they usually have retinas at the corner. Sometimes patients may describe it as a rash or a ulcer. Sometimes they may even tell you that they keep getting cold sores at the corner of their mouth. But what they’re really describing is angular cheilitis. [Jaz]Does it always have to be bilateral? [Amanda]No. It can be unilateral as well. Good question. Okay. Yeah. So angular cheilitis is something that we see fairly commonly. I think one of the really great things for a dental professional to pick up is actually if there’s loss of vertical dimension. Have they had dentures for 20 years and is it about time to get them new dentures? But it is thought to be a polymicrobial infection. So the candidal species and also staph aureus and things like that have been thought to be associated. So first thing I would do is do all of the basic things that we talked about, about making sure that there’s, or identifying any obvious systemic contributors. So, checking are they anemic? Are they taking their denture out at night? Are they rinsing their mouth out after using a steroid puffer? And then if all of that is maintained and you’ve optimized that well, then you can get them to use a medication that they can apply to the side of their lips on the outside. Now, there are a couple ways to do this. One of it is that if you suspect that they have an oral candidal infection, as well as angular cheilitis. You can actually try getting them to use something like the Miconazole or Daktarin Oral gel. They can apply it to their tongue four times a day for four weeks that we talked about. They can also put a little bit on the corners of their mouth and they can see if it clears up. Now if it doesn’t clear up, because sometimes, as I say, it could be polymicrobial and obviously the Miconazole only works for fungal infection. You can apply something like Kenacomb which basically has a mild corticosteroid, a antibiotic as well as an antifungal. So there are similar formulations where you can get these types of medications that have multipurpose, and they can apply a little bit on the corner of their mouth. You can do clotrimazole as well cream which you can apply to the corner of the mouth. Now, I do want to- [Jaz]And these are all GDP friendly, you think, or this is something that we should be referring to you guys for okay. [Amanda]No, I don’t think so. Yeah, I think, I mean, I think if you do suspect that oral candidal infection, just starting off with the miconazole oral gel is probably the easiest. Sometimes if I do suspect that the patient has nasty or what I think is like not like the angular cheilitis is not going well. Then I might get them to use miconazole oral gel in the mouth and put them on Kenacomb extra orally. But I think, this is something that I think is fairly safe, but there is one word of caution that the patient shouldn’t be using steroids on their skin for too long. So if you give them Kenacomb which has the antibiotic, the steroid, and the antifungal, you want to make sure that they stop using it after a while because steroid can actually atrophy the skin. So it can actually make it a little bit worse. So if it’s something like Kenacomb I get them to do it two to three times a day for about two weeks. And then once it clears up, I tell them, make sure you stop. Don’t keep applying a steroid on your skin cuz it can make things worse. So that’s generally how I would approach the angular cheilitis. Median rhomboid glossitis I would approach fairly similarly to how I would with the rest that we just talked about there, they can apply the daktarin oral gel into their oral cavity, same as the denture dermatitis. But probably one of the things to know about median rhomboid glossitis, and the denture dermatitis, sometimes after treating them, it may not go away completely, so that little diamond shaped erythema on the dorsal surface of the tongue may actually stay there even after you’ve treated the fungal infection. Another thing is that it’s actually really common to get erythema of the hard palate based on a poorly fitting denture. So if you’ve treated the patient for an antifungal and the surface of the hard palate still looks very red, you need to consider if the denture is rocking and causing trauma and causing erythema, or if you’ve got something in there that needs referral. [Jaz]Very good. I actually remember so random things you remember from Dent School. Remember Prof. Nick Martin telling me that sometimes with a denture and you’ve got patients got recurrent denture dermatitis that they may need the denture rebasing cuz apparently the candida actually goes into the acrylic is from I remember. So how successful is just miconazole And then it gets better with improved oral hygiene or sometimes if it’s persistent, such a thing as rebasing and or replacing the denture. Is that something that’s accepted? [Amanda]Yep. So the thing that I would like to bring up there is actually how you’re giving your patient the denture hygiene instructions cuz you may, like in Australia here, there was a little bit of discussion around the fact whether when the denture is removed at night, whether it should be kept in water, whether it should be kept dry. Cuz some people argue that taking it out and leaving it dry at night will change the dimensional stability of the acrylic. And I think someone then published a paper and said that it was very minimal. So what I tell my patients to do when they take their dentures out at night is to give it a good clean not to use toothpaste cuz it scratches the acrylic and gives more areas for the candida to colonize. But to use something like dish soap and a very soft brush, give it a really good clean rinse it, leave it dry overnight. Now, in most cases, by leaving it dry overnight, you should be able to reduce colonization of the candida by that. And then also, don’t forget, you’re also applying like the miconazole oral gel directly onto the denture itself. Now, in some cases, if the patient is due for a new denture, it’s poorly fitting. It’s not up to par. Then I think replacing the denture or relining the denture, if it rocks or if it doesn’t fit well, I think it’s perfectly justifiable. [Jaz]Amazing. Wow. So a 40 minute mark and you’ve literally blasted antifungals and all those things. I’m so happy. I think everyone’s going to love this. I think the Protruserati chopping onions right now are going to feel much more confident now about diagnosing and managing of fungal infections of the oral cavity. Is there anything else that you think we need to noteworthy for the general dentists who are tuning in, either on YouTube or the app, or listing in on Spotify? [Amanda]No, I think we’ve covered Oral Candida quite well. I mean, there are some things that are out there right now about emerging resistance of bacteria and fungus and medications that we do use. So if something feels a little bit funny, if it’s not going well, or if it doesn’t heal right or it keeps recurring, then I think that’s definitely a good thing to consider referring. I think this is also dependent on where you are, but I think getting to know your local oral medicine specialist is actually a good idea as well cuz I think it’s very common and I certainly felt it when I was a dentist as well. You don’t know whether these cases need referral or not. So if you are friendly with your local specialist, you can open up the doors to conversation. You can ask them, hey, I’ve got this patient, do you need to see them? And I think in most cases, if it’s something that we feel that is very, that is completely fine for a dentist to manage. We will talk you through it. So I think, dentistry is all about community, so make connections and get to know your local specialists too. [Jaz]Yeah. There’s a shortage of, I don’t know. I feel there’s a short shortage. There they’re few and far between. So it’s good to find these guys and be able to lean on them for advice and guidance. And I think you have provided so much advice and guidance in just a clear manner. So thank you so much. Where can we learn more from you? What are your channels to follow you on and to absorb all this wonderful helpful content that you’re generating so we can help our patients? That’s ultimately, that’s what it’s about. How can we serve our patients in a predictable manner? How can we learn more from you, Amanda? [Amanda]Oh, thank you very much. So, I do have an Instagram page that’s called, Oral Medicine, Oral Pathology, and then on Facebook, it’s a spoonful of oral medicine, so I’m the same as you. I do love talking and educating. So I do put up a few posts on things that I think people will, or hopefully people will find helpful. [Jaz]I can vouch for it. When I saw your page, I was like, yes, this is who I want. Come on Protrusive to talk about all these things all medicine. So I mean, thank you so much. I will have to invite you back cuz I loved it so much. It was so direct. One of my team often worked together and we make these infographics and stuff, so, I’ll be able to short set, send it to you for you to get your seal of approval so you can share it with everyone. It’ll be a nice summary for everyone cuz there’s a lot to grasp. But if you can make it into an infographic, which you will, it’ll be really nice for them to follow and that’ll be yours because that’s your work based in your delivery of the content. And I look forward to making that real and sharing as well. So, Amanda, thank you so much for giving up your time today. We appreciate it. [Amanda]Oh, not a problem. Thank you for having me. I had a really good time. Jaz’s Outro:Well, there we have it, guys. Straight talking Amanda did a fantastic job at breaking down. I think that’s it, right? We’ve absolutely smashed antifungals. You know what to prescribe now, and you’ll have the infographic, which you’ll download of course. And if you are a Protrusive Premium member, you don’t need to download anything. You don’t need to sign up for anything, you just head over to the app. The Protrusive Vault Section where we’ll find hundreds of PDFs and goodies. And of course you’ve got a premium monthly content, which I’m adding to, and we’re loving it. And of course now the OBAB, my occlusion course is published and I’m not having to dedicate my entire life to that occlusion project. I can feed the app a lot more now. So thanks so much for sticking with me, but the best is yet to come. And thank you for listening all the way to the end. I’ll catch you in the next episode.

May 31, 2023 • 38min

Occlusion on Class IV Composite Restorations – PDP150

What should the occlusion look like when you are restoring or replacing a Class IV restoration? This question is so basic yet so complex which is often not talked about enough. We go on all these composite courses and talk about the layering, but we don’t talk enough about how to put the principles of occlusion into action. In this episode, Dr. Ibrahim will be talking about how Class IV Restorations can be optimised to get a long term predictable result. We also shared the two mechanical failures in dentistry and the step-by-step process of a Class IV restoration with occlusion in mind. https://youtu.be/JgbO6PDjSOg Watch PDP150 on Youtube The Protrusive Dental Pearl: Occlusion Whisperer – Ask your patient to bite together and listen – in a “good” occlusion you should hear lots of tooth-to-tooth contact, whereas a thud indicates an issue. Use this in addition to more traditional methods of assessing the occlusion, and make sure you are satisfied with the occlusion before asking the patient “how does that feel?” Are you ready to learn Occlusion in a way that makes sense, in your own time, with first class support and career boosting confidence to deliver Restorative Dentistry to the highest standard? Then join Occlusion Basics and Beyond Online Course with IAS Academy Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 00:49 The Protrusive Dental Pearl02:23 Dr. Mahmoud Ibrahim03:07 Class IV Lesions07:21 Mechanical Failure09:28 The “Envelope of Function” and “Chewing Space”13:50 Dealing with Limited Chewing Space17:49 Mock-Ups19:35 Dots and Lines21:14 The Process If you enjoyed this episode, check this another episode by Dr. Mahmoud Ibrahim, Next Level Occlusion (Basics Part 2). Click below for full episode transcript: Jaz's Introduction: What should the occlusion look like when you're restoring or replacing a Class IV Restoration? It's a really interesting question actually. Like it's so basic, yet so complex. Jaz’s Introduction:So we’re going to make this topic, which is often not talked about enough, and like we’ve got all these composite courses and they talk about the layering. But we don’t talk enough about how to put the PRINCIPLES of OCCLUSION into action on your Class IV Restorations to actually get a long-term predictable result. Hello, Protruserati. I’m Jaz Gulati, and welcome back to PDP150. We’ve got over 200 episodes of Protrusive now with you, include the Interference Cast, and all the other branches of the podcast that we do. Thank you so much for joining me time and time again. If you’re new to the podcast, welcome. You picked a really interesting and fun topic to join us on today. Protrusive Dental Pearl:Now every episode I give you a Protrusive Dental Pearl. And of course it’s going to have to be an occlusion one. Okay, so this is something I learned in my time at GUYS Hospital when I was at DCT. This was like nine years ago now. And it is when you’re checking the bite, do you listen to the bite? Now it sounds really funny, but we check tactile, we check with the shim stock foil or the articulating paper. We check visually because we see the ink marks on the teeth. We could check with our fingers. When you bite together, you feel some pressure, feel some vibrations on the teeth. These are all methods of checking. The occlusion is something proud, is it not? But sometimes a really good thing that I like to do routinely after restorations is just listening to the bite. I tell my patients, I’m the occlusion whisperer. Okay? So I come up by their teeth and I say, ‘can you tap your teeth together like this?’ And that’s what a good occlusion sounds like. Okay. Lots of teeth hitting together at once. If there’s a thud, then you know that you are proud basically. And this is a really good additional tool that you can use. The very last piece of information that you gained from the patient is, how does it feel? That’s not the first thing. Usually we are guilty of doing our restoration and saying, we are usually guilty of restoring the tooth. Then asking the patient straight away, how does that feel in the bite where really we should do all our checks, make sure we are satisfied, and then the very last piece of information we collect is, how does that FEEL? Because remember, that’s subjective. Whereas if you are using objective data, then that’s much better. Often helps if you listen to the bite beforehand if you are new to doing this. Main Episode:Anyway, let’s join Dr. Mahmoud Ibrahim and I’ll catch you in the outro. Mahmoud Ibrahim, my occlusion brother from another mother. Welcome back to the show, man. How you doing? [Mahmoud]Yeah, I’m good, man. I’m good. Thanks for having me again. [Jaz]Dude, I’m so pumped because now obviously OBAB was launched. It was the most difficult year of our lives and I think we’ve talked about that already, so we won’t bore everyone about that. But today it’s a really cool occlusion topic that Dr. Humer on the app sent in. So, on protrusive.app, on your browser. Or on iOS, Android, there’s a community section within the app. And Humer who’s actually a delegate of OBAB, actually she’s a delegate of OBAB. Yeah. But she’s done a few with the first module and she’s like, actually, I’ve got a question. Maybe you cover it later in the course, but I just want to know, and she asked basically and I’m going to get up the actual full question. Okay. So Houma said, ‘Hey, Jaz, I’m enjoying OBAB so far, but my question, which I’m sure you’ll probably answer in the next few episodes, when restoring Class IV Lesions, okay, so Class IV guys is something that involves incisal edge and the facial often, and the palatal. So a fair chunk of an incisor, an anterior tooth could be an upper or lower. For example, you check the occlusion beforehand, dynamic and lateral excursion, what is our aim in order to avoid early occlusal failure? What shall I actually look out for when checking the occlusion once the restoration is complete?’ And so Mahmoud, this question, it could almost be like an essay question in a dental exam, because it’s not like a one or two word answer. You can literally philosophize and debate, which is what we’re going to do today, in the next 26 and a half minutes. And I got pumped and I wrote a little answer for little, it was a little bit longer than little, and then you wrote an answer and we thought, okay, this would make a really fun, fun for me and you, podcast episode about what should the occlusion look like on a Class IV Composite Restoration? So I guess where do we begin? And I think the where to begin is, I thought Mahmoud, like what is the reason for actually replacing that Class IV incisor, right? [Mahmoud]Yeah. I mean, so ultimately, it’s actually a fantastic question because we all know occlusion courses tend to go on about full mouth rehabs and stuff like that, but this is the nitty gritty that we all do day in, day out- [Jaz]And no one talks about this. No one talk, even on the composite course I’ve been on, they show us how to layer. It’s so crazy. Actually, they showed us how to layer the Class IV, use 17 different shades and tints, but no one actually said what the dots and lines should look like. [Mahmoud]Exactly. So this beautiful layer of composite is going to break off because you haven’t paid attention to the occlusion. So it’s a fantastic question. And what I love about the question is that she’s already mentioned the fact that she’s going to check the occlusion beforehand because I think that’s where you need to start. That also is never talked about. You can’t check the occlusion afterwards if you don’t know what the existing inclusion is. So it’s good to at least initially, let’s say we’re going to be doing this Class IV, because there is caries, there’s a trauma fracture existing. Class IV has failed. Maybe just aesthetically stained- [Jaz]But let’s talk about that Mahmoud one second on, there’s so many different facets of all the different reasons why you might do a Class IV Composite Restoration. But, the easiest one, maybe just to tackle straight off the bat and just tick off is the one that’s been there for 17 years and it was used to be an A1 and now it looks like an A6, right? And otherwise it looks completely unworn. The composites, it looks good still, the shape is good. The patient’s happy with the shape. It’s just the shade you want to change. And if that composite in that mouth has survived all those years, then the answer is very simple. Whatever the dots and lines look like beforehand, you just completely replicate it and that’s why you make your putty and you change it over. So that’s the easy one to tick off. And I guess the other easy one we can just really quickly tick off before we get to the more complicated ones is if your patient has an anterior open bite. You could even make a 3D composite initial of your name on that composite, and it’ll still be okay because a patient has an anterior open bite. Okay? So patient’s not occluding functionally or para functionally on that Class IV. So I’m not saying do that because it’ll feel strange to their tongue and stuff. So really with with AOB cases and you’re not doing anything about the anterior open bite, then you can get away with anything and just pretty much copy what’s there before. Or roughly follow the contours or what an incisor should look like. But the main lesson is if the composites has been working well and it’s an aesthetic failure, then copy all the good features and just change the aesthetics. [Mahmoud]Okay. So those are the easy ones. Now, the more difficult ones are the ones that the patient has walked in either with a fracture or an existing composite that’s come off, especially the ones that the patient walks in and he says, this is the third time this has come off in a year or whatever. Those are the ones where you got to be careful and start thinking about why has it come off? Why do we now need to start thinking maybe slightly differently? But yeah. I was just going to say, one important thing to say is that at the moment we’re conforming to the existing occlusion. Okay? So when you’re just doing a single Class IV on a patient, you’re not going to be changing the rest of their bite. You’re going to conform to the existing occlusion. Now, as we say, as well in OBAB, doesn’t mean we’re going to blindly copy what’s there. Sometimes we can idealize the situation and sometimes the reason it’s failing is cuz no one’s bothered to look at what the occlusion is doing to it and idealize it. [Jaz]Absolutely. And this is a good point, maybe Mahmoud to mention as something I talk about which a lot of the stuff I talk about is completely stolen and borrowed and regurgitated because I’ve learned so much from my mentors and I pass it on to you guys on the podcast, listening and watching right now. So, very few bits of what I say is original, and I’m happy to say that. This bit I think is my own thinking. Maybe everyone’s thought it, but the whole thing about there’s only two types of mechanical failure in dentistry. That’s it. There’s tooth to tooth. And tooth to something else. So assuming the tooth to something else bit is something you educate your patient. It’s out of your control, but you educate your patient. So what I mean by tooth to something else is tooth to fingernail. Yeah? The fingernail will win. Tooth to sellotape being cut between your front teeth, tooth to ice. I made an Instagram reel recently. I mean, we might have seen it. Okay, so ice chewers are dangerous. Crazy people. Okay? So you need to inform them. Even if you’ve got like a resin bonded bridge or quite a fragile, large Class IV composite, you do not want your patient to bite on their crusty pizza or baguette directly on that tooth and tear it or corn on the cob. Another dangerous thing to attack with your bridge or a adhesive restoration, right? So assuming the tooth to something else, you’ve educated your patient. The only other cause of mechanic failure is tooth to tooth. And so when we talk about tooth to tooth, we can branch it into two different things. There is functional failure and then there’s parafunctional failure. [Mahmoud]Exactly. So the way you want to check whether you think the patient’s occlusion is pathologic or physiologic. So we’re going to look at the rest of the dentition. You can’t really just look at one tooth, you’re going to look at the patients, the rest of their teeth. Is there signs of wear, cracking, fracture on the other teeth? If there is, you know, the patient’s doing something weird. They’re grinding teeth. They’re doing something that they shouldn’t. It’s a parafunctional movement. And then when we talk about, I believe you had a whole episode on constricted envelopes, constricted chewing pattern envelopes. So again, if the envelope of function isn’t respected, you’re going to have excessive forces, especially on the upper incisors, and that can lead to early failure of your restoration. [Jaz]Let’s break that down, Mahmoud. Okay. As someone who might have never heard of OBAB before, never heard, never seen our previous episodes on occlusion, which we haven’t actually talked about the envelope of function so much in our previous episodes. We really boiled down even more fundamental than that. But what is the Envelope of Function? Let’s just talk about that in a moment. [Mahmoud]Okay. So essentially the way we chew isn’t just down to your teeth. So you’ve got your neuro muscular system, your muscles fire in a particular way. You’ve got ligaments that are particular length, the bones of the jaw, particular length. So the jaw has essentially this pattern of movement. This what we call sort of on OBAB I call it the ‘mandibular swing’. Okay? So once the swing in a particular way. Now if their teeth happened to be in the way of how the muscles want to move the jaw, you could accidentally be bumping into these teeth a bit more than you should, so you’re adding extra force onto the teeth. But essentially the envelope of function is that movement that the mandible wants to do when you are chewing a sandwich, when you are speaking, when you’re swallowing, et cetera. So that’s sort of built in and what you want to do is not put stuff in the way of how the mandible wants to move. [Jaz]I like to call the envelope of function, the ‘chewing space’. The worst, I mean, the patient we can think of, which has got trouble written all over it is, the patient who’s almost edge to edge Class III, but not quite. So maybe they have like, one millimeter overjet, like the lower incisors are right up against the palatal of the upper incisor. Okay? So when this patient is chewing, they don’t have much chewing space. So as they make that teardrop shape anteriorly, if you trace the movement, it’s just classically a teardrop, right? And so as they open, they come forward, the mandibular swing, and then they come back. And what we have here is a high frequency, low intensity, because functional force are lower than parafunctional, but they’re still 30, 40% of your maximum force. They’re still decent. So if you’re constantly chewing, chewing, chewing during the day, during from eating and all the other functional things that we do, every time you swallow your teeth comes together and they’re constantly bashing, then something is going to happen. Either teeth will wear, teeth will chip, teeth will migrate. Right. Mobility and movement over time. And that depends on the patient’s own genetic and biological, I guess the weakest link factors, which is something else we talk about. But envelope function is a chewing space. And so the classically, if you have this patient, just like you said, who’s broken their Class IV Composite three times in a year, and you’ve looked everywhere else and you think that, okay, there aren’t many cracks and there aren’t much signs or parafunctional grinding. You got to look, how much overjet do we have? Is it potentially a restricted envelope or a constricted envelope, or a frictional chewing pattern? All these things we’ve talked about before. But essentially it boils down to there is not enough chewing space. [Mahmoud]Yeah. And the only way you’re going to pick that up is if you look, I mean, I’ll admit too, in the first few years of practicing, sometimes I’ve restored a tooth and then got the patient to bite, and then realized that, okay. There’s just no room for my restoration. Or even more embarrassingly, there’s no opposing teeth. You’re getting the patient to check the occlusion and there’s no opposing teeth. So really it’s about checking beforehand. And we talk a lot about checking for fremitus as well. So even though physically you might look and there might be space for your restoration, it’s very important. So what fremitus is, is when you take your finger, then you put it so on the facial surface of a, say an upper incisor. And you get the patient to tap their back teeth together, you’re just getting them to bite into MIP just asking them to tap, tap, tap. So what you’re checking for is you’re seeing whether you can feel that tooth sort of vibrate and sort of get pushed out a little bit as the patient taps together. If that’s the case, it might indicate that actually there’s just a little bit too much force on that tooth. So maybe it’s in the way of how the mandible wants the bite together. You also want to check fremitus for when the patient grinds forward, grinds side to side. Again, you want to feel, is that tooth being pushed out as the patient’s grinding? Again, is that tooth taking a bit too much of the load when the patient grinds side to side? That’s sort of my preferred way of checking the envelope of function. I think you also talk about doing the dinner plate test, which is something we show, but that’s really, really important and something that’s not really told very well. And you want to check that with the patient sitting up as well as lying down. Cause we don’t usually chew when we’re lying down. [Jaz]Exactly. And so when you’re doing these functional checks, it’s sitting up when you’re doing the para functional checks, it might be when the patient’s laying down, you’re completely right. Now let’s talk about the, just finish off this chapter of is there enough chewing space? Let’s assume there is not enough chewing space and you’ve come to the conclusion and then you’re going to now communicate this to the patient and you’re going to get your hands out. You’re going to show them what’s happening, you’re going to take some photos. Ideally, we know the answer is orthodontics, right? To create some overjet and that kind of stuff. Create some overjet, create some chewing space, and then we can restore the case. But let’s talk about some cheat codes. Let’s talk about some ways that perhaps we could do it. Now, some of these are kind of regarded as naughty ways of doing it, but if the patient’s point blank, not going to have orthodontics and you got to stick something there, maybe they’re getting married tomorrow, then what can you do to make sure that by the time they walk through the door, this composite’s going to survive? So, any tips you can give us? [Mahmoud]Survive the honeymoon. You going to put the Robin Hood analogy. So, one way is look at the opposing teeth. A lot of the time in these constricted envelope cases, because the teeth have been sort of rubbing over time, not only have you chipped the upper composite, but that lower tooth had this like sharpened edge, this sort of angular wear on the facial. You end up with a very thin edge, which then chips and leaves like these little short bits of enamel stick in it. So you can do yourself and the patient a favor. And just adjust those. You’re creating a little bit of space by taking away a little bit from the lower, giving it to the upper as per your Robinhood analogy. So that’s one way to do it. And then, I mean, already we said that the ideal is ortho, but if they’re not going to do that, if you can’t take away from the lower. Then really you’re the only other option is you’re going to have to create room by repositioning the mandible, by opening the bite, but then you’re into far more complicated territory. So the cheat code is look at those lower incisors and see whether you can maybe do a little bit of enamel plasty. I usually tell the patients I’m going to manicure your lower teeth, tends to leave them nice and smooth and they like it. [Jaz]And I think getting the mirror out and showing the patient and getting your probe and saying, look, can you see that this lower tooth is sticky outy and your upper tooth is sticky in? Right? And they get that. Usually it is the way, right. They can see that there’s no. Chewing space. And they say that, okay, if you know you’re getting married tomorrow or whatever, and ideally, and you need to plant that seed, ideally it’d be really good if we can just bring this upper tooth out and bring this lower tooth back in so that everything is going to be nice and straight. You’ll have a beautiful, healthy smile and these filling will actually not keep breaking. This is why it’s been breaking. Mrs. Smith, can you see this? Can you see that it’s getting in the way and that’s powerful for patients. So then what you to then get is consent for, look, the only way I can resolve this now for you and make sure it survives your honeymoon is I’m going to tickle, I’m going to manicure the lower front tooth just a tiny bit with this little disc, just mostly to get rid of any sharp, annoying bits. And then what you would also do perhaps in the upper opposite is, and this you show that you demonstrate is beautifully on the course is bringing out the composite, a little bit more labially so you want to bring it a little bit more labially. Now this has other nuances like, okay, are you now going from a Class IV? Are you now veneering it at the same time? Because you need to have enough thickness because if you make it too labial, you’re going to have too thin of an edge, so you need to then beef it up labially and then it becomes from a Composite Class IV, it comes a class IV Stroke, Composite Veneer. And sometimes that might be the right way to go if the patient’s not going to have ortho, I guess. [Mahmoud]Yeah, I mean, probably one of the biggest reasons for failure in Class IV Composites is not leaving enough thickness of composite. You want it to be at least a millimeter thick buccal lingually, especially on the edge. Bringing it out facially does have some aesthetic implications, especially if you’re just doing the one tooth, but it’s usually better than not having anything there at all. And if you are on a strict timeframe, a lot of people would rather just have a front tooth, even if it is maybe slightly, you’re not talking like half a millimeter labial, or you can do a mockup, show the patient. And say, look, this is if I can’t make it look like this, it’s just not going to work. With the adjustment of the lower tooth. And then they have to make a decision ultimately. Ortho’s usually the best idea, but sometimes we’re stuck and we have to deal with the situation we’re giving. [Jaz]With mockups what I like to do is use a, I have got a whole stash of expired composite. Listen, if anyone around the world has got some expired composite, post it to me. I’ll give you my address. Just send it. I use a ton of that stuff, right? And certain samples I go to like dentistry shows and stuff, and I just click all these composite samples I’ll never use, but I use it for my mockups, right? So you put it there, you use the ‘optrathumb’ and you get it looking as you want to, right? And then once you cure it again, this is no etch, no bond. The most common question I get when I talk about this ahead. Do you etch it? Do you bond it first? No. You don’t need to etch it, bond it just get a nice dry tooth and put it on, sculpt it. I love to use my KC3C instrument, which you’ve seen me talk about before. And I get roughly the shape, which I think will respect the chewing space, but also get decent aesthetics. I cure it and now can check the occlusion. And make sure and I can even get a rugby ball, diamond bur and adjust this composite and adjust the lower tooth if appropriate. And then now I can take a putty of this scenario. Now, even though in this perhaps emergency appointment, I’m not layering, I do actually do 99% of my dentistry one shade wonder. I’m a one shade wonder kind of guy, right? I know you are very skilled at layering and stuff. I’m a one shade wonder kind of guy, so I’ll just stick in the one shade. It’s all we need exactly. Now, even though I’m not layering the benefit of the putty is that I can just whack it on, do my etching bonding, whack it on, and just get plenty of paste on there and just sculpt it and not have to worry about the occlusion afterwards. It’s just polishing afterwards. [Mahmoud]Yeah, and that’s what you should be doing as well. If say, the other scenario you’re talking about where we’re replacing a Class IV, that’s just cosmetically failing. Everything else is fine. You’ve got all the data that you need. For the occlusion, everything right there. So I think it’s an underused technique really doing mock-up takes. I’m in it, five minutes if you’re just starting out. [Jaz]Okay, Mahmoud, let’s now talk about the final bits, the technical bits, right? Let’s talk about the dots and lines. I know you’re going to talk us through a little step by step, which will really make it tangible. But as a quick tip here is if you’ve got, let’s say, two dots on an upper center incisor from your lower incisors, right? And I’m okay for a dot be on my Class IV Composite, but if for some reason it’s a very fragile composite, then I’ll make sure that dot is a lighter dot or no dot. Okay. As long as there is another dot on there. And then now we got to talk about something really important is that if the patient had an incomplete overbite i.e. there were no dots, the front teeth weren’t touching, then that’s fine. That makes your job a lot easier in terms of dots. But if they started off with some dots, it’s good practice to have a dot still. So if you’ve got a couple of dots, one on the composite, one on your enamel where the tooth is unrestored, then the dot on the composite on tap, tap, tap will be a little bit lighter. So maybe the, the dot on the enamel will hold shim. Shim is eight microns. We use it, check the occlusion, and the dot on the composite will pull, just pull shim so it’s lighter. So that’s good practice. And then if it’s a really fragile composite, we check for protrusive and excursion left and right, and often you are going to accept having a line on your remaining enamel, but maybe the line on the composite will be much lighter again, because remember, what we are doing is we’re sticking a piece of plastic to some tooth that’s going to be subject to sheer forces. So really it can’t do as much work as what your natural tooth can do. But what I’ma let you do now is, talk about the step by step of actually getting to that scenario. [Mahmoud]Yeah. So as the person who asked the question said, I’m going to check the occlusion beforehand. So that’s where we start. Okay. So we’ll go through this in detail on OBAB, but essentially you want to make a record of what the existing occlusion is. So we’re going to check that the patient has a repeatable MIP, right? We’re going to check, just get them to bite together and just have a look. That’ll also tell you if you have space for your restoration, is there a constricted envelope? Has the tooth over erupted? If the Class IV been there a long time, I used to check you’ve got space, not just in MIP. Get them to grind as well and see if the lower tooth then passes through the area where your composite’s going to be. Because if that happens and you put composite there, if the patient has happens to grind that pattern, They’re going to knock your composite off. Okay? So this is especially important if you’re doing edge bonding, you’re doing composite veneers, always check the excursions. Where am I going to put the composite? Is it going to be in the way of those lower incisors, like you’ve already said? We’re going to check shim stock holds. Okay? So I’ll check the tooth I’m working on and I’ll check the few on either side as well. Document the teeth that holds shim stock and the teeth that drags shim stock. So we talk about, put the shim stock in between the teeth, get the patient to close, squeeze, and you pull on the shim stock in that. If it slides out with a little bit of resistance, that’s a drag. If it slides out with no resistance, that’s a no hold. If you can’t pull it out or you tear it, that’s a hold. So document those. [Jaz]All you have to do is just tell the nurse, right, you’re doing this and you educate your nurse. This is shim. I use it to precisely check the bite. And then you are just speaking out loud while the nurse is now going to be trained to record shim holds colon, these certain teeth shim drags certain teeth. And then the rest of teeth will assume to have no hold. [Mahmoud]Yeah, exactly. You don’t have to do the whole mouth, I’ll just do the tooth I’m working on and couple of teeth, and I decide. It’s really all you need when you’re doing one tooth. Okay. Once we’ve done that, then we want to check the fremitus. So again, finger on the tooth you’re going to restore. And maybe the one next to it is on just get the patient to tap, tap, tap. Can you feel a vibration? If you can, again, you’re just telling the nurse fremitus positive, upper right one, upper right central, upper left central. But you’re checking the fremitus with, they have this Class IV cavity there, right? [Jaz]They haven’t got their composite, so your job is now, so checking their fremitus but really what information that’s giving you is their fremitus with the situation they’re in at the moment, there might not be fremitus, but when you now put your composite later, then that’s the reason you’re doing it. You’ve got a baseline recording, right? [Mahmoud]Correct. Yeah. Think about it this way. If there is fremitus already without you having restored the tooth, and then at the end you check and you haven’t checked. You don’t know that there is fremitus, and then you do your restoration and now you’re checking for fremitus and you feel, okay, there is fremitus here and you keep adjusting your restoration. And now your restorations out of contact. And then the contacts- [Jaz]Getting thinner and thinner and thinner. [Mahmoud]Yeah. And the contact’s still on the tooth and there’s still fremitus and you start adjusting the tooth. Now you’ve actually changed things because you don’t know what they were like before. Now you could end up removing more enamel. You could end up essentially unnecessarily removing tooth structure or composite when you wouldn’t have needed to. Okay. So what was important to find out what the state is beforehand. [Jaz]And also the problem with thinning the composite is even if you’re using a single shade, it becomes grayer becomes more translucent. It affects your aesthetics. [Mahmoud]A hundred percent. A hundred percent. And if it’s there, it’s weaker. And the tooth, something else becomes a problem. First time they have their French baguette again, and then we’re going to check the bite marks with some articulating paper. So, I think both of us like to do it the same way, so I like to check the excursions first. So, dry teeth, put the red paper in. Get the patient to close, get them to grind in all directions. Forward, left, right, you’re going to see some marks. And then I like to, once I’m done with the red paper, I get them to open and stay open. Put the blue paper in and just get them to tap, tap, tap. Just telling them to tap, tap, tap seems to work. That’s the one thing patients seem to get easily. Just tap, tap, tap on your back teeth. All right. And that will give you your results. [Jaz]Now those new two occlusion, Mahmoud, why are you checking the excursions first and then checking the MIP? This is a basic tip, but I think for those who aren’t doing it already, they’d be like, oh, wow. It makes so much sense. [Mahmoud]Yeah, I mean, because if you do your tap, tap first, then you’ve got your dot, and then you put the red paper and you get them to grind. They just smear the blue dot that you had everywhere, and it’s hard to tell where the actual dot is. So it’s easier to do the excursions first and then do the tap, tap, tap. [Jaz]Absolutely. [Mahmoud]And then you need to document that. My preferred method, I think it’s yours as well, is just take an intraoral camera photo, right then it’s on the screen. I don’t have to worry about it. If you don’t have intraoral camera, you could either just try and remember it or you could sketch it out. Okay. It’s really easy. Or you could describe it. You can write a note saying, protrusive contact on adjacent tooth. And really with the tap tap, you’re trying to see how far is the MIP contact going to be from my margin? Is it going to be on composite, is it going to be on tooth? And where is it relative to my margin? Because I want the MIP contact at least a millimeter away from my margin. [Jaz]It’s such a huge tip there. I mean, if you guys, if anyone here is multitasking, you’re doing the gardening, you’re running and you just missed that tip. [Mahmoud]Chopping onions. [Jaz]You don’t want your dot, your chopping onions. Yeah. Yeah. The people who chop onions are good listeners usually. Okay. The Protruserati chop onions are the best. So the dot should be either on enamel. Or fully on composite, it should not be on the interface, which just makes sense, right? You don’t want to put all this force through your poor little interface. [Mahmoud]Absolutely. And that’s why the reason you’re checking this before is cuz it might alter your prep design. So especially on Class III, for example, you might not bevel as far as the MIP contact, for example, if you know where it is, right? Because you don’t want that thin composite that’s sort of feathering down into nothing to be where all the occlusal contacts going to hit, because then that’s going to fracture, which means it’s going to stain and et cetera. Okay? So we’ve documented our existing occlusion, so shim holds, fremitus, MIP contact your blue dot and excursions, your red lines, and you’ve documented- [Jaz]That takes a minute. Like you said all these things and people thinking, whoa, you’re checking all this, you’re going crazy about the occlusion. But really all just it, it takes a minute, man. [Mahmoud]It’s so quick. It’s only quick when this stuff is ready. So your nurse needs to know, have the shim stock ready. [Jaz]Can you get the millers forceps out? Can you get the shim? So what’s the shim stock? It’s the silver one. Oh how do you open it? Get scissors. [Mahmoud]Exactly. Exactly. But if it’s ready, it literally takes a minute. Okay, so once you’re done and you’ve documented that, now you’re going to go ahead and restore the tooth. Now, if you’re lucky enough that the Class IV that’s there is just failing aesthetically, you’re hopefully going to take our advice and maybe use a putty to conform. Okay? Just make your life easier. If not, you’re going to use your digital matrix as they’re, say your thumb at the back and do whatever is you need to do. And then once you’re done, that’s when you’re going to check the occlusion, and now you can actually check it against the pre-op occlusion that you’ve documented. And for a Class IV, the way I like to think about occlusion, I think this is how we do it in OBAB, because occlusion could be very, like, it’s such a big topic. Right. When people start getting confused, just break it down into five occlusal positions, and you can do this with any restoration anywhere in the mouth, and you’re going to think about five positions. Okay? Position number one is your centric relation. So if we go back a little bit, we did this in occlusion part two together, right? We talked about centric relation, but essentially- [Jaz]And we talked about it in the last tooth in the arch syndrome episode. [Mahmoud]Yes. Yep, yep. So lots of stuff to go back and listen to. If this quick description isn’t enough, but it’s essentially when the condyles are fully seated in the socket, in their snug position. [Jaz]I think let’s skip over CR buddy cuz we can just talk about five hours for CR. So in this case we know that we’re conforming and therefore we know our joint position is, we can just ignore that cuz we’re just keeping everything the same. [Mahmoud]Yeah, so MIP, so CR you don’t have to worry about it. Okay. Now MIP, what’s the secret with MIP, generally is forced distribution. You want as many teeth to contact evenly as much as possible. So your dot on your Class IV needs to not be high essentially. It shouldn’t be the only tooth that’s touching simple enough. Right? And ideally you want the tooth to contact where it used to before. The other thing we already spoke about is the location relative to the margin, but also when we’re looking at the lower teeth. Even if there is space restoratively, but your MIP contact is against a really sharp bit on the lower tooth. This may be the time to smooth that lower tooth down and then ensure you still get MIP contact because you can build your composite as much as you want, right? Because hopefully that’ll prevent that lower tooth from chipping later on. So again, just try and get broad areas of contact on as many teeth as possible. So that’s MIP. It’s very simple. Then you’ve got your pathways. Right. So pathways, basically just the path along the palatal. The lower incisors or lower teeth track, as the patient grinds forward, grinds sideways. And the seeker here is, is we want to spread the load. So you want your contact to be on a broad area of contact. You don’t want a skinny line. I think you give the analogy of do you want to be stepped on by stiletto or by some flat shoes? [Jaz]Flats. [Mahmoud]Yeah. So you want flat shoes. You want broad, and we give a lot of good vision. [Jaz]Nice thick lines. Nice thick lines. Not these skinny chicken scratches. [Mahmoud]Yeah. Because that’s spreading the load on that area. The other thing is, let’s say you’re doing an upper right central and when you check the occlusion beforehand, the upper left central had a line on it. What you want to make sure at the end is that line is still there because if the line on the tooth you haven’t restored isn’t there anymore, but there is a line on the tooth you have restored, it means you’ve put all that force in the protrusive guidance on your restoration. Yeah, it may be fine, but it might be too much. [Jaz]Because if you’re relying on just looking with your eyes, without inking it up, then you’re missing that little detail that, hey, there was a line there before. Now there isn’t, and therefore my restoration or my tooth with the restoration is having too much of a line. You’re completely right. [Mahmoud]Yeah. Okay. So broad lines, try and share the guidance if it was shared before. So that’s your pathways. Then edge to edge. An edge to edge really is where ceramic and composite restorations live or die. Because especially if you see someone with worn edges, and I mean, who doesn’t have some worn edges, to be honest with you, in this day and age, that’s where your restoration needs to have, again, broad areas of contact. So if your composite edge isn’t at least a millimeter thick, how can you get a broad area of contact? You can’t, if your composite comes down to a knife edge, it’s going to be thin, it’s going to be a thin area of contact, and then it’s just easier to fracture it. So again, you need to build that into how you’re building a restoration. So have at least a millimeter thickness all along the incisal edge. And then when you get the patient to go edge to edge, just check that you’ve got broad areas of contact that again, ideally are shared if possible. So in protrusive, if I’m restoring one central, ideally I want to see. When they’re edge to edge in protrusive, I’ve got contact on both centrals on broad flat areas of contact and it’s got to be smooth. [Jaz]And that transition from the pathway as they make that palatal transition to the edges. There’s no jolt. It’s a nice smooth transition, which I know you talk about so much. But these checks, these five positions are checked pre-op and post-op. [Mahmoud]Exactly. And then you’ve got a reference because either it stops you taking away too much or taking away too little because you have a reference. And the fifth position, again, we’re probably not going to go into too much detail here. It’s called crossover, but essentially it’s when they go onto edge to edge and then past edge to edge. And really the management of crossover is all about smooth transitions. We spend a lot of time on OBAB going over smooth transitions because smoothness really is probably the underrated hero of occlusion. Cannot underestimate how important having to things smooth and not increasing resistance is to occlusion. And the last you’re going to check your envelope. Okay, so again, this is something we do not do. You’re, sorry, not last thing. You’re going to check your shim stock holds. Okay. So like you said earlier, if they had contact on this tooth in MIP before treatment, really, ideally they should have it again at the end. Why? Because if you don’t, that tooth could over erupt, could move, right? You’ve left it in a, maybe a slightly unstable position, so you want to replicate what the patient had before, and then you’ll check your envelope. So when they’re lying down, I’ll do my fremitus check. And I’ll compare it to what I had before. And then last thing, I’ll sit them up and I’ll do the fremitus check again. [Jaz]Brilliant. Now because of the interest of time, I’m just going to say that was brilliant. I really enjoyed that chat. That was fantastic. And I think we’ve made it very tangible about occlusion on Class IV composite restorations, which again, no one talks about. I’m just going to end by Mahmoud reading to everyone this awesome comment we had at the end of module one. So OBAB has five modules and this is just hilarious. [Mahmoud]I know which one you’re going to read now. [Jaz]Me and you are so scared that the first module would be the boring one, right? Because it’s quite lecture heavy where later we get cases and videos and that kind of stuff. So we were so scared about that. But then the feedback has blown us away from just module one. The boring one, right? So, Dr. Claire Laing thank you so much for your comment. It says, ‘excellent module guys. Thank you so much. I could literally kiss you both for clarifying between anterior and posterior guidance in a very clear way, especially, but I actually have a few takeaways from each section. The models and diagrams used are also helpful. Also excited for module two, but very grateful. I can revisit module one whenever I want. Smiley face’. I mean, we’ve had so many great testimonials and reviews already. That’s my favorite. [Mahmoud]Yeah. Yeah, definitely. That made me laugh. That’s brilliant. She’s clearly passionate about occlusion, eh? [Jaz]Yes. This is our tribe. Yeah. This is our tribe. Yeah. Not because we are some sort of like tribal, like, crazy people about occlusion. We just want success. We just want restorative success. And part of that is occlusion. And like I said in the first module, we could have called Occlusion Basics and Beyond. We could have called it the restorative course. We could have called it that because it’s, it’s, it’s one and the same. We spend too much time isolating the two, but they’re one and the same. [Mahmoud]You know? No, I was just going to say, there’s nothing as practice building as when you get that patient that comes in and says, I’ve had this frustration done like six times in the past two years, every time I do it, it comes off within two months. Can you help me? And then it’s usually an occlusal problem because most people just do not understand it. And then when you fix it and they come in, I usually make a bet with my patients. I’ll say, okay, how much do you want to bet I can make it last at least five years. I’m underestimating, just make I look good. And then when you do hit that mark, it’s just, it’s crazy. The patients think you’re a genius. [Jaz]And you just have to make sure you educate them about the whole tooth to something else. If they play rugby, make sure they have their mouth guard. The whole cellar tape, the hair pin, the ice chewing, the chewing, what foods and how to consume certain foods. When you have bonding, it’s, it’s about a puff aftercare of your bonding, right? It’s a piece of plastic glued the edge of a tooth ultimately, right? But, what you control and educate them on that, and then do all the things we said in this episode, which is to tooth to tooth, then really the only thing that can get the patient now is caries and stuff. So hopefully, that part is under control as well. Mahmoud, thanks so much for giving up your time once again for the Protruserati. And you are always welcome guest, and I’m sure we’ll get you out soon. I think next episode we should talk about the whole thing about fremitus. Right. It’s such a fascinating topic, right? Fremitus, the management. Is it okay to observe and watch fremitus? So if you guys want that, I’m not going to do it until we get enough comments on the video below that you want this, and then we’ll make it happen. If there’s no comments, then we won’t do it. [Mahmoud]Fair enough. [Jaz]Thanks, buddy. [Mahmoud]All right, man. Jaz’s Outro: Well, there we have it, guys. Who knew that we could talk just 40 minutes and just scratch the surface of occlusion on a Class IV restoration. Hopefully there are lots of gems in there. Lots of peripheral things that you perhaps you may not have considered. And of course, if you knew everything they were talking about, it was hopefully good revision for you. And after all, who doesn’t love learning about occlusion? If you want to do a deep dive, 30 plus hours into occlusion online, just like in this format, actually, individual videos, lessons that are five minutes long, 20 minutes long, a few odd half an hour lessons, and lots of clinical videos and case walkthroughs. Then check out occlusion.online. It’s Occlusion Basics and Beyond online course with me and Mahmoud. If you are looking to take the next step in learning occlusion, that’s going to make your restorative dentistry predictable. If you’re not interested in learning more about occlusion or you are already enrolled on OBAB, then if you enjoy the podcast, don’t forget to give it a rating wherever you listen to it really helps me a lot. But if you give the podcast a rating and leave a comment, If you can, thanks so much and we’ll join you in the next episode. And by the way, if you answer just a few questions, you can get a CPD or a CE certificate by being a Protrusive Premium member. You know the drill guys. Just answer those questions and you’ll get your CPD email to you. Thank you again. I’ll catch you next time.

6 snips

May 22, 2023 • 40min

Bruxism and the Airway – PDP149

The podcast explores the link between airway issues and bruxism, emphasizing the need to screen for airway problems before treating bruxism. It discusses the three levels of diagnosis for sleep bruxism and highlights the importance of considering the airway in dental care. The podcast also explores the factors and challenges involved in diagnosing bruxism, as well as the complexity of studying the link between bruxism and airway obstruction. It provides guidance for dentists in diagnosing and communicating about bruxism, and discusses the significance of micro-arousals in the brain.

May 11, 2023 • 55min

Apicoectomy Tutorial – When, Why and How – PDP148

You’re faced with a beautiful crown with what seems like a decent root filling – but there’s an apical infection present. Is the answer always endodontic re-treatment? When should we instead consider apical surgery so we can clear the infection WITHOUT drilling through the crown or having to dismantle posts? In this episode, specialist endodontist Dr. Peter Raftery and his associate Dr. Manpreet Dhesi will be talking about the Apicoectomy procedure that can be used to treat root-filled teeth using a ‘retrograde’ approach. They will discuss about how it fits into general dentistry, its indications and contraindications, its cost analysis vs implants and and the entire protocol for performing Apicoectomy https://youtu.be/sZOsLuuf-Vo Watch PDP148 on Youtube Protrusive Dental Pearl: The periradicular surgery guidelines issued by BES and the Royal College of Surgeons. Download the guidelines about periradicular surgery or on the app under the Protrusive Vault (where all the different files and infographics and the different things that you get as a Protrusive premium member) BES-RCS-Peri-Radicular-Surgery-GuidelinesDownload Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 1:37 The Protrusive Dental Pearl 3:32 Dr. Peter Raftery’s introduction 4:05 Dr. Manpreet Dhesi’s introduction 5:16 What is Apicoectomy? 6:29 Oral Surgeons vs Endodontists? 8:48 Is a Microscope mandatory for Apicoectomy? 10:08 Apicoectomy for posteriors 11:00 Isolation Protocol for Anterior Apicoectomies 11:35 Apicoectomy Protocol 15:03 Disinfection Protocol 18:41 Moisture control from the bleeding 20:43 Risk of surgical emphysema – Is special handpiece needed? 21:52 Indications and Contraindications for Apicoectomy 27:46 Endodontic Re-treatment 29:05 Cost benefit analysis of Apicoectomy 31:20 Success rate for Apicoectomy 34:19 Case Scenario 1: 82-year old patient with a singular crown, root filling and a radicular pathology 42:10 Retrograde fillings of choice 44:09 Grafting after Apicoectomy – is it needed? 45:04 Equipments for Apicoectomy 47:11 Learning more about Apicoectomy Apical Microsurgery Instrument Kit- the mirror, the pluggers, and the little curettes by Hu-Friedy UK Apical-Microsurgery-Instrument-KitDownload If you enjoyed this episode, check this another episode by Dr. Peter Raftery: How to Save ‘Hopeless’ Teeth with the Surgical Extrusion Technique Click below for full episode transcript: Jaz's Introduction: Root canals are not 100% successful. Let's face it, nothing in dentistry is a hundred percent predictable, and sometimes we are confronted with a scenario such as a beautiful central incisor crown and it's a root filled tooth, or worse yet a tooth and incisor, usually with a long thick post inside of it. Jaz’s Introduction:Now, just because it looks good on the radiograph doesn’t mean it was a good quality x-ray. We all know that. But anyway, let’s say it looks like a decent root filling. There are no voids in it, and now you’re really questioning whether it’s really feasible to go down a root canal re-treatment, or is there another option? And sometimes that other option, which really comes into play in these scenarios is an apicoectomy where a flap is raised, the infection is curetted, and a bit of the root, a bit of the apex is chopped away, and then boney healing takes place. Now this is known as microsurgical endodontics. It used to be done a lot by oral surgeons in the UK at least many years ago. And now endodontists have reclaimed this territory and suggest that actually this is the way we do it to get high predictability. And that’s exactly what we’re got to discuss in this episode. Hello, Protruserati. I’m Jaz Gulati. I’m joined in this episode by Dr. Peter Raftery, specialist endodontist and his colleague Manpreet Dhesi. We’ll be talking about. All the things you’d want to know about apicoectomy, does it have a place in general dentistry? How does it compare to an implant in terms of cost benefit analysis? What are the indications and contraindications of this, as well as talking you through the entire procedure from start to end, including the little details such as what is the retrograde filling material of choice? Protrusive Dental Pearl:The Protrusive Dental Pearl for this episode, which really compliments this theme of apicoectomy really well, is the GUIDELINES. The peri-radicular surgery guidelines issued by BES and the Royal College of Surgeons. This is such a beautiful document, which covers so many themes of this episode, actually is a great revision for this episode itself, and talks about the indications, contraindications, and really just summarizes really nicely all the guidelines for carrying out peri-radicular surgery. Now, you can download this document on the Protrusive website. That’s protrusive.co.uk/148 because this is episode PDP 148, so /148, or if you’re on the app, it’s on the Protrusive Vault section of all the different files and infographics and all the different things that you get as a Protrusive premium member. I’ve also recently added to the premium clinical video section of the app, a complete guide on how I did the walking bleach technique on a patient So discolored and non-vital lateral incisor, how I bleached it internally using the walking bleach technique, which we discussed in the previous episodes. If you haven’t listened already, do checkouts episodes out with Dr. AJ Ray-Chaudhuri. And then I also show you how I did the bonding, including removal of the old composite. And mocking up and actually lengthening the teeth while respecting the occlusion and making sure that restorations are got to be unchippable. So that’s all in the premium clinical video section. If you’re not already a Protrusive premium member, it might be right up your street. If you’re a dental geek like me, or for the cost of a tax deductible mandos per month. The website checkout is protrusive.app, or you can download it on the iOS or Android store to check out all the protrusive goodness. Now let’s join the main interview with Peter and Manpreet. Now catch you in the outro. Main Episode:Dr. Peter Raftery and Manpreet Dhesi, welcome to the podcast. Peter, we had you a while ago on surgical extrusion technique, which is a really interesting way to save hopeless teeth. And today we’ll be talking about apicoectomy. There’s so many questions that come to mind about apicoectomy, and I know you two are got to be really great in helping us. But before we go into that, just remind us again, Peter about yourself, your practice, and you Manpreet, it’s the first time on the show. So tell us about yourselves, guys. [Peter]Yeah. We are in Hampshire endodontics at the minute. We are coming from, speaking from Haven in Hampshire. Got a branch in Winchester also, but an endodontics only practice. My background was the sort of formal training route at the Eastman a long time ago now. But then as things got busier here, put the feelers out and delighted for about a couple of years now to have had Manpreet. He’s been a great addition. [Manpreet]Yep. So I’ve been with an associate with Peter for past two years. I didn’t do full on specialist training. I did a part-time MSC at Queen Mary, which I completed probably maybe six or seven years ago, and now spend three days a week doing purely endo and then two days a week, still doing a bit general practice as well. So, bit of a mix. [Jaz]So Manpreet, you did your master’s and now you split your time between practice limited endodontics and also general dentistry. Is your plan potentially in the future to do more and more into endodontics, or do you like the balance and the split kind of like a GDP with enhanced skills? [Manpreet]Yeah, I mean, I do like still keeping a hand in with the general dentistry, kind of just so I don’t forget doing all of it, but it does have a knock on effect on my endo as well. So it does help me in terms of being able to restore teeth nicely, sort of tying things in with GDPs who refer. So yeah, maybe eventually I’ll start focusing purely, purely on endo, but for the time being, it’s nice to do a little bit of a mix. [Jaz]Okay. Great. Well, thank you very much for the introductions. Now, let’s get to the meat of the episode. So apicoectomy, right. Just for our young colleagues, just so we’re on the same page. When I say, apicoectomy, some endodontics say, ‘we don’t call it that anymore. We call it microsurgical endodontics.’ And that kind of stuff. So I, I’ve heard that one before. And also the spelling of apicoectomy, I’ve been told before by consultant for spelling it the way it kind of sounds like it should be spelled apparently is different. That always confused me, but that’s just semantics. Tell me, what do you guys mean when you say apicoectomy? [Manpreet]So an a apicoectomy for me is a procedure where we purely come from the apical part of the, an apical approach, leave the coronal portion completely alone, and then we’re essentially cleaning the lesion out directly from the bone and resecting a portion of the route as well. And I guess, yeah, there are lots of different terms for it. We call it surgery. When we’re talking to patients here, we just purely call it apical surgery. But yeah, you’re right. Some people call it microsurgery. When you look at courses, a lot of them, they focus and they call it endodontic microsurgery. So there are a few different names, but yeah, we generally tend to call it either apical surgery or apicoectomy. [Jaz]And do you think this is more the domain of the oral surgeon? Or the endodontist because when I was at dental school, the oral surgeons would actually be doing in the hospital department. Cause we didn’t have any endodontists. They’d be doing some apicoectomy and historically I know that it was a lot of oral surgeons who would just dabble and do these root end resections. And there’s a huge difference. I’m sure you can elaborate in terms of what an oral surgeon does and what endodontist does. So, is it a collaborative thing or do you think endodontics have now stated their claim in this type of surgery? [Peter]Yeah, I think they have won that argument. Convincingly comprehensively, I think it will boil down to funding and historical funding structures where everyone knows on the NHS you can get stuff done surgically for free because the NHS chose to fund orthodontics and oral surgery, wisdom teeth out, biopsy of lesions, things like that. And yeah, apicoectomy was rolled into that. But interestingly, the reason I say it’s the argument I feel is now comprehensive one is that in all of endodontics, the success rate in nonsurgical treatment famously has not really moved much in the last few decades. Lots of theories about that, but it’s frustrating that it hasn’t really come on leaps and bounds. The only area of endodontics where the success rate has gone from being a little bit hit and miss to wildly predictable and high is, surgical endodontics done via more modern approaches. We just call it modern because no one really wants to hear that. I had a hidden hope of a procedure done on in the past. For example, we just call it a modern revision. If we are taking out an amalgam that’s nowhere near the apex and filling the canal for the first time with anything. So yeah, it’s the area where endodontics has really come on leaps and bounds is apicoectomy. Which is why we’re so eager for everyone to know that. And I’d love to think a few people, followers, listeners, will be motivated to take the next step towards getting involved. [Manpreet]And I guess this is where the microsurgery part of it comes into it as well, because that’s essentially what has made those success rates go up with apicoectomy, being able to do the procedure with much more precision, and I’m sure we’ll come onto that in a little bit. [Jaz]So do you think one needs to have a microscope to do a good quality apicoectomy? [Peter]No. [Manpreet]No, definitely not. [Peter]But magnification and illumination of some sort. [Manpreet]Magnification for sure. I mean, I personally actually prefer using my loops when I do apicoectomy. I’ve got a couple of pairs of loops. In general here, use a microscope for everything, for all our non-surgical treatment. But actually, if I’m doing a anterior apicoectomy, I sometimes prefer using my loops just from the fact that you’ve got more flexibility with the field of vision, you can move your head around and visualize things for me, a little bit better. So I actually tend to use my loops and I don’t think and microscope is completely necessary to be able to do apicoectomy. [Jaz]How much mag we talking Manpreet? [Manpreet]My loops are five and a half. [Jaz]Okay. [Manpreet]Yeah. [Jaz]Good, good, good. That’s pretty decent. But, I mean, obviously most apicoectomy, and correct me if I’m wrong, are anterior and so you’ve got a nice, nicer field of view and we’ll talk about how you manage the soft tissues. Like for example, I’m a big fan of using Optric Gate for my bonding and stuff. Is that the kind of stuff that you’d be using or using like, I don’t know, split down? I mean, that’s got to get in the way obviously. So what kind of things are you using to get the soft tissues out the way? But before you touch on that, can you just clarify for me, are apicoectomy of posterior teeth still a thing? Do you think there’s a place for that? [Peter]Yeah. That’d be more your probably specialist and microscope strictly one of the mic, I believe, with a microscope thing with a microscope treatment or modality. The microscope does allow you to document things nicely with a camera attached. Of course. Yeah. Yeah, yeah, absolutely. You’ll see molar yeah. Anything that’s, we’re an endo only practice. Okay. So we are going the extra mile and a half to not be having to say, I can’t help. So, yeah, absolutely. What’s the word? The mother of all invention necessity. So yeah, if there’s a molar, well buried in bone part of a bridge and there’s one, clearly one route, that’s the problem then. Yeah, absolutely. [Jaz]Okay. And then for anterior teeth, if that’s what mostly is being done, what are you using just to, before we can talk about flaps and stuff, what are you using to keep the soft tissues out the way? [Manpreet]So we’re normally just using a normal retractor. Surgical retractor just to keep the soft tissues retracted the whole time. We’re not using any rubber dam or optragate isolation during a surgical procedure. So yeah, it’s pretty much just your normal surgical kit, which a lot of dental practices are going to have. Yeah, because they might have someone who does wisdom tooth extractions, things like this. So, just normal surgical retractors. [Peter]Okay, so while we’re talking about retracting stuff, let’s talk us through like in a minute or so, just a general procedure, right. So you got your, we’ll come onto diagnosis, indications, contraindications but just to give people a flavor of what’s involved, for someone who hasn’t seen this before start from raising a flap and what is it that you actually doing that formulates this apicoectomy and how you actually finish the procedure as well. Yeah. We’ll, following local anesthetic, we’ll get them to mouthwash for about half a minute a minute. So that the sort of field is, reasonably aseptic as can be. And then yeah, when we talk about flaps, we’ll talk about flaps, but you’ll want your blade to be hitting bone so that you have a shot at getting the periosteum and the flap up together. If you start to shred the periosteum, you’ll know about it. Lot’s of bleeding. lot’s of bleeding. So you’ll try and get that incision onto bone, a very firm incision into the bone. Can’t stress that. Yeah. Then, with a nice new periosteum elevator. Cause I think the ones I’ve seen are usually ancient. They were bought 10 years ago. And again, that lack of a sharp edge, I think will fray and shred the flap. As you try and get the, there’s clearly the bit of gum that you’re looking to mobilize versus everything that’s staying put. So you’ll try and get, I’ll use a boozer and I’ll try and get a really nice, clean, sharp flap raised, and more often than not, the cases that you’re tackling, as soon as you get the gum out of the way, there’ll be a big circular hole in the jawbone. Corresponding exactly to what you saw in your pre-op x-ray, and within a few seconds you’re staring at a root tip sat in the middle of that circle. That’s I would say, how most anterior apicoectomy go. [Jaz]Hey guys, it’s Jaz. I’m just interfering again with another piece of feedback for the Occlusion Basics and Beyond course, OBAB occlusion.online. So we’ve had our first delegate complete module two. Module two is a beast. There are 48 lessons. So on lesson 48, where we do like the wrap up, I encourage all the delegates to write a summary of what did you learn during this module? And we do that for all five modules. But this is what Dr. Andrew Hong had to say. He said, ‘ my biggest takeaway was looking and identifying wear facets. I picked up the obvious ones that missed the others, something for me to work on. The articulating paper marks is now making sense to me. Thank you for the wonderful presentation. The other concept I took away was a positive and negative errors with articulators.’ So we were like, thank you so much. It’s great that you’re making so much progress. And then Andrew replied saying, ‘thanks Mahmoud, will do. I will reiterate that this is great material. Well done to both yourself and Jaz for putting this together.’ So, Dr. Andrew Hong, a massive shout out to you for being one of the first delegates to finish module two. You’ve still got three, four, and five to look forward to, and we look forward to reading more of your reflections as you progress through the course. So regardless of whatever stage you are in your career, if occlusion confuses you, you need OBAB in your life. So check out occlusion.online to enroll. Get one year of access. To rinse it as much as you can. You get mentorship on the forum and a starter kit delivered to you. This is occlusion made tangible. Now, back to the main interview. And so at that point, so I’ve never actually seen one, I’ve seen maybe some videos of one being done at that point, yes, the root end resection will start and there’s, I remember being at some lectures many years ago talking about that the angle in which you do it to not expose tubules and stuff. So maybe you can talk about that. But once you get to that stage, are you actually using hydrochloride? I know it sounds like a silly question. I’m guessing not, but what kind of disinfection protocol are you using at that point? [Manpreet]So, I guess your main thing here is once you’ve reflected your flat back, once you’ve visualized your lesion, your main thing that you’re trying to do is to remove all that infected tissue. And so you’ll be using your curettes and you’ll be detaching all that infected granulation tissue from the bone, from the healthy bone, and that’s what you’re really focusing on in that first part of the procedure. Sometimes you’ll find that tissue really detaches nicely. Sometimes you might have to work at it a little bit more, and there’s a bit of a technique to detaching it. And then once you’ve done that, once you’ve cleaned that lesion out, you’ve got this nice crypt, you’ve got this nice big open cavity in the bone, which is hopefully nice and solid. Then you’re looking at resecting your root, and you’re exactly right. You want to try and come in as horizontal as possible when you’re resecting your route and you’re aiming really to remove probably about three millimeters in a normal case from the tip of your root. [Peter]And why is that? [Manpreet]And that there’s a good reason for that. And that’s because most of your, when you think of a tooth, when you think of your root canal system at the tip of your root, in that final two or three millimeters, you have a lot of complexities, a lot of lateral branches, et cetera. And so when you are removing that three millimeter tip, you are removing all those irregularities. You want to come in as horizontal as possible. And that’s because when you have a beveled root resection, you’re exposing a lot more tubules and you’re creating a lot more of a surface area where you can get bacteria leaking in again. So horizontal resection. And then really we want to try and use specific ultrasonic tips as well. I don’t know if there’s different brands which make the ultrasonic tips. [Peter]Yeah, I think, so the majority of your bacterial killing is probably, removing three millimeters of habitat, literally cutting out the root tip. And so the bacteria that are in those nooks and crannies and the habitat that they could otherwise occupy. But then you’ll, then you will probably go for a three millimeter retro prep with an ultrasonic tip. And that is the equivalent of, I says mechanical debridement. So you’re mechanically you get a bit of heat with an ultra sonic tip. But yeah, you are mechanically debriding the inside of the canal. That’s another nod towards our trying to kill bacteria when a case is going incredibly well and bleed, blood bleeding has stopped nicely. Then yeah, you absolutely can introduce sodium hypochlorite. If you have, I’d say it, it wouldn’t be on your first case or even your fifth case. But yeah, when things are going really nicely, I will introduce a little bit of sodium hypochlorite. [Jaz]Okay. [Peter]We’re talking a lot less than one milliliter and it’s sat ever so nicely in there. But don’t forget a bit of dilute sodium hypochlorite does not do any harm. In extruded sodium hypochlorite under pressure does harm, but simply bathing. And, but if by accident a droplet were to spill out over the retro prep into the crypt, it will do less than zero hung. [Jaz]Okay, so it’s quite different to a hypochlorite accident. That’s a different beasto. We’ve covered that before in a medical legal episode we covered, so it’s good to know actually, just to make it tangible. A few points that come to mind. When you’ve done your root end resection or raise a flap and you’ve curated out all the junk, what’s stopping the bone? Just constantly bleeding and filling up the crypt with blood. How do you get that moisture control from the bleeding? [Manpreet]It quite often does. And one way that we try to normally control that bleeding is just with packing gauze, sterile gauze into that crypt. You can soak that gauze in some hemostatic and pack that into the crypt. You may have to keep on replacing that throughout, but that normally does enough to stop the bleeding so that you can actually visualize your root and you can carry out your prep and place your retro fill. Sometimes you’re lucky and you’re doing a procedure, you’re cleaning everything out and everything’s just nicely under control. There’s not much bleeding at all. I guess another thing which makes a difference is actually your local, at the beginning, putting plenty of local in there, actually injecting it. Through when you’re giving that buccal infiltration, actually trying to guide your needle into the lesion, so you’re injecting it in there and getting some vasoconstrictor into that lesion. [Peter]Yeah, that’s something that’s very different from what anyone will have done before. So you, you’re lining up an a apicoectomy case and you are deliberately trying to get the tip of the local aesthetic needle into the lesion. We’re always told, aren’t we to just barely touch bone and then retract? So not to disturb the perio, but in these instances, if you don’t introduce local anesthetic into the mushy soft tissue, occupying the space where bone should be, then curating that stuff is got to be very, very painful. And I would just say, I’m certain that the stuff that’s causing the bleeding, preventing your visualization is the soft tissue occupying the space where bone should be. So I probably would just spend the first few minutes curating, curating, curating. And once you’ve done that thoroughly, that’s the stuff that pumps blood in my, typically. [Jaz]Got it. And then just another real world question, like, if GDPs were to tackle their first place question that might Protruserati might be thinking right now is, do I need a special handpiece? Is there a risk of surgical emphysema if they use their standard fast handpiece with the air mist and the water, or do you have to use saline? These are the real world questions that might be going through someone’s head. Any advice on that guys? [Manpreet]Yeah, you don’t want to be using your normal fast hand piece. Your normal air turbine. You want to be using something specifically for surgical procedures. So you’ve got a few options. That could be a reinventing turbine that could be an electric hand piece. But yeah, you don’t want something which is going to be blowing air into that surgical area. You want to have a specific hand piece, which is made for during surgery. [Jaz]Okay. I thought so, but it’s just helpful to clarify for that. So I think that’s enough on the procedure because I’d really like to get into indications and contraindications. Cause this is a big one when dentists are faced with that diagnostic dilemma and they’re thinking of referring or doing the case themselves. What would you say is a, let’s start with contraindications might be easier, right? Like a crappy root canal, primary root canal treatment. How far do you go with that? What are the contraindications and therefore how do we spin that on his head and say, what is the ideal scenario for apicoectomy? Because remember Peter, we talked about the hopeless teeth and the surgical extrusion. You gave some very good guidelines. Okay? Yeah. Well, this is a good scenario. This is a bad scenario. What kind of guidelines can you give to us for choosing the right tooth? [Peter]Well, if I could, I’ll start off with some of the more dry, formal bit and then I’ll let Manpreet give you his sort of personal flavor on the job as it were. But the British Endo website, British Endo Society website has free PDFs, very recently updated guidelines for surgical endodontics, which has contraindications also. Again, almost like an exam answer would be medical people who you don’t want to be doing surgical procedures on MRONJ and RRONJ and the other ones. The radiation boney non-healing type people iv bisphosphonates, along oral bisphosphonates with steroids for an extended period. People who are so, I guess, incredibly unwell, the ASA classification, people who, I don’t tend to find that the INR or blood thinners are an issue, if I’m honest. But yeah, I’ll let maybe Manpreet whilst there’s a good list of them, an exam style answer on this PDF that’s freely available. Maybe Manpreet who has more recently embraced it, I’d say is younger than me. So, he might be able to give you some of his real world more day to day answers. [Manpreet]Yeah. I guess when you’re assessing a case for apicoectomy, there’s a couple of things which I think of. And your usual, your standard situation is that you’re got to have a tooth in front of you, which has already had a root canal treatment, a root canal treatment’s failed, and now you’re thinking of what are you got to do next? So for me, I’ll sort of look at this and I think, is there a coronal issue here? Is there something that is leaking and causing bacteria to leak in coronally, or is this a purely apical issue? Because that’s got to guide you on what approach you’re taking. If there’s something going on coronally, you are going nonsurgically, you are doing a, a re-RCT. And what I mean by coronal, I mean is there a very poor filling on the tooth, which is leaking? Is there a very poor crown which has bad margins around it? Is there a post crown which has come off recently and bacteria has leaked in? All these things. You are not looking at doing that, doing an apicoectomy. You are looking at going in non-surgically and revising everything. If everything coronally is perfect, we often ask the patient if they’ve got a crown on the tooth or they’ve got post on the tooth, has this ever come off? Has this come off recently in the last couple of years? If everything is fine from a coronal aspect, then a apicoectomy starts to become a realistic option. And so in those sort of situations, I think what I would look at is the quality of the root filling, the existing root filling. And I always ask myself, is this a root filling, which is instantly improvable? Is there areas of that root filling which can be made better? Is it halfway down the root? Is it a really crappy root canal to begin with? Because if it is, then again, ongoing non-surgically. If that root canal is generally looking good, if that is a root canal treatment, which has been already retreated in those sorts of situations, then I’m leaning more towards surgery and apicoectomy, it has to be really for me, a root filling, which is serving its purpose, and I’m not going to gain much by redoing that root canal. [Jaz]That’s brilliant. The only issue which you guys probably say this all the time and you guys are more aware of this than any of the GDPs, but when we see a radiograph and when we see a root filling that looks apparently decent, we don’t know if hypochlorite was used. We don’t know if rubber dam was used. How do you make that judgment to, yeah, okay. Just cause it looks good is actually good. There is a bit of a leap of faith in terms of how well the root canal treatment was done. Right? [Manpreet]It definitely is. And again, this is where during your examination, you’re asking questions like, who did the root canal? Was this done by a specialist or someone with special interest? Do you remember your dentist placing- [Peter]Hold up a rubber dam. [Manpreet]A rubber dam. Yeah. [Peter]Do you recognize this? Do you recognize this? And if they’re not instantly like, oh, that thing, you’re like, okay, possibly wasn’t used, you know? [Jaz]It’s getting little clues, right? Because it is difficult. [Peter]Possibly in the real world. The biggest tip of the balance is, is there expensive, good looking, recent prosthodontics on top of this tooth? And if there is, it might be that the dentist is perfectly reasonably chosen not to revise an endo on a tooth that they’re incorporating into a bridge because the endo looks all right and has been there for, it looks sort of 8 out of 10. It hasn’t been a bother, I don’t think it’s got to be very easy to sell on top of the expensive bridge to that person, an specialist root canal, redo, just in case it becomes a problem. So I do think and I think it’s reasonable that the dentist might well then put some new, expensive, good looking prosthodontics onto the teeth and then Murphy’s Law, St. Patrick’s Day the other day, things might flare up. And then we are looking to preserve that expensive prosthodontic work. [Jaz]I mean, how far do you go? I mean, you were talking mostly about, let’s talk about anterior teeth. A lot of times you can root treat through a crown. You guys are way more experienced than I am at that, but it’s probably the post that obviously you think, okay. Yeah, we’ve gotta look at the other side here. But in terms of drilling through zirconia, anterior crowns, for example, to do a re-treatment, does that worry or bother you as a limited endodontics? [Manpreet]No. No. Something we do commonly, I think zirconia is actually not as difficult to drill through as a lot of people think it is. I was told a little tip a while ago by someone somewhere. It might have been been on your podcast to use a red band polishing bur when you’re going through zirconia and it works wanders, you’re through the zirconia in no time at all. So going through a crown and redoing and endo is something that we do very commonly, but I’d start to say that that’s when you do start to need good magnification. You do start to need a microscope when you’re doing something like that because it’s very, very easy to not be able to see what you’re doing underneath. [Jaz]Yeah, yeah. There’s always more risk involved when you’re going through crowns and stuff. Totally concur. Yeah. Using a a yellow band or red band bur does help cutting through zirconia for sure. In terms of cost benefit analysis though, right? It’d be nice to know, there’s forums on Facebook and dentists talk all the time, like, ‘okay, how much people charging for implants nowadays?’ And the general consensus is, 2.5 to 4k. How much, if you don’t mind me saying, is roughly the range of a apicoectomy? Because one of the considerations one may have, because if you’re doing surgery anywhere and the patient’s suitable for surgery, then instead of doing the apicoectomy to extract the offending tooth, graft it and then go for an implant in the future, that’s something that’s got a discussion that you, I’m sure you have as part of your consent. So if you do a cost benefit analysis, what’s that looking like for versus an implant? [Peter]But we have a very narrow range is single figure. We charge a fee per procedure per tooth, whether it’s non-surgical treatment, non-surgical re-treatment, apicoectomy, just whatever it is. We’ve just got this one figure comfortably less than a thousand pounds. So yeah, I suppose we’re trying to incentivize people to give it a go. The modern mantra is save teeth, et cetera, and if they’re happy with that bridge, or casting. If they don’t, if they’re not saying, yeah, it falls out all the time. And even if it you or I’m itching to replace it, as soon as I spend some money on this tooth, some of the money I spend on will be getting that gray margin removed. But if they are entirely happy with the casting usually is, then yeah, I would just leave it alone and just sort of go up above apicoectomy wise. Yeah. So I think we are costing them for the cost for exploring whether an apicoectomy is got to work is about a quarter of the price of an implant. And it’s kind of over with in two hours. There isn’t a scan, a graft. Wearing a flipper plate for a few weeks. [Jaz]No, no. Lab bill. [Peter]Multiple surgical, yeah. Nice. Yeah. No lab bill there, so. I don’t know, is that kind of, if this works, I am streets ahead financially. I think patients are thinking, but yeah. We are not successful, a hundred percent of the time. So for those people, I’m sure they see it as a unfortunate waste of money. [Jaz]So let’s talk about that. What are the accepted success rates in the literature? And do we have any data? It’d be really interested to know if there’s any data on, I know there is data. I couldn’t quote you the authors right now, but for GDP primary endo versus specialist primary endo. That kind of data I’ve seen around. Is there anything on the apicoectomy side, just in general, what other success rates we’re looking at? Obviously every case is different, but also do we know about GDPs versus specialists in that domain? [Peter]Well, yeah. Another useful free PDF download is from the Royal College of Surgeons that we all make sure you have, but in their document, they quote, ‘Success apicoectomy success rates in the sort of nineties, low nineties. So that is where it has really come on leaps and bounds with just modern everything. Modern materials. Modern equipment, materials. Literally. Yeah. Modern materials, modern instruments, and modern concepts. So, yeah. Nineties. Yeah. Apicoectomy is, I would say very predictable. [Manpreet]In a lot of the literature now, the success rates for apicoectomies aren’t particularly different to the success rates of normal endo. They’re up there in the same sort of ballpark and from experience in practice as well. I’d say that probably 90% of the cases we do heal up. [Jaz]And in terms of GDP, do we have any GDP data? I mean, I don’t know how many GDPs are doing this kind of work, to be honest, to do. But, an experienced GDP who has some surgical skills and raises flaps, this is a nice little thing to add on in terms of keeping your interest and try and go the extra mile safe teeth. Do we have any data on how GDPs are, are ferrying when it comes to apicoectomies? [Peter]No, I don’t believe that. I don’t believe that exists. But distant recollections from training and when I was literature, savvy, there just was an appreciable difference between the apicoectomy coming out of the oral surgery department and apicoectomy is coming out of the endo department for fairly obvious reasons. The oral surgery department are using amalgam. They’re not using, they are slash were using amalgam. They were generally, I suppose, being remunerated at a lower level, which possibly, probably influences the time they might attribute to that procedure. And I suppose we have that intimate knowledge from the all the ortho grade treatments, intimate knowledge of the kinks and the looks and the crannies that we are maybe dealing with. [Jaz]Mm-hmm. [Peter]So there’s an appreciable, significant daylight of distance between the success rate from modern techniques, materials equipment compared to traditional, but I don’t think there’s the exact answer to your exact question. Unfortunately. However, we are all for and all about dentists getting involved. [Jaz]Absolutely. Well that’s good because like I said, it adds another string to people’s bow. It is a good thing to have. I’m just got to load up a photo, guys, because the next question is about do you always need, like, I think we’ve kind of touched on it, if you’ve got like a really good orthograde restoration, sorry. Like a coronal restoration, well sealed looks pretty, and you’ve got a good root feeling. Yes. This is in play. You’re considering an apicoectomy, but I’ll show you a recent case. This is my grandfather in law. Let me just see if I can show you so those who are listening will describe it. So he’s got a resin bonded bridge, which you may remember from a video I posted on YouTube. It debonded. I didn’t do it in the first place, but it debonded. But I had the privilege of going through a full protocol and showing you how I rebond these bridges. So that’s what we’re looking at here. And next to it is a singular crown on an 82 year old gentleman. It’s got a root filling and instead of me saying about the quality of the root filling based on how it looks, I’ll get you guys to judge that because this is what you do day in, day out and it’s got a lovely round. I don’t know, i’ll size that is maybe 10 millimeters. You guys are again, a better judge than I am. Radicular pathology. Nice circular one. So what do we think about this Coronal restoration? What do we think about this root filling and the diagnosis of the pathology that we see? Is that cystic? Is it the granuloma? What are your thoughts, chaps? [Manpreet]So I guess when, when I look at that, in answer to your original question, you wouldn’t necessarily have to redo that endo underneath there. Again, sort of as I was mentioning before, if I’m happy with the seal on that crown, I definitely wouldn’t be redoing that endo just as a precursor to going in and doing surgery. But I guess my concern here with this tooth would be the fact that that lesion extends so far up that root and how much root are you going to have left here when you clean out that lesion and resect it, is there going to be enough for that tooth to be strong enough? Is that that’s a very heavily prepared tooth? Is that root cracked? Because there’s a, it looks like to me as a little bit of a communication crestally on that mesial side of that route. So there’s a few things that would worry me about going in and trying to save this tooth with a surgical procedure. [Jaz]Peter, anything from you though? [Peter]Well, yeah. But if we were to, I just, I’m repeating the point really. It is just that if we were to insist on taking the crown off, revising the endo prior to any surgery, it just becomes from a faff and a cost point of view and an inconvenience point of view, unattractive, unpalatable. So what your grandfather in-law might go for is if someone could say, well, look, I could execute a really modern apicoectomy and do you know what, if it’s endodontic in aetiology, it probably will resolve. And if it doesn’t, it won’t. Which is a little bit maybe imprecise in terms of the 21st century offering to a patient. However, in the real world is the language, a lot of patients I think can digest. Pretty much instantly. Well, oh yeah. So if that tooth compromised in support though, it might, if it’s not wobbly pre-op, I’m thinking I can only make it better. So yeah, if it is not wobbly grade two or above, if it’s grade one or less and it, yeah, I think that when I get in there and do my bit, I’m got to be making it firmer, not less firm. So Yeah. And from our previous podcast about extruding teeth. I’ve got a great faith that teeth can function reasonably on less root, buried in bone than we would otherwise think. [Jaz]So obviously we’re talking about the crown root ratio, which is always important to consider. And I know this is limited information. This is not how we do in dentistry. We want to fall diagnosis, full picture, the occlusion, the pocketing. But with this limited information, we’ll get a vote from each of you, with the limited information provided based purely on radiograph, which is not how we do dentistry, but just for the, amuse me, are we going for a re RCT? So that would involve either going through the crown or dismantling the crown doing the re-RCT, and then restoring the crown or doing a new crown potentially depending on what we find inside. Versus go straight in for the apicoectomy for this 82 year old fairly healthy gentleman otherwise. [Manpreet]Personally, if he was keen on treating and saving that tooth, I wouldn’t be redoing that root canal. I don’t see much benefit to be gained from that. I would be going in and just dealing with it surgically the benefit of just purely going in one procedure in and out. See how it heals, see how it responds. [Peter]Well, a lesion of that size and of that vividness I don’t find will often heal nonsurgically. It is true that big lesions heal, and you do see those people with their five year follow ups, et cetera. However, there’s something really attractive. Within a single procedure, doing a nice, modern, thorough apicoectomy, scooping out all the mush, letting fresh blood bleed in there, which in the absence of any infection will become rock, heart, bone, nice and quickly. So, yeah, I would absolutely be offering surgery. [Jaz]That’s what actually I was thinking as well because of how well defined that radiolucency was and therefore it may well need some surgical intervention anyway, right. And to extend some time for this tooth, rather than having to go through and a come some process of drilling through the crown. And yeah, we know that lower incisors that have got crowns, especially way back when, when he had it, is not an ideal restorative scenario. Can you guess, any guesses as what’s what the NHS hospital said? [Peter]Yeah, I wonder. The oral surgery department, we can’t help. [Jaz]Yes. So they said, you need to, we need to tick this box that you’ve had a re-RCT. Can we tick this box or not? No, we can’t therefore, no apical surgery. So it’s like a tick box thing for them. Like, okay, no re-RCT, no surgery. So they sent him back saying, okay, find someone to do a re-RCT. So I’ll be sending him to Ammar Al Hourani for a consultation now to see if he fancies this and let’s see what he says. [Peter] Yeah. Yeah. Well, I look forward to seeing how it goes. Yeah. Now we’re invested. [Manpreet]I guess the only thing I would say about that case is a CBCT scan might show that there’s an extra root canal inside. There may be a link branch or something, in which case, maybe you’d consider going in and redoing it. But yeah, that’s the only thing I can, that’s the only possible reason why I would be taking off the crown and redoing the root canal on that. [Jaz]Yeah, good point. As someone who’s had all four of his lower incisors root filled, and all four had two canals, yes I can definitely vouch for that, but that’s for a story for another time. So to answer bluntly, do you always need a re-RCT? I think the answer there is no, you don’t always, because you gotta take every case from its Merit and look at what’s on top. Are you happy with that? Answer that, yeah. It’s not a guaranteed rule that you have to always have a re-RCT before considering apicoectomy. [Peter]Just a Reading District Hospital by the sounds of it. Isn’t that where you are? Up in barkshire, pan born or something? [Jaz]The hospital was, it was either GUYS or Eastman. It was one of the two. [Peter]Eh, yeah. No, so no, outside of the ivory towers. No. It’s just, it’s not I incredibly infrequent. Yeah. In the real world of Endo, incredibly infrequent. One or the other, it just becomes unrealistic to do both. [Manpreet]By the time you factor in re root canal, apicoectomy, a crown. You’re looking at significantly more. Possibly in an implant. So yeah, not realistic. [Jaz]Yeah. So for pragmatic reasons, sometimes it is appropriate to make apicoectomy the next choice and not necessarily go, always going for the re-RCT when the conditions are right. So final question before I ask about GDPs trying to get into the skill is just a little bit, just tell me retrograde filling of choice nowadays. So, we’ve in the past amalgam then, I know IRM was in favor. Is it now MTA and biodentine, or is there something newer that I don’t know about? [Peter]I think we differ on that. What’s your go-to? [Manpreet]There’s a few options. There’s a few options. So, IRM is good because it’s easy to handle. And that can’t be overstated. When you are in the middle of a surgical procedure, you’ve got this very, very, very tiny retro prep, which you’re trying to fill. You may have a short window of time to get that filling in before your crypt fills up with blood again. So IRM is very good in that respect because it’s nicely packable. MTA is very, very good, but it is difficult to handle, the original MTA. The one which you mix as a powder and a cement. Very, very difficult technically to place into your retro filling. But nowadays there’s newer materials. There’s a bio ceramic putties, which you can get, which are available from all sorts of places, and they are basically MTA based, but much easier to place. And I think that’s what a lot of people are starting to shift over to. But I would say we use IRM a fair bit, don’t we? [Peter]Yeah. Your MSC coordinator Chung, he’s got a good paper showing no difference in the outcome, but the vasectomies between IRM and MTA. Yeah, I absolutely latched onto that paper and yeah, I find a IRM, I’m so familiar with it. I know when it’s on the turn and I can really start to pack it. I don’t get that with biodentine or MTA or those putties. Yeah. [Jaz]Okay. So something we already have, which is good to know. [Peter]Familiarity. Yeah. [Jaz]Exactly. And then, so just last question before I ask you about actually getting the right tools and whatnot to do this because you mentioned a little bit about the surgical kit and stuff, but what are the different things that, which you might need to get, but, just last question, grafting. So once you’ve done your, procedure and you are happy and you put your retrograde filling, do we need to put some cow bone in there or what is the sort of packing procedure, if you like, of the crypt? [Peter]None. No substitute for a blood clot. Blood is incredible. That’s why the Kardashians are putting it all over their face. Blood, blood is incredible. Our blood clot. Yeah. Just blood. You break, if your kid breaks his god forbid, breaks their bone. You just put the two ends of the bone together and the blood clot does the rest. Blood clot, no grafting, no membranes. Generally I can think about one case of where I’ve used membranes. One case I’ve used grafting. But lots of cases that have succeeded without it. But yeah, you be careful not to get too, I’m feeling I want to be careful of not getting too overcomplicated, but yeah, no, if you eradicate the infection and the blood clot will become bone. [Jaz]Okay, brilliant. So tell us about equipment, because I think so much of the success, even specialized mirrors and the ultrasonics that you said, what kind of kit would a dentist to invest in to get some predictable outcomes? So we’re as far away from the oral surgery way of doing it as possible and closer towards microsurgical endodontics. [Manpreet]So yeah, I think there’s, to be able to do an apicoectomy using microsurgical techniques. There are a few. Bits and pieces that we need to have. We’ve already touched on magnification, I think for the GDP out there. Loops. Loops are definitely sufficient. We’ve touched on the hand pieces. I think the ultrasonic tips are brilliant. Absolutely recommended. I personally tend to use a 3 millimeter retro prep for most cases, and I think that would be sufficient for most GDPs. [Peter]And just describe what they are. [Manpreet]So they’re sort of your normal ultrasonic tip is that shape, but these retro prep tips are like that. And so you can bring your ultrasonic tip in same angle as your handpiece, but that tip can actually hook into the end of the root. It can clear out about three millimeters of a root canal space. Gives you a really, really nice clean area, which you can pack your retro filling into. So I’d definitely recommend those ultrasonic tips. I’d definitely recommend, like you said, some micro mirrors. Micro pluggers. Again, micro surgically. If we’re going to see what we’re doing properly, we need small mirrors to be able to get into that root surface. We need small pluggers to be able to pack into that very, very tight space to condense that filling in there. And then, yeah, what sort of material are we going to pack it with? So we use IRM, but I guess that’s up to the dentist themselves. [Jaz]Well, I think to get a feel for the kit and stuff and to really delve deeper, I won’t expect anyone to listen to start doing it in the back of this podcast. Obviously it’s a good overview and start to get you to think about it as an option whether you are referring it or considering doing it. Tell us about the type of courses out there for dentists at the moment. Is it something that you run or something that you recommend for dentists to consider? [Peter]If I may just briefly, quick, but I once saw a Hugh 3D glossy document came out and it had various eminent clinicians talking about their ideal set of instruments for this procedure. Free gingival graft, that procedure, second stage implant surgery. But endo was overlooked, so I got in touch with them and this is probably 10 years ago now. Hu-Friedy UK and specifically Chris Mason, but we sort of put together a Rolls Royce of a kit for modern endosurgery now with a specific accent on the listeners who are thinking of getting involved. Just prior to us doing this, this evening, I was in touch with Chris Mason at Hu-Friedy, and he sort of, he might expect one or two emails from someone. And he’ll have costed up a bare bones of a kit that you could do endo with the mirror, the pluggers, the little curettes, things like that. So there’s a reasonably convenient one place gets, you could one stop shop perhaps for a, maybe a small and a large surgical kit. I think the small one’s about five instruments and the large one’s maybe about 12. On the subject of courses- [Jaz]I mean, I’ll put the link by the way. I’ll put if someone may want to get the kit. So I’ll put the link in the show notes for anyone who’s interested in the kit that you said would be a good one to, for a GDP to look into. [Peter]Courses that I’m aware of. My old buddy, Daniel Flynn is later this year, he’s toothsaver.co.uk. Later this year, he’s taken a bunch of delegates out to Columbia to do an in-depth endosurgery course. [Jaz]That is cool. [Peter]So that sounds like real intense. Yeah. Up in Manchester, endo 61 is the practice, the immediate past president of the British Endo Society, I believe immediate or maybe one prior Sanj Bhanderi. He is very active as well in promoting his endosurgery course. [Jaz]Sanj was a great guest of the podcast. I don’t know if you’ve got to listen to that one very real world about irreversible pulpitis and hot pul ps and how to manage that. So yeah, it’s anything by Sanj is always appreciated. Thank you. [Peter]Yeah. So elsewhere, there’s the Italian guys who run sort of Delta Dental Academy. I think they have an offering where it’s sort of like a live demonstration, I believe. But there’d be three ports of call for anyone with a mobile phone can send off your email. [Jaz]Yeah. Well, I appreciate you, you’re putting together some ideas, different people to learn from on this technique that you guys are so passionate about and you want GDPs to consider. I definitely think it adds a new string to their bow and makes it more fascinating and even if dentists don’t go ahead and consider doing apical surgery, in that way they’ll get a few nuggets in terms of diagnosis, in terms of what’s actually needed what to consider, what’s a reasonable referral and when they might actually be better off. Looking at the coronal restoration and re-RCT. So it paints a good picture for the GDP to consider. Any final words, chap? I really appreciate the time this evening. Any final words on, apicoectomy as an overview for the general dentist. [Peter]But one point want to say is that the listeners, Protruserati, should be emailing slash badgering their local endodontist. What we do here in Hampshire is on occasion we’ll get a dentist to send in a case. But they’ll also often say, PS, I’m sort of doing an MSC and will, it has happened where the person patient has come here, the dentist has come here. I’ve set aside a couple of hours in my time. I should confess. I take the fee, the endo fee, but I’ll watch them, supervise them, do the surgery, and usually then, where I can make it work and viable is that the dentist will then take the stitches out 4, 5, 6, 7 days later and do the follow up. Et cetera. But yeah, if someone were to email us, say, look, I’ve got this case. Do you think it’s a good one to start with then? Yeah. It is not beyond the realism that they might be able to do the apicoectomy at their local endodontic place. We do that. [Jaz]I mean, that is brilliant. I mean, that is the highest and best form of learning, right? That is way beyond you in shadowing that is actually having over the shoulder someone watching and guiding you. It’s a bit like what they do in the implant world, right? So why can’t we have it in the endo world? So, well done Peter, for having that kind of availability and allowing dentists to do that. That’s a hats off to you, mate. [Peter]Yeah. [Manpreet]So as someone who comes from more of a general dentist background and hasn’t done specialist training and always used to absolutely hate surgery and always shy’d away from it, I would say to anyone out there that once you’ve done one or two apicoectomy, they are nowhere near as difficult. Or as scary as you think they are. I would second what Peter says. That’s what I did myself. I watched a few procedures a good few years ago, got my hands stuck in to the point where I was comfortable to have a go myself. And just from doing one by yourself, you gained that confidence, that real world experience of trying to figure out what you’re doing. And then from there you’ll be happy to tackle anything. It’s just having a go at it in the first place. [Jaz]Like with anything in dentistry, like any new technique. [Peter]Almost finished with a riddle, but cause I’m conscious the time, et cetera, but getting comfortable with surgery makes your non-surgical treatment and offering better. Definitely haven’t got the time to expand on that, but it’s one that might rattle around. Yeah. You take on more, your more, if you think I can rescue this surgically should the need a right. You just become a better non-surgical endodontist if you are at least of surgically. [Jaz]Amazing. Well, guys, I really appreciate you guys giving up your time and talking about a topic that’s almost overlooked. It’s definitely the first time we’ve covered apicoectomy, so as well overdue. And I appreciate what you guys do, especially Peter with you guys having dents over and getting them to do it so they can learn. I mean, I just love that so much. So I appreciate your time. Please send me those links so I can populate the show notes with the PDFs and the links and how dentist can reach out to you to collaborate and work together and just getting advice from, because you are very good at helping dentists out based on that hopeless teeth episode that we did as well. So we appreciate your time and wisdom. I know you are a busy father as well as an endodontist. So, guys, thank you so much for giving your time up. [Peter]Thank you very much. Go from strength to strength. Good luck. Yeah, keep it up. Jaz’s Outro:Well, there we have it guys. Thank you so much for listening all the way to the end. If you are a Protrusive Premium member, you’re just a few questions away from gaining some CPD on the app. So just answer a few questions. Get your CPD email to you by Mari, who’s my CPD lead, and it’s also a great way to validate your learning. Now remember that some of the things that Peter and Manpreet shared, the documents they sent me, they’re on the website /PDP148. That’s protrusive.co.uk/148. As well as the RCS guidelines Peter’s also sent me like a recommended equipment list. Like if you’re a general dentist who wants to do this kind of treatment, what is the kit that you should buy? And that’s all there provided by Peter. Thanks so much, Peter for that, and Mandeep, and I’d catch you guys in the next episode. Thank you again for listening all the way to the end.

6 snips

May 3, 2023 • 58min

Recommend Treatment Plans with Confidence – IC038

4 snips

Apr 27, 2023 • 0sec

Internal Whitening Protocols Pt2 (Non Vital Bleaching) – PDP147

Following the cliffhanger from Part 1 where the theme was Diagnosis – we now discuss the two main protocols of internal bleaching: the Inside-Outside Bleaching technique and Walking Bleach Technique for non-vital teeth whitening. In this episode Dr. AJ Ray-Chaudhuri discussed how to prevent peroxide gel from entering the root canal system while performing non-vital bleaching. We cover every detail of the procedure and offer step-by-step guidance on how to make a tray, how much to charge patients, which gels to use and much more. https://youtu.be/5Pl238679j4 Watch PDP147 on Youtube Protrusive Dental Pearl: The full protocol workflow – summarised PDF of Part 1 and 2 of this Internal Bleaching Series plus the patient advice sheet AND lab instruction sheet by Dr. AJ Ray-Chaudhuri Click Here to Request the PDFs Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions + You can get EARLY ACCESS to the episode + EXCLUSIVE content Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 2:28 Protrusive Dental Pearl 3:40 Tips and Advice for Internal Bleaching in Practice 7:21 The Inside-Outside Whitening Technique 17:45 Internal Bleaching Protocol 23:21 Getting the proper access cavity 27:21 Dealing with patients who do not follow instructions well 31:47 Considerations and Tips to maximize success or to avoid mistakes 33:08 Internal resorption and relapse If you enjoyed this episode, check out the first part of this episode: Internal Whitening Protocols Pt1 (Non-Vital Bleaching) Click below for full episode transcript: Jaz's Introduction: Hello, Protruserati. I'm Jaz Gulati, and you are listening to this episode because you've just finished part one and you are pumped to get into the full protocols for internal bleaching where Dr. AJ Ray-Chaudhuri, or you just clicked on. Jaz’s Introduction:Because you’ve got a patient next week who’s got a black tooth and you want to follow all the protrusive pearls shared in this full guide on how to actually carry out internal beach treatment, or you are in luck because we cover all those things today. In the previous episode, so part one of internal bleaching we covered about getting your diagnosis right, making sure you’ve got a really good root canal treatment, and also the difference between a yellow tooth, which is more likely be like a calcific metamorphosis versus an actual non vital tooth. Now, why one will not need a root canal treatment? So if you haven’t listened to that one yet, please go back one episode and check that one out. Now towards the end of that episode, I left you on a cliffhanger because you got really saucy. We started talking about barrier materials. Like what material, what restorative materials should you put over your gutta percha before you put your whitening gel, right? Because the logic says that we need to put a barrier to prevent our peroxide gel from actually going into the root canal system. But you know what? I’m going to give you a spoiler now, right? What AJ actually practices is no barrier material, providing you don’t have a scope because the problem is like, imagine you don’t have a scope and you’re going to provide some sort of a barrier. Like have you ever tried placing GIC deep down three millimeters below the CEJ? And how difficult it is not to smear that glass ionomer material all the way up the tubules. Because if you smear them, then how is that whitening gel? How is the proxide gel going to enter the tubules? And that’s when you get ineffective whitening. That’s when most of the tooth whitenings, but you get a neck that’s still discolored. So his argument actually is really good. So we’ll listen to that first thing up. But we also talk about my protocol and what I’ve done as well. We go through every single detail and step-by-step protocol of non-vital bleaching, including tray design, how much to charge your patient, which gel to use, what do you put over the gel, but before the restorative material, yada, yada, yada. There’s a lot of ground we cover when it comes to internal bleaching. There’s the ultimate guide you always wished you had. Hello, Protruserati. I’m Jaz Gulati and if you didn’t hear from the previous episode, I’m not in my usual recording studio. So sorry if I sound a bit different. I’m also a little bit ill at the moment, so probably sound a bit nasal, but I look different because I’m in West London where my parents and my in-laws are. So we got a lot of family support as my wife’s heavily pregnant, expecting baby number two any day now. So that’s why I’m in a different place. But the show must go on. You’re going to love the Protrusive Dental Pearl. Not only did we summarize the both those episodes and easy to follow diagram with a flow chart just like we did for the icon one also, which is the best ceramic episode, and you can download that. Plus AJ is very kindly donated his patient advice sheet and his lab sheet, so you get. Three PDFs. Now, if you’re Protrusive Premium, head over to the app or the web app, which is protrusive.app, and then you can actually just download it. It’s there in the Protrusive Vault section. Go ahead, download it right away. But if you’re not Protrusive Premium, and if you want to gain from this pearl, head over to protrusive.co.uk/blacktooth, or one word that’s /blacktooth and you’ll get all three PDFs. So thanks AJ for donating yours and the protrusive team have put together this fantastic little diagram inspired by these two episodes. There’s loads of facets to this part two is very, very clinical, it’s very geeky. But we also talk about communication, like patients often use the word ‘perfect’. They want things to be perfect and there’s lots of connotations and things to be careful when we’re talking about perfect. Because remember, beauty is in the eye of the beholder. So AJ actually talks a lot about communication when it comes to doing this kind of treatment, which I think is absolutely golden. So please enjoy this episode, I’ll catch you in the outro. Main Episode:Any tips and advice you can give to the humble GDP try and do this in practice? [AJ]For the humble GDP who does the vast majority of the dentistry in the UK. I’ll tell you what I do. I don’t put a seal on that. And I was taught this technique by Martin Kelleher and he published that paper, the original paper, one of the original UK papers with Poiser. Peter Briggs and Martin Kelleher and he said, ‘AJ, why are you sealing it?’ Firstly, you can’t do it well. And for the exactly the reasons you described, because this is when I was a first year registrar, I couldn’t use a microscope. I couldn’t use that microscope until much later. So he goes, ‘AJ, you’re just going to smear all of this up the walls. It’s going to look like a bird poo in there’. And the second thing is, he goes, ‘and also what you’re filling it with, we are filling this with carbamide peroxide, which is dissociating into hydrogen peroxide’. ‘ What is hydrogen peroxide, AJ? What’s Its job?’ Obviously as a 28 year registrar, I not the first idea, and Martin Kelleher is just in many ways a polymath, and we say, ‘well, AJ, let me give you a history lesson and it would be a long one’, but cycle forward, he goes, ‘well, have you heard of Vincent Angina?’ No, ANUG. We just about heard about it. Trench mouth, maybe heard about it. He goes, ‘well, actually, one of the reasons we used hydrogen peroxide was actually because it releases lots of oxygen, is very good for killing anaerobic bacteria. And that’s all they kind of had a hundred years ago to stop ANUG and ANUP occurring in the trenches’. So one of its primary jobs as we discovered it is to kill bacteria. So you’re filling this entire chamber with a enormously hostile oxidizing product. You’re not going to get any bacteria in there, AJ. And actually- [Jaz]Especially for the short while that you’re working and doing this procedure, it may not be worth without a scope to make it so messy with the glass enema. So I really respect that you said that actually, if you’re in that scenario and you haven’t got access to a scope and you haven’t done this before, then maybe just to have a really good root filling root seal with the GP at the correct level, three to four millimeters below the CEJ. And then allow the proxide to get in there. Right? [AJ]Absolutely. And except that’s a niche, that may be a niche opinion. And if I’m doing my own whitening, which I almost always do, but if I’m returning it to a colleague, right? The colleagues that I work with in private cloud, they’re just brilliant. I’ve got no problems that they’re going to drop the ball. I worry about the patient in between who goes floating off, and that’s when I want to seal something. So under those circumstances, I will see it. If I’m doing the endodontics of somebody else. I don’t have any strong views on what should be in there, really. I think it can be GIC. Or it can be something like IRM or kalzinol, so something zinc oxide eugenol based. But I’ll be placing it using a microscope if you’re going to do it. It doesn’t have to be a microscope, but I think you need magnification. And the trick is not to go runny. The trick is to the opposite. You get your nurse to get it, let’s say GIC or whatever. And so it’s almost crumbly. And then you pick it up and you pack it in there. So it should be rollable into a sausage and you pack it into and go for the tiniest amount you can. Pack it into there and as long as soon as you’ve got a seal of a millimeter or two, you’re fine. But the important thing is not to smear it up the walls, and that’s one of the reasons I quite like. Something like radio-opaque ketac chem which is a white GIC, old-fashioned GIC. Or IRM because it’s white. So if I have submitted up the walls which you will still do, depending on how closely you look at it, then you can identify that that needs to be removed before the whitening occur. [Jaz]Plus you’ve got the pluggers that can reach there and do it. So if you don’t have those pluggers, how you going to reach that far below the CEJ? So you’ve got to have the right tools to be able to do that. So if you are really keen to seal it, then maybe consider, are you going to make a mess of it or not? So I think it’s a really tangible, really key gem right there actually. [AJ]You need a masseter, or you can plugger to do that to a high standard. [Jaz]Exactly. Now in that scenario, so you are tending towards, I think, based on the PDF you sent me, walking bleach technique, right? The inside, outside technique. That’s your preferred technique. [AJ]Yeah. And I- [Jaz]Can you describe this technique for young dentists and students listening? Because I stopped using that technique a while ago. I use a different technique, so I’ll be able to share mine. I’m sure you probably use it as well, but if you describe this technique, I’ll later tell you why I moved away from this one. I’m sure you’ve spaced these exact same issues as well. But your handout was much better than the advice I used to give my patients, so it’s probably something to where I dropped the ball. So please. [AJ]I mean, an insider. So I, again, I’d never come across this until I did registrar training, and it’s in essence, it sounds a bit obtuse, you’re leaving the access cavity open, and what the patient is doing is the patient is using the gel, the carbonide peroxide, and they’re inserting it into the access cavity, and they’re replenishing it. They leave it overnight. And when they’re awake, they replenish it every couple of hours and at the same time, they replenish that. They use a normal whitening tray and they put a blob of it on the front of the tooth. So then they’re both bleaching the tooth from the inside, intra-coronally and extra-coronally. [Jaz]And do you again put a window adjacent teeth? [AJ]Yes. Yes, I do. Because otherwise what they’ll do is everything will change color and actually the other teeth will then go whiter quicker than the dark one. And actually they’ll get worse. And I did do that a few times. I made plenty of errors, especially as a registrar. I was in a very safe learning environment where they’d laugh at you and then they’d help you. So yes, if you don’t cut out the adjacent teeth, they’ll whiten everything else. But what I found is this works extraordinarily quickly. The first time I heard it described, I thought, this ain’t going to work for toffee. But anyway, I thought I’d go with it. I mean, I’ve had patients who phone you easily with like the next morning and say, this tooth is already white than the other teeth. It doesn’t always work that quickly, but you really get very excellent results within, let’s say a week, two weeks max, if it hasn’t worked within two weeks. I’ve had a few patients in the past where it’s got two weeks and they’re like, it’s better, but not quite. And I know they’re not doing something right. Or they’re basically just misunderstood my instructions, in which case it’s my fault. But most of my patients, it has rapidly, the problem is, that level of rapidity is that actually I can’t get them back in time. Quickly enough to do the next things. If you’re friendly up within a day or two to say, I want to see you, that’s actually a bit problematic. [Jaz]Yeah, I agree. That’s why actually getting them in the diary and zoning them in that way is to predict how quick that’s going to happen. Usually I agree with you, happens very quickly and let’s say you’ve got a compliant patient happens very quickly and they’ve got the gel at home in the fridge and they’re, every couple hours, they’re replenishing it, they’re washing out, replenishing. And obviously using something like a TePe brush and single tufted brush to clean out the gunk. [AJ]Yep. Yeah. [Jaz]Obviously when they’re eating and stuff from inside there. So very important to have a good compliant patient with good hand skills to do this. And then once they’ve done it and the tooth’s gone much whiter, then they come back to you. Can you just explain, can you just finish off the protocol and then we’ll talk a little bit about the mini steps within the protocol? [AJ]Yeah, sure. So then once I ask them to over bleach the single tooth, And objectively, I just say, so it’s visibly whiter than the, sorry. Subjectively I say, ‘look, just tell me when it’s visibly whiter than the adjacent teeth’. And objectively, I say, ‘look, if it’s 10% whiter, but I mean, look this is more arts than science, but I know there’ll be a degree of relapse’. So as long as it’s visibly whiter, then that’s the time to stop. Nowadays with social media, people are sending you lots and lots of selfies. Selfies didn’t exist. Unfortunately, or fortunately when I did this after I started doing this. So you can really get a sense of the direction of travel if they’re kind of 90% there within a day. You can’t wait two weeks. So once they’re happy, and I’m happy I get them back in. And the first thing I do is I clean it up a little bit, something simple, clean it up a little bit and I will put some endo sponge in there or some sort of, so I don’t put any cotton wool roll, or cotton will pledges in there. I will use endo sponge or something visible, which is bright blue or bright purple. And all PTFE tape is quite reasonable. [Jaz]Yes. [AJ]And then I’ll put just a plug or something simple like IRM over the top of it. And then I’ll leave them alone for a reasonable period of time, minimum of 48 hours for me. But, if it’s a reasonable plug of IRM they could be left alone for a week, two weeks, a month. That’s quite reasonable. And the reason I don’t go directly to the final restoration is, again, is not evidence based, but working on first principles. We know, like with resin based materials, composites, things like that, the oxygen inhibited layer is both a good thing and a bad thing. Oxygen inhibited layer means that there is a layer on top of our, let’s say, our composite, which isn’t fully polymerized, but it means that it allows modern composites to stick to itself and you can layer on top. When I was an undergrad, we were sometimes taught to put composite down, put another layer of resin, then put another composite down, another layer of resin. I’m showing my age here, but we don’t need to do that because you have a layer that sticks to the next layer because of the oxygen inhibited layer. However, the final layer of composite being oxygen inhibited means it’s kind of sticky and not fully polymerized, and thus people will use glycerine or some sort of barrier product to like cure through that. Yeah, but the reason I’m drawing attention to that is if you think about what the whitening process is, that whitening process means that the tooth will cons still be releasing oxygen or free oxygen species for a period of time after the whitening stops. So if you put your composite straight in there, you’re going to have a layer of unpolymerised composite exactly where you want your coronal seal. So what you want to do is you want to let all that oxygen be released from the inside of the tooth before you do the final restoration. Does that make sense? [Jaz]Which is why you go for the IRM and then at some point later, now at this point, you’re going to make them a new tray to do the whitening all around for the rest of the teeth, a new whitening tray. [AJ]Good question. So the answer is, it depends. So the time to do your impression for your inside, outside white training is on the consultation. Or just before you do the access cavity, because on the palatal aspects of my whitening tray, there’s no divot that goes into the access chamber. It just completely covers over the top. So what that means, it allows the patient, let’s say, is it just a single tooth problem, right? It allows the patient to continue reusing that tray then for a very long period of time. If the tooth, let’s say, they’re not happy with the tooth or whatever gets dark after a year or two, they can use the same tray again, my tray to re-whiten that single tooth. If they want to whiten all the other teeth, I need to know that beforehand. And even if they don’t mention whitening, I have a conversation. I say to them, ‘look, please don’t misinterpret this. I’m not in the sales business. I don’t think there’s anything wrong with the color of your teeth. And nor do I want to sell you tooth whitening. But if this is on your radar for your other teeth, you must let me know now cause I need to plan this differently’. Because then what I need to do is I can’t get the patient to over bleach by 10%. Compared to the adjacent teeth, I need them to over bleach, so it’s 10% whiter than the final color. They want all the other teeth. That creates a bit of unpredictability, so they sometimes have to go for a very white tooth, wait for that to relapse. Then their target tooth is white than their other teeth. Then they get their other teeth to match. When they get some degree of relapse, then they have to use two different trays. And it takes a level of bit of sophistication for them to understand that just re whitening with a normal tray will never get them exactly the same result in the future. So there’s a level of- [Jaz]Yeah, it’s part of the consent process there that, look, this is, we’re going to significantly improve things, but there’s going to be a little bit of difference if someone comes up close sometimes. And we were talking earlier before we hit the record button. There’s these two really cool handouts, which you sent me, which had this addendum at the bottom, which shows patients examples of what this patient here because there was a rotation and also because this tooth was difficult to bleach in the neck area. There is a difference, but it’s still a lot better than it started off with. So it’s not really a failure because it’s a great improvement, but so that the patient doesn’t interpret that as a failure if it happens to them. You’ve already shown them as part of your consent process, at the beginning. So I really like that. [AJ]And oddly, of course, this is just a matter of perception, right? If a patient has been walking on a single dark tooth, they’re like, I’ve got a single dark tooth. They don’t notice the rotations and the whites and things. They’re just obsessed about that. You get rid of that. Then they go, ‘oh, my teeth are crooked’. I was like, ‘yeah, they were two weeks ago’. But now of course, now it’s a thing, right? So if, if it’s a cosmetic thing, I try and draw attention to it a bit earlier. If they’re not, I just say, ‘oh, just remind you, this is exactly the same as it was before. You were crooked before you’re crooked now’. The wording we use is important, I think unfortunately, is permeated. The word perfect has permeated in our vernacular in our profession. And I don’t like that word because I can’t deliver that. And if the patient uses the word perfect, I pick them up on it. I say, ‘oh, you use an interesting word, perfect’. Because perfect means it’s a categorical, it’s perfect. And it’s really important that you realize I absolutely cannot deliver perfect. And if you want a perfect result, you need someone better than me, because I can’t do that. What I can do is I can make it significantly better. But I can’t make it perfect. And I try and again, some people being a bit more objective, I say, ‘well, what would you describe the cosmetics of your teeth being?’ And they’re like, out of 10. Oh, is it three? Is it four? They’re like, ‘oh, it’s five’. I say, ‘okay, fine’. So as I’ve told you, I can’t get you to 10 out of 10, because 10 out of 10’s perfect. But what number, if I got you two, would make you happy. And a lot of patients go, ‘oh, if it going to seven, I’d be happy. Or if an eight or a nine’. If someone’s a nine, you’ve got to think, okay, can I get there? But if someone says 10, you need to get out. That is a big. [Jaz]This is such good advice. Like if those listening, just rewind the whole minute. Listen again to the conversations that AJ has with patients because as a young dentist like you hear your patient use the word ‘perfect’ and you may not think anything of it because just like you said, the word is banded around so much, perfect dental, spa, whatever, all these names of practices they’re calling themselves perfect smile. How do you set those expectations? So I think it’s a great thing you mentioned to pick up on your patients and actually just pause a moment. Okay. You use interesting word. Let’s talk about this and certainly this can sometimes bite you in the ass. So definitely pick up these terms and make sure that you set realistic expectations. [AJ]Always. And one of my things is with my team always, I’m saying, look, I want to under promise and overdeliver. If they’re expecting a 7 out of 10 result, I’m not going to get a 7 out of 10 result. I’m going to do better than that. I know that. I’m going to tell them that, but I know that. Under promised, over-deliver. [Jaz]Amazing. So now let’s say you’ve got the full tray. Now you’ve now whitened everything, the patient’s happy, you’re then going to replace the IRM with some composite. [AJ]No, because if you- [Jaz]GIC? [AJ]Sorry, I’m being a pedant here. If you replace it with some sort of anything, you’re going to have a problem. So I think you’ve already realized I am a bit of a pedant, and this is not a simple, quick, cheap process. This has going to be done to exacting standards. If you whack a bit of composite in there, it’s going to fail. So, as you can imagine, I have a proper protocol for it. So this patient needs to be booked in for a long appointment, alright, a reasonable appointment rather than just me cramming some IRM there, rubber dam isolation back on. Of course, IRM comes out really easily, you get a bit of a poke or an ultrasonic, something like that. I’ve got bright blue or purple endo sponge, which I take out. Pretty easy. I’ve got a really quite a long access cavity so your standard composite, if you just put some composite in there, you will absolutely get a void 100% of the time. So that ain’t going to work. So the next thing I do is I irrigate it with some hypochlorite, simple hypochlorite, dryer. And then I use some isopropyl alcohol. Yeah, and this bit, again, it’s maybe a bit controversial, maybe not that controversial because you can buy it in the UK for endodontic purposes. But one of the isopropyl alcohol is brilliant at is getting rid of all the bits of eugenol. Some of our colleagues will be concerned that actually I’ve introduced eugenol into that area with IRM or kalzinol, which is a zinc oxide eugenol, that’s fine. But actually the way to get rid of Eugenol is isopropyl alcohol. But it’s just another way to get rid of all the other crud that’s developed in that area. So you have a meticulously clean endo chamber. Then you go back to your bonding. Okay. So this is, in my opinion, like using a one step or bond, et cetera, is not going to work. I go back to a very, old-fashioned, boring, three-step bonding protocol, etch prime bond. I personally use Opti Bond fl, but there’s lots of- [Jaz]And I knew you’d say that. Yes. Good man. [AJ]Predictable, but optibond FL has been ED before I went to dental school, so it’s mid 90’s, so we got nearly 30 years of data on it. So, but the first mistake I used to make, I’d get all of it really good. I’m really happy. But actually if you get pooling of your, even though it’s 48% filled, if you get pooling of your primer or your resin, you get this little layer. Now, in the old days when I graduated and an x-ray was that big, you couldn’t see it. Nowadays the x-rays are that big and it drives you a bit potty having this light. So the trick is you do the etch, you get it immaculate, isopropyl alcohol, sorry, then etch. Then you put your number one, which is, let’s say your primer. [Jaz]Primer. [AJ]You try and put the smallest amount you in and you’ll still put in too much. Then you’ve got to spend the rest of the time rubbing it all out, really rubbing it over those areas, over the dentine, but not the enamel. So you’re taking it out more than you put in. You air dry it and don’t blow some air in it. Like no matter how good quality your three and one tip is, you’re going to blow some water in there. So you either use high volume suction or you blow the air onto your mirror and then you use your mirror to blow the air into there. You get that spotless. Then you introduce your resin. And then again, you’ll have a pool of it at the bottom. It always happens. Then you’re going to spend the rest of your time getting it back out. It’s really important. Then, because the cavity depth is so low for me, I can’t put a standard composite in there. I mean, it’s all I can, but it doesn’t look that good. You have to do it in really small increments. So one of the changes in my protocol is I use SDR. And I get it right to the bottom of it, and I basically jiggle it around, make sure I get rid of any of the voids, and then I slowly backfill it. And then, right. But I don’t leave my SDR exposed, so I still cap it with some normal composite, something radiopaque like gradia PA one. [Jaz]Is that because that’s part of the protocol with SDR? I don’t use SDR much. I used to use it. Or does a dentsply claim that you can leave it exposed? [AJ]So, good question. So I think certainly it was described that it shouldn’t be used in occlusal loaded areas. So I think they would probably say that it’s quite reasonable to leave it on the palatal aspect of a central incisor. But I don’t fill the entire access cavity, and it’s the same way I do endodontics outside of the aesthetic zone. I will fill the base layer with SDR. And then I’ll put a capping composite. It’s still quite recognized to do a normal capping composite for occlusal areas. And I ideally that want that. You should have that radio opaque because again, that last bit of composite is radio lucent. Again, it’ll drive you, it won’t annoy anybody else, but it’ll annoy you. So, that’s my protocol. So can you see actually though, that’s why I was thinking it’s very different to actually just whacking in some composite, because you whack in some composite, you’re going to go around in circles. [Jaz]On that note, one thing I tend to do and please let me know your opinion and if you disagree, that’s totally cool. Something that Ian Harris taught me, if you know, from Sheffield where I did my DCT is Phil, I actually do the seal next to the GP, if you like, with, GIC. So let’s say you’ve done your internal beaching. Everything’s gone well. And you now you’ve got this large and long access cavity. About 70% of it will be with a glass ionomer cement and then the final 30% with composite, because of the predictable of the chemical bond to GIC, is that a bit outdated you think? [AJ]No, not at all. And in fact, when I was taught depending on which consultant would supervised me, some of them would say fill the entire lot with GIC, it’s completely fine. that’s chemically bonded. Others would say, do it that way. Actually no one taught, but SDR didn’t exist. You know these back then, if it was like a highly flowable composite with just lots of resin and not much filler. So actually you didn’t want that. And that’s very, that’s different to SDR, even though it might look similar. So it was always GIC either the whole lot or with capped with composite, and I think that’s still very reasonable. I don’t think something, if you were to inject some GIC into that in my hands, that would just put lots of voids in it. So if you’re going to use GIC, you kind of want to do the opposite. You want it so it’s quite thick. Again, like a sausage, take a little bit of powder onto your plugger, and then plug that GIC so you’ve got a really nice densed GIC layer. And then either leave it exposed or put a small amount of composite over the top of it. [Jaz]Okay. Just in case anyone’s not got SDR and they have, so, GRC composite is a valid way to do it. I appreciate that. And then one thing that we didn’t actually discuss, which I found to be quite significant is the access, a proper access cavity and making sure that you remove the horns of the pulp chamber. Because a few times where I’ve had a slow start and I’ve actually gone back in and checking the modification after actually, there’s so much of the pulp chamber that I haven’t removed or has not been removed properly. And even especially as endodontist, we all make mistakes stuff. Previously I got one back from them and I thought, ‘whoa, hang on a minute’. And I’ve got photos of me having to open it up and exposing the pulp chambers. And now this was amenable to good whitening. So the mistake I made in the past is actually making these tiny access cavities. Well, actually you want to make them full form because a lot of these people are young when they have the trauma and then you get intrinsic bleeding into a tooth and a black tooth and whatnot. And quite a lot of these patients are quite young. Any comments on getting the correct form of the access cavity? [AJ]But I’m glad you actually, I’d forgotten that, but that is a common error I used to make because you take the history of where the patient rocks up, right? But really you’re treating a 10 year old tooth, a 10 year old’s tooth on a 40 year old’s patient. So yeah, you’re used to access cavities getting smaller and smaller, but so yes. The mistake that I used to make was exactly that. So if we take a step back, really what you’re describing is that they would bleed their hemolytic products from the pulp. They break down, they create iron. The iron gets stained and that causes that red staining, right? So your access cavity needs to be appropriate for, let’s say a 10 year old or whatever they were. Ultrasonics, I think make quite a difference to me. So ultrasound’s a very important part of my access plan and what other things do I do? So, yeah, so I mean, taking up those pulp horns and like an Endo Z bur can be quite reasonable. But on that theme, actually, as you know, rightly, access cavities are getting smaller because of armamentarium and things. And endodontists rightly are obsessed about saving peri-cervical dentine. [Jaz]Ninja. Ninja, access cavities. [AJ]But that, that is very good from an end Doty point of view, but in the aesthetic zone that if I had a ninja access, that would actually completely compromise my endodontic treatment. So under those circumstances, I still like, as part of my access to use something I guess would be considered a bit old-fashioned, like a Protaper SX bur, which will flare the coronal access much more. It’s got a little bit like maybe a Eiffel tower shaped and making sure that actually that that’s flared quite nicely. And sometimes I flare, if the demographics I treat sometimes are older patients who still knock their tooth earlier. I take my access cavity might be larger than you would even think because some of them, especially in the laterals, have had amalgam in there. Now that’s quite an important subtle thing because actually even if the amalgam is now gone, the staining for the amalgam is still there. And unfortunately I’ve seen one or two that the tooth has gone a bit green. And one of them was properly green and I had a panicked friend and colleague telling me about it. And actually it is actually at that stage, it’s a bit tricky to to deal with. But the history of that is what they would’ve had is an old amalgam with high copper content and- Have you been to the United States, been to New York? [Jaz]Yep. [AJ]Do you see the Statue of Liberty? [Jaz]Yes. [AJ]What color was she? [Jaz]Yes. Yeah. Very, very green. [AJ]Green. Right. So here’s a fun fact for you. She was not green when she was delivered. She was actually a lovely golden bronze colored copper. It was height she had covered in lots and lots of copper. When there’s a guy called Bardi, who designed her, and it was made by George Eiffel, Eiffel Tower fame. And over these many years, she’s become greener and greener because the copper in here has become oxidized. And with the old high copper amalgam, it’s the same process that causes the teeth to go green. But the problem, that’s not just the amalgam, that’s all the bits that have actually gone into the dental tubules. So I’m afraid you’re going to have to drill quite a lot of that out because you can’t actually get those amalgam products out of these lateral incisor kind of the pit. [Jaz]I’ve never actually seen that, but I can imagine it’s not a pretty scene and I don’t want to ever see it. [AJ]I look like a Hulk. [Jaz]Yeah, fine. That’s very interesting. I’d never heard of that, but it’s a good point to make sure you get all the amalgam out those just because of time and stuff. I want to talk about an issue I had using this technique, which I used for some years, is that, some patients were just hopeless. Have you met a hopeless patient that you’re constantly having to pick bread or something out of the access cavity and they’re just progressing slowly and because they’re just not able to clean, even though you made this perfect access cavity, you’ve rehearsed it. And in your handout I said that you given a little mirror to see and stuff, but some patients just can’t do it. Have you experienced that? [AJ]More recently, no. But I guess it’s part of case selection, but certainly in the past, because I didn’t really understand. This is for an educated patient. I don’t mean someone with lots of letters often though. They’re seeming to be deadly educated, and they need to be dextrous. So under those, if they cannot do that, this is where we talk about failure. These are the patients who, to be honest, they will still get in my hands. They’ll still get a very good result, but they won’t maximize their result. It’ll be good, but they’ll never get to excellent. So that’s where you got to work it out. If it’s a patient who’s completely uncompliant, then this technique won’t work. So in between, if I was to come across that in the future, I think then that’s where like some of the walking bleaching techniques would be appropriate. [Jaz]So that’s what I use. Maybe if we’ll talk about that, if I’ll just describe to you my technique. What I do now, nowadays is patient comes in for consultation. Make sure you get your diagnosis correct. Make sure that everything we said before that the tooth is ready to go with the lovely seal. So usually, Caesar would see them and do the endodontics and bring up this perfect plug of resin or GIC, whatever it is. And I can see beautifully inside there. So at that appointment, I would scan their teeth ready for whitening trays. I would then actually put rubber dam on, gain access, and place my carbamide peroxide inside there, followed by a bit of a PTFE and followed by some IRM. Okay, I just leave that on. And then a few weeks later, when they come for their whitening tray fit, the tooth a lot of time is significantly whiter already. I would then reaccess the tooth. Wash it out, replace the carbamide peroxide gel, make my seal again with IRM, and then now give them the whitening tray and then they’ll be doing and then sometimes I do it where they have the adjacent teeth cut out and sometimes I’ve been brave enough because it’s going well just to give them the full tray. And then they come back a few weeks later and now everything’s whiter and the tooth is whiter. So you got to pick your cases. I guess. I have been burnt before where all the other rest teeth whiten and there’s one lags behind. So you got to just pick and choose carefully. And then when they come back for the final time, I’m then happy to wash it out, my GIC all the way, and in the future checkup, I’ll then replace that last bit with composite. So that seems to work well in my hands at the moment. And that’s my preferred way at the moment, just because to get someone in a few days later is a nightmare. And so sequencing wise, I like that. Have you experienced this technique? Anything that you think that we should be careful with when doing this technique? [AJ]No, I think actually that’s for a less compliant patient that is, or someone, I think that’s a far, when I say safer technique, as in like your results will be, they’ll be slow, but they’ll be predictable. The walking technique. There’s a degree of unpredictability about it. I think it will always work. I don’t know how quickly my technique works. So under those circumstances, yes, I’ll happily seal it in. But with that technique that described and my technique, have you thought about how time consuming this is? This is not a quick solution to something. The very little data there tells us this is five to six hours that we’ll be spending. [Jaz]Wow. Okay. So I’m spending way less and like typically I charge around about 900 to a thousand pounds for a single tooth. This is after they’ve got their root canal and they’ve paid, yeah. After endodontics they come and see me and all I’m doing is the whitening, the access, two times the bleaching, and then the restorative. So we’re spending in total about one to two hours. So, that’s my fees. But I think, I guess if you include the consultation appointment and the root canal and the follow up review, then yes. That they can add up to that much. [AJ]You’ve got to charge for the review. You’ve got to factor that in and that’s fine. So really what you do is you take your hourly rate, you multiply it by how long it takes you, you add your laboratory fees. You include the review equipments. That’s how much you- [Jaz]I mean, the lesson there, the great lesson you shared there, AJ, and it could have been missed, is that, when you’re doing these internal bleaching techniques, don’t charge for just a little bit more than your normal whitening. This should be significantly more than your normal whitening by multiple fold because you are re-accessing in the tooth, you are placing rubber dam, but you’re doing all these things which are time consuming. Very good point mate. [AJ]So, and ultimately, look, we are here talking about this because it’s the right thing to do, right? So why charge less for doing the right thing? What we don’t want these patients to do is wander off and have a veneer or a crown or things like that if that’s not indicated on these teeth. So, we’re going to charge well for doing the right thing. [Jaz]Yeah. Very very good point mate. Any final considerations or tips that you want to pass on to the young dentists listening who may be coming up to trying it for the first time and looking into which techniques they can use to maximize success? Or any mistakes that you’ve made in the past that you just remembered that you want to share? Anything that you could share with us? [AJ]Yeah. Well, I mean, yeah. All of this, I’m telling you is based on my own mistakes. So, I mean, I’ve given you the way I do it. So having an educated patient is quite important. Them really understanding and just from a legality point of view, that you’ve going to remember that the currently we’re in the first course of whitening needs to be done by the dentist. So what that means to me is, I want to load the gel in there and I want to put some on their own. Start them off as they leave. And then I’ve fulfilled my responsibilities as doing the first course of whitening this is in the UK regarding cleaning. Go on. Tell me. [Jaz]Cause two things I actually just sent my notes now that I want to discuss and I forgoing to mention. So let’s just also touch on what do you tell the patient regarding relapse and also what do you tell the patient and do you worry about internal resorption? When I started to do this techniques many years ago, My principal said, ‘oh, but make sure you’re warned by internal resorption’. And so I’ve never experienced it so far with any of my patients. I believe and you’ll know the history of this way better than me, is that this used to be from times when we used to use much stronger chemicals to whiten the tooth and also heated techniques. I believe they used to get a ball burnisher and put flame to make go red hot and then stick it inside, which we don’t do anymore. So, is internal resorption a as big of a concern now than it used to be? And then also just talk about relapse. That’ll cover all bases. [AJ]Fair enough. So firstly, we are looking at survivor bias here, right? These are often traumatized teeth and traumatized teeth get resorption. You just didn’t realize it before, and someone did whitening and then there’s a resorption. Then two must come together. It’s a classic post-hoc fallacy, right? So actually now I do kcts and I see there’s plenty of preexisting resorption for a start. So that’s one thing. And secondly, that was one of the real concerns. You will probably be too young to remember, certainly when like, so tooth whitening was illegal when I graduated. It’s illegal by the letter of the law and only became legal not that long ago. Let’s say probably legal in the last 10 years, something like that. [Jaz]I think it was 2010. [AJ] Something in that region. Yeah. And one of the problems was there were questions about safety. Now, because people were mixing up all these techniques. Yes. So the classics sort of, is it spazzer, I think. And then there was the nutting and poe techniques from the early sixties where they used these sodium poborate and heated them and they’ve released enormous amounts of hydrogen peroxide, what would now be illegal amounts of hydrogen peroxide, and it’s one of the reasons that the European laws came in for this particular thing is to actually, to stop these like very large productions of hydrogen peroxide. So that’s why we are limited to 6%. So carbonide peroxide kind of, there’s different kind of ways that it dissociates, but fundamentally it splits up into urea and hydrogen peroxide, and then the hydrogen peroxide usually disassociates into water and free oxygen species, right? And that’s what caught the whitening. So even though we are buying high carbonide peroxide, really we are, the law relates to the hydrogen peroxide. So 10% carbamide peroxide, 16% carbamide peroxide is fine because it disassociates to less than 6% hydrogen peroxide. [Jaz]By about three to one. So the maximum would be about 18%. Carbon peroxide would be- [AJ]But interesting if you’ve got to be careful because you can certainly buy a lot more than that in the UK. So if you went on the internet, you can get, let’s say po. 22%, which is completely fine, but actually is not designed for the European markets. And is, you can buy it, but you can’t give it to your patients because it’s illegal, unfortunately. So just be a bit careful of that. But these old-fashioned techniques used to disassociate the massive hydrogen peroxide, which were heated and would cause resorption because fundamentally they’d kill bits of the cement blasts and the periodontal ligaments, the sharpeys fibers, and they would lead to resorption. But that is very different to the carbamide peroxide that we use now, which disassociates it to very small amounts of hydrogen peroxide. And that’s part of the basis that we have a legal limit to what we can provide for our patients. So do I worry about internal resorption or external resorption? Well, internal resorption, no. Cause it’s a pulpless tooth. External resorption, no, I don’t worry about it in as much that I know I’m not going to cause it. But it’s preexisting in more patients than you think. And you’ll realize that the more cone beam CT scans you take. [Jaz]I mean, that really aids us in terms of making sure that when in doubt, a CBCT scan, like you said, really has its value. So that’s, that’s a real gem that you shared there. And regarding relapse, I always find that even just for success rate, I find that the black teeth whiten super well to white teeth in my experience, but sometimes the dark yellow, orange ones, That, maybe still leave a tinge of yellow brown. And then someone once told me that, I don’t know if it’s evidence based or not, that perhaps those orangey ones are also the troublesome ones when it comes to relapse, but I have no scientific basis or data on that. But in terms of relapse, what have you observed and what do you tell your patients? [AJ]Okay, so they all relapse in my hands. They all relapse. And that’s part of my consent process to say, ‘look, I can’t do any dentistry that lasts forever’, but we have failures. There are good failures and there are bad failures. If you do a full mouth of a full arch of implants and they fail, that is a bad failure. If you have a single tooth, which you have done a root filling on, and you’ve whitened that, it gets slightly less white. That is a different level of failure. So I kind of talking about it early, that’s just part of the consequences. [Jaz]AJ, I think the true failure would be to not talk about failure when you’re doing this time trip. That’s the true failure, right? [AJ]If you miss your future, talk about failure at the beginning, that’s when you get yourself in hot water. So the orange, so personally, I haven’t noticed that subtle distinction, but can I go back to diagnosis? Diagnostically, they’re usually different if you’ve got a tooth which has not been root-filled. And has got blood products in there and they go that brownie, black color purplely sometimes, they white in fantastically well and equally so do the ones which have discovered cause of endodontic products fantastically well. Cause you can solve the problem if, but you mustn’t confuse that with the patients who actually have, let’s say, have a vital tooth and have orangey brown discoloration, which you often see when they get sclerosis because really what they’re doing is building more and more and more dentine. So those two are not comparable because the one with more and more dentine on a vital tooth will be harder to whiten and will relapse more because they still grow more dentine, whereas the ones you do the proper internal external whitening on will, again relapse, but will not relapse at the same rate. And just because they’ve relapsed, my patients have unfortunately been standing still long enough to see plenty of my own failures. It’s actually very easy because often you could just reuse their same tray. You don’t need to do internal whitening again. All you do is use that same bleaching tray that I’ve given them to just target that one tooth. And what they need is just some more gel. And that could be from me, that could be from their general dentist. As long as it’s from a regulated healthcare professional, it doesn’t matter. So as failures go, that is a real good failure. [Jaz]When you put it like that, in that perspective, that is really good to hit. And I think those who are considering to do this technique, don’t be scared. As long as you get your diagnosis right and you have a plan and you want to use one of the protocols that we discussed. AJ, this was immensely valuable. I’ve been getting asked about this kind of topic and I’ve been looking for the right guest. So I really appreciate you coming on and discussing this, I think your experience and your handouts. Do I have permission to share your handouts with the Protruserati? [AJ]Absolutely. And any of the papers and stuff like that. I can certainly give them to you. I don’t know if, if you’re allowed to distribute them or not, but no, look, we’re standing on the shoulders of giants. I’ve quoted lots of names, but not to name drop, but I’m just, I’m really just reusing what I’ve learned from them. And as, as you do so, no, please- [Jaz]Always, always, absolutely that’s the name of the game and that’s how we just share what we’ve learned before and improve one day at a time. So, AJ this has been absolutely amazing. Just tell everyone where you work and someone who has a tricky case maybe near you and whereabouts, exactly. What’s the name of your practice they might want to refer patients to? Also any educational content that you have. Any courses that you run? Perhaps, you involved in teaching? Cause I know you said you did a BDA webinar recently. So tell us about those kind of activities. [AJ]So my practice is in Hasek, which is just north of Brighton. About our catchment area, because we’re a purely specialist referral practice, we have, there’s about 10 or 11 of us all specialists and consultants. So we see patients from all over Kent Surrey and Sussex. We do a lot of children’s dentistry and things like that. And I don’t do much national lecturing or anything like that, firstly, cause I don’t have timers. I’ve got three daughters, but also because we just do our in-house CPD evenings, they’re free. We have dentists which come over from all over kent Surrey and Sussex just come and hang out. You’ve seen how I lecture. Most of my lectures will be about the things that I’ve messed up and what I’ve done to get myself out the c [Jaz]I love it. I love it. [AJ]So they’re free evening lectures at Greystone Referral Center. And then I do a few some of the national talks. I do the BDA cone beam Masterclass, and I teach on the BDA restoring implants masterclass. And that’s pretty much and the rest of the time I’m just in private practice doing lots and lots of dentistry and making lots and lots of failures. And having a laugh about the woodwind makers and learning more, and then doing the best I can. [Jaz]I really appreciate your humility and your humble attitude. It’s really nice to hear. And AJ, thanks from Protruserati for coming to making this complex topic a little bit more easier to manage and breaking down really nicely for us. So, thanks so much and it’d be great to have you on again one day. I think I really like your style and the way that you brought in some stories and we end up talking about the Statue of Liberty, so that’s pretty cool. So thanks again for your time. [AJ]Pleasure. Jaz’s Outro:Well there we have it guys. Hope you enjoy that very detailed guide into internal bleaching and all you have to do if your protrusive premium is answer a few questions and yet again, you can get another verified CPD or CE certificate and a chance to validate your learning, what’s not to love about that. Don’t forget in the Protrusive Vault section to download those three PDFs that we’re giving away at the end of this episode. And if you ever have a colleague who’s stuck on internal bleaching protocols, you better direct them to this episode. So thank you once again for listening all the way to the end. I’ll catch you in the next one. I don’t know exactly when the next one might be. Might be in four days time, might be in eight days time. It depends on when baby number two lands. It may have landed already by the time you listen to this, or I might be patiently waiting for baby number two. We’re super excited. Thanks for all your love and support guys, and I’ll catch you in the next one.

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Protrusive Dental Podcast

Episodes

Mentioned books

5 Things I Do Differently 10 Years after Dental School – AJ004

No Post? No Crown? The ‘Anti-Biomimetic Dentist’ Part 2 – PDP153

Audio Recording Your Consultations? The Future of Dental Record Keeping – IC039

The ‘Anti-Biomimetic Dentist’ – Restorative Lessons from Pasquale Venuti Part 1 – PDP152

Prescribing Antifungals as a GDP – Diagnosis and Management – PDP151

Occlusion on Class IV Composite Restorations – PDP150

Bruxism and the Airway – PDP149

Apicoectomy Tutorial – When, Why and How – PDP148

Recommend Treatment Plans with Confidence – IC038

Internal Whitening Protocols Pt2 (Non Vital Bleaching) – PDP147

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