Protrusive Dental Podcast

Non-vital bleaching or internal whitening comes in many forms, but it’s often confusing which exact protocol to adopt. When you learn this technique you can make a HUGE difference to a patient’s smile in a minimally invasive manner. Restorative Specialist Dr. AJ Ray-Chaudhuri covered the all-important diagnoses and indications of internal bleaching as well as how to treat tooth calcific metamorphosis (the obliterated pulp). We answer the key question: do you always need to have a root canal treatment present? https://youtu.be/mEHIypt-WW4 Watch PDP146 on Youtube The Protrusive Dental Pearl: When carrying out internal bleaching make sure to clean out the entire pulp chamber especially the necrotic pulp horns – clean the necrotic tissue inside using ultrasonics. Ensure the entire chamber is de-roofed – remember that these are mostly trauma cases and the pulp went necrotic in youth – hence large pulp chambers. No role for Ninja access here! Need to Read it? Check out the Full Episode Transcript below! 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 Highlights of this episode: 3:03 The Protrusive Dental Pearl  5:55 Dr. AJ Ray-Chaudhuri’s journey into restorative dentistry 13:02 Internal Bleaching Protocol 15:45 Whitening obliterated pulp (Calcific Metamorphosis) 21:22 No prep veneer/Composite veneer VS Tooth Whitening 22:50 Q: Best time for Internal bleaching after Endodontics? STAY TUNED for Part 2 Next week when it gets really spicy – we have a PDF infographic to follow! If you enjoyed this episode, check out Post Operative Pain after Endodontics – Prevention and Management Click below for full episode transcript: Jaz's Introduction: Non-vital bleaching or internal bleaching is something that you don't really learn or get to practice at dental school. It's something that you don't really often get to do, but when you get to do it, you get to make a huge difference to a patient smile. Jaz’s Introduction:But there’s lots of different ways to do it. It can get very confusing and the first time you come across a case, you end up going online and searching for all the different papers and different techniques out. And you just end up getting confused, which is why I’ve got this killer two-part series with Dr. AJ Ray-Chaudhuri, restorative consultant. We both discuss the indications, the diagnoses, so basically it’s two parts. This first part you listen to right now is going to cover his journey as a restorative consultant. The diagnoses that you can make, like when you have a yellow tooth, and you take a peri-apical radiograph and you observe that, ‘Hey, where’s the pulp gone? There is no canal anymore.’ That’s a calcific metamorphosis, right? That’s a sclerosed canal, and that can be a discolored tooth. Now, how do you whiten that, and how is that different to an actual non-vital tooth where you actually drill an access cavity if there isn’t one already and you whiten the tooth from within the tooth? So your diagnosis is really important. And some of the big questions that we cover are things like, do you always need to have a root canal treatment present? Does that root canal treatment need to be perfect quality, even if the patient is asymptomatic? And then we go on to discuss about which barrier material. Barrier material is something that you put over the gutter percha before you put the whitening gel to whiten the tooth. So these are all the nitty gritty things that we build up to. And in part two next week, wow. That’s really going to go into the full protocol for non-vital or internal bleaching. Hello, Protruserati. I’m Jaz Gulati. Those of you who are listening, I probably sound a bit different. And those of you who are watching, yeah, I look in a different place. So, I’m actually in between Reading where I work and live and West London at the moment because my wife is heavily pregnant. And so we have a lot more family support in West London. So kind of between two places at the moment. But the show must go on, right? Protrusive must go on. And I owe you a killer episode because I’ve been so busy with OBAB, so happy it’s been launched. As you’ll know, it’s been a really tough ride for me to actually put this occlusion course together, and I had to do it now before baby number two comes. But I’m just so happy I’m going to read to you the first bit of feedback that I’ve got. So at the end of every module we have a video like, ‘Hey, congrats to finishing the module. What did you learn?’ And so at the end of module one, so well done to the guys who already finished module one, remember this is a 30 hour course. So it’s pretty killer. So, Aysha Dhanani, thanks so much. You wrote, ‘I found myself wanting to click on the next video rather than fall asleep (what’s happening to me?)’ And then Aysha goes on to write all the things that she learned from module one so far. So that kind of feedback just means so much and there’s loads more at the end of that lesson. I’m not going to bore you with. So it’s been such a graph and so busy doing that, that it’s about time I release an episode like this. This is like my Trump card. I’ve just kept this episode on the DL for you because I knew that you’d be a little bit upset with me, that ‘Jaz, you haven’t been dropping the pearls as regularly as you used to’, but now I’m back. Okay? I know baby number two’s coming, but I’ve got loads of content for you and you’ll love this two-part series. Very comprehensive series with Dr. AJ Ray-Chaudhuri. Protrusive Dental PearlThe Protrusive Dental Pearl for this episode is very relevant for internal bleaching or inside outside bleaching or non-vital bleaching. Lots of different terms for it. And the pearl is that if you ever attempt to do this treatment, I’m hoping that this, by the end of the two part series, going to give you lots of confidence to take on cases like this. Like I said, these cases can be extremely rewarding and they can really lift up a smile, and it’s a lot more intricate and more fun than just regular whitening. So a lot more to it, a lot more hands on. But when you get to do this, you have to make sure of one thing that you clean out the entire pulp chamber. Now, usually it’s incisors that need this kind of treatment, right? Internal bleaching, and therefore the places where you might miss in terms of cleaning or your access cavity is the horns of an incisor. So make sure those necrotic horns are completely cleared out with ultrasonics and there’s no necrotic tissue inside, which is not going to help your whitening. And also why would you want to have necrotic tissue, right? Like you don’t want that, obviously in your root canal system. Now, for those of you watching, there’s some images on the screen right now showing you how I’ve done a few cases before where when I’ve inherited it. The root canal was good, but the access cavity was insufficient. It was too small. So all you have to do is actually remove all the old material and really assess, have we gain full access to these pulp horns? Because remember these people with dark incisors, black and yellow, and various colors, even purple I’ve seen before. It’s usually due to trauma at a young age, right? Maybe, 12, 13, that kind of stuff. And therefore the pulp chamber of these centrals and laterals and pulp horns are very large. So it’s well worth cleaning out. There’s no place for ninja access cavity. When you’re doing this kind of treatment, ask me how I know. I’ve had a failure before many years ago, and that’s where I learned that actually you can’t do these tiny access cavities. You need to make them big enough for a reservoir, for your whitening gel. And also just to make sure you removed all the necrotic material. So lots of pearls where that came from. From this episode and the next one. I hope you enjoy these two parts. A full protocol guide to non-vital bleaching. Main Episode:AJ Ray-Chaudhuri, welcome to the Protrusive Dental Podcast. How are you, my friend? [AJ]I’m very well, thank you. Thank you for the very kind invite. [Jaz]This is going to be a really huge topic because I find that internal bleaching, I don’t know how you learned it, and it’d be great to hear about not only your journey into restorative dentistry and your a little bit about your career ladder and that kind of stuff. But in terms of specifically internal bleaching, How you get into it and how your GDP friends got into it because it’s something that we don’t really learn or do very unlikely to do at Dental School. Because it’s more postgrad kind of stuff. And then when you get to DF1, you might see someone with a dark tooth and then you ask your principal, or you ask your trainer, how’d you do this? And then they have their own version that they do it. And then you might be brave enough to try it and you try to search some literature. So it’d be cool to learn about how you got into that. And then I’ve got some cases and failures to share and I know you do as well. And we could talk about your protocol and my protocol and just discuss a few things. So it’ll be great to learn from you. But first, AJ, just tell me your journey into restorative dentistry. [AJ]Into restorative dentistry. So- [Jaz]And tell us also about where you work and what kind of stuff that you do. [AJ]Well, okay. I’ll give you brief, I’ll won’t go back too far. So, born in India, move to England in 1986. Couldn’t speak a word of English and I moved to Luton where it’s not really necessary to speak English anyway. And then, secondary education. I went to King’s College London and then kind of came out in VT went, it was in the Northampton Ski, which was just brilliant and probably quite important to know. I was got into dental school through clearing when it, I don’t know if that exists anymore. And I really was not a great student. And because I think you have some student listeners possibly. And- [Jaz]Oh, yes, yes, yes. [AJ]And so not a great student. And it didn’t really ignite my passion for dentistry at dental school, and that’s not a criticism. That’s a criticism of me. My aims were simply to not get thrown out of dental school and just have the time that I could and I achieved those. [Jaz]But AJ I just want to mention on that I’ve spoken to so many guests and they all say the same thing, that it’s not so much what you do during your time at dental school, it’s more about after dental school where really your sort of career trajectory can get some sort of direction, would you agree with that? [AJ]Absolutely, a hundred percent. I guess I, I’m quite removed from undergraduate education now, but the skills, the things that I needed to do to get into dental school and not get thrown outta dental school were completely different to the skills that I think you need to be a good dentist. Not well, yeah, not completely diametrically opposite, but many of those skills are not necessary. I don’t remember much of the things I was taught as an undergraduate. And nor do I need to, but yet we’ve all got some other skills based in communication and emotional intelligence, which we now, we trade on far more than our ability to remember or not remember the krebs cycle. [Jaz]Very true. And then so what lured you into the restorative pathway? Because you are restorative consultant now? [AJ]So I know I’m a consultant in restorative dentistry, so I’m the head of restorative dentistry at Brighton. And I’ve been there since 2014. [Jaz]Awesome. And, how did you know that restorative was your calling? Because it can be a, not only very competitive to get into restorative training, it could be a grueling process while your friends were in private practice doing that kind of lifestyle. And then you had to sacrifice some of your best years young family. Cause then you got three kids and stuff and you were this perpetual student, if you like. How did you find that? [AJ]Well, that’s one of the things that drew me to it. I thought, I was determined not to get a proper job, so I thought, let me go with, do some postgraduate education. But that kink in the journey was quite important. I had absolutely no aspirations of doing anything like that. And like a lot of people, these things came by chance. You could tell the story differently, but the truth is our decisions are half chance. So I did VT and I worked as a general dentist to meet. I went as into working as an associate. I used to work in BMW, in Cowley, so where the minis are made. So that was my job. And this takes us up to, it’s kind a 2005. And that’s critical because you won’t recall, but you may know that the UDA system came in about 2006. So it was advised to me, and I think it was good advice to say, ‘look, AJ, you’re not going to make any money doing in this UDA system. You’re too slow, you talk too much, want go and do something else for a little bit and then come back and work in primary care’. And that was advice given to me by people who knew me very well and with very good intention. So I thought, let me go and hide in hospital for a bit for a year, basically. And I’ll come back when this whole UDA business settles down and many, many years later, it hasn’t really settled down. I’ve still never earned a UDAs. Don’t really understand what it means, unfortunately. But so I did a maxfax, SHO job then of course, and then I did kind of MFTs as it was called then, and suddenly realized- [Jaz]What did you know when you did your maxfax? Did you know that you wanted to go into restorative at that point? Or this is just something you took one year at a time? [AJ]Just wanted to wait for these UDA systems to settle down so I can go back to primary care and be a proper dentist. And, but then I love maxfax, but then I thought, I’m not going to be a maxfax consultant. That’s not for me. So then I did a couple of years of SHO in Restorative in Birmingham, where I met some absolutely fantastic people, people who I’m still very, very good friends with. That’s the first time I really came across a restorative dentist, a restorative consultant. And they were just cool and they could do loads of stuff that I thought didn’t exist. And that’s when I thought, and I went in at kind of 26, and I came out at 28 as an SHO. And by that time in that transition, I thought, that’s what’s my calling. I really want to do that. But it was very competitive then, I think it’s even more competitive now if I’m being honest. So I wasn’t really sure I was going to get in and I was already dabbling in a few other things, my masters at that time. But that was nonclinical. It was in medical law. So I felt a bit behind the curve. But next thing you know. I’ve got a registrar job at Kings with some amazing, amazing consultants, who are still very now friends of mine and are still amazing consultants. So, that’s how I got in. [Jaz]And what’s your split like now in terms of how many days in hostel doing the, I mean, are you doing the cancer kind stuff? Trauma, tell me a bit about that and then the rest of the week private practice, but, what’s your split like? [AJ]So, head and neck cancer was the big thing that I did up until very recently. So my primary job in Brighton was to sit on the head and neck cancer MDT and be the only restorative consultant there to do oral rehabilitation. So obturators and implants and that kind of stuff. But, covid changed lots, children changes lots. So now I work one days a week as a consultant and I spend four days a week in private practice where I work as an associate one day a week, and the rest of the time I’m in my own practice. My own referral practice in Hassocks, which I co-own with my wife, Emma. [Jaz]Awesome. And AJ I mean, just your story. I, unlike you, when I qualified, I really wanted to be a restorative consultant. I really wanted to follow that pathway. That’s why I specifically did, DCT1, these two, both in restorative, but when I did them, I realized that the training pathway wasn’t for me. For me, hospital was very slow pace and stuff, but, I knew that I wanted to upskill, so I went about the other way. I just did lots and lots and lots of courses, and now I’m in private practice. I’m happy. I’m getting to practice the kind dentistry I wanted to practice minus the head and neck cancer stuff, I guess. So I got the fun bits and stuff, and I guess at the time it was very attractive to be a specialist in, this is way before they made you choose like a mono speck before it was like, you’re a specialist in perio, you’re a specialist endo, you’re a specialist in a prostho. You’re like this hotshot, right? And I was like, wow, I want to be this awesome dentist and whatnot. But then just the way I experienced training, I thought, okay, this is not the most effective learning for me. And that’s why I went the way I did. And it’s great to hear that you are very wet fingered, very much a restorative practitioner. And so that goes in very handy with the topic we’re discussing today of internal bleaching. So, thanks so much for that intro. So let’s dive in straight away. This is the kind of stuff, as I was telling you before I hit the record button, that when you come across it, you don’t relearn it in dental school. And when you see your first case with someone with a black tooth or a yellow tooth, and you think, hang on a minute, I think we can whiten these, but I don’t know how to whiten something from inside. And they end up speaking your trainer or your principal and then they give you their version and then you end up looking at a few papers and yet confused, wait. There’s a lot of different ways to do it. And then you get worried about internal resorption and relapse and stuff. So why don’t we all bring it together and talk about your protocol, then I’ll share with you my protocol because I think I know which protocol you like to use. And tell me, do you ever switch protocols as well? So we’ll get into that. But what is your standard protocol, but maybe even before then? I think I’m jumping the gun here is just describe the process and when it is an appropriate option to go for internal bleaching, just for students who might be listening. [AJ]Okay, sure. So, yeah, absolutely. This didn’t exist, this wasn’t on my radar until a Beckham registrar actually, so I’m not surprised. Some people haven’t come across it. So, as part of this process, I see there’s three people involved I think. So there’s me as the dentist. There’s a patient and there’s a lab technician, and if we bring our A game, we’re going to be fine. And if one of us drops the ball, this is not going to work. So part of my job is diagnosis, so I’ve got to work out this, let’s say, single discolored tooth. Is it because there’s extrinsic staining? Is it because there’s intrinsic staining? Or is it because there’s internalized staining? Most people kind of split things up into extrinsic, so stuff on the outside, in which case they need maybe a good scale and polish or something like that, or drink less tea and there’s no place or inside outside whitening, or is it that there is an internal issue, an intrinsic issue? And if it’s an intrinsic issue, is it a systemic issue or for example, a metabolic issue where they’ve got like liver disorders or kidney disorders, but generally that tends not to present as a single discolored tooth, or is it something that we have done. For example, it’s fundamentally, it’s a dead tooth, which is not root-filled, or it is a dead tooth, which is root-filled. And that’s kind of, I think, the focus of our conversation today that single tooth, which is discolored. [Jaz]I mean let’s go with that specifically. That one tooth with the black or the dark yellow tooth. And then let’s assume that they come to you for the first time and you find that, oh, it’s non-vital. It hasn’t gotten access cavity. So you find that okay, it hasn’t been root filled. And then the first step is take a PA and then I guess who’s got to put your end it on his hat on and make a diagnosis. And think, okay, we need to obviously do I say obviously, but there might be scenarios where you may not need to do a root canal treatment. Now, specifically what I’m thinking of is that scenario where it’s calcific metamorphosis, right? Where the pulp is completely obliterated. And therefore the tooth has a yellowish appearance in that scenario. Obviously to do a root canal, there’s no canal to obturate. So in those scenarios, is it safe to just go ahead and whiten? [AJ]So here’s a good question. So I’m glad you talked about that because I think that’s one of the things that is one of the subtle but important academic points that could really get people in trouble in the UK. And that is fundamentally, does that tooth need root filling or not? And so this, and how do you make that decision? So in the scenario you’ve described there, in my opinion, in my very strong opinion, actually one of those teeth does not need a root filling and should not be root-filled and the other one does. So how do we discriminate? So if we go back to diagnosis, I split up my endodontic diagnosis. Now this is with my specialist Endo hat on, you’re right. I split up my diagnosis into two parts. I’ve got a Pulpal diagnosis and I’ve got an Apical diagnosis. So let’s say a patient comes in with a history of trauma to a tooth classically, for example, if you’re in middle class, sort of Sussex. They were standing in slip, they missed a catch, they took a whack 20 years ago, and the tooth has started to get a bit darker, right? Maybe they get some odd pain, maybe they don’t. Then someone does vitality testing on them. Primary care practitioner rightly does the things, does vital testing on them, and it’s negative. So what does that mean? So you put that information together just from a history point of view, and that would be pretty much all of the discriminators you need to say, this is a dead tooth, right. But you take a radiograph and what you see is, let’s say calcific metamorphosis, sclerosis, whatever you want to call it. [Jaz]This episode is brought to you by Enlightened Smiles. They have recently launched their EVO four protocol, so usually now for teeth whitening, it’s three weeks of treatment and there’s no longer an in-office stage. Their trays are awesome. The gel is always fresh. So if you’re in a country that offers enlightened whitening, do check it out. Now, if you want to learn more about whitening techniques, then the best thing to do is join some free online training. If you head over to protrusive.co.uk/enlighten. You could check out Payman Lang Rudi and all his pearls about teeth whitening. So it’s well worth a shout if you’re learning more about teeth whitening. So once again, that’s protrusive.co.uk/enlighten. Let’s get back to the episode. So just as for students, you take this radiograph and you do not see, a pop, you don’t see that radiolucent line going across. It’s all dentine. [AJ]So that to me means that tooth is, or certainly was for a very long time, vital, because you can’t create the secondary and tertiary dentine in a non-vital tooth. So, does that make sense? So actually what you are almost certainly looking at is a vital tooth, or certainly a tooth, which is vital for some time. That tooth will still give a negative response to cold thermal testing. So I use something like Endo Frost, which is like minus 45, minus 50 degrees, and it does give a negative response often to electric pulp testing. So can you see? That’s a very confusing picture, but diagnostically that is not a necrotic pulp and diag. So if you talk about the end, the pulpal diagnosis, that’s not necrotic. Apical diagnosis, you’re not going to have an apical area. So is a healthy periapex. So diagnostically, what are you telling me? You’ve got a healthy pulp and you’ve got a healthy periapex. No root filling. And I do, let’s say once a year, maybe a bit more, maybe a bit less, get referred or at least ask an opinion on it. Say, AJ, how am I going to root refill this tooth? Because the tooth patient wants tooth whitening. And the first thing, that’s one of the things I dropped what I’m doing, said, don’t take a birth of this tooth. This tooth does not need a root filling unless proven otherwise. The final question is how many of those teeth go on to develop necrosis and actually then become non-vital because they call strangulation of pulp and things like that. The data, there’s a positive of data on that. But actually the vast minority of those teeth ever go on to need a root filling. Depending on Andre’s old data was less than 10%. Some of the more modern data will say maybe it’s up to 25%, but the standard answer is less 10% or less will go on to ever need a root filling. Does that makes sense? [Jaz]So something you should warn the patient, but in this case, you don’t need to do a root filling. Obviously you’d struggle very much even if you tried. ‘ [AJ]Then you walk course, and then you do all these other bits. And then you actually, you really end up in the chocolate, don’t you? Because then someone rightly after the event going, yes, you went of course, but this is not a tooth that needs a root filling because what’s the diagnosis doc? The diagnosis is healthy periapex. [Jaz]Yeah. Yeah. And so in that scenario, just are normal whitening protocols, would you say? Or would you say that to have a special type of tray whereby the adjacent tooth, let’s say it’s an upper left one or upper left central incisor. The adjacent teeth, the upper right central and the upper left lateral are cut out from the tray and they’re just whitening that one tooth only. Would you adopt that protocol or just go normally? [AJ]No. So a normal whitening tray will not work. What you described there is, I have a modification of that, but yes, fundamentally, so what I do is I make a normal tray. Let’s say it’s upper left central incisor, which I want to do, we call that the target tooth. Then I’m going to cut out windows in three of the adjacent teeth, either side of them. Because if you don’t. The patient will whiten the other teeth accidentally or on purpose. They’ll whiten the other teeth. So you wanted targeted tooth whitening on that one tooth. But be in no doubt, that is a much slower and less predictable protocol than when you root fill the tooth. Yep. And some, and these are the patients that sometimes do need some top up treatment, but what, in my opinion, what you mustn’t do is then go immediately to a veneer. Because if you think about it, you’re taking off the translucent white enamel and you’re going back down to the further bulk of dentine, which has got primary, secondary, and tertiary dentine. So actually the first thing you’re going to do is make the tooth darker. [Jaz]And in those cases, I guess, every case is different. And I would say from experience that if you have such a tooth, which is a bit yellower because it’s grossed. And you are thinking that, okay, it’s going to be a very slow process with teeth widening and the patient’s after a quicker result. If that tooth is now slightly in standing and you can get away without prepping, then just go for a minimal prep. No prep veneer or composite vene or something to, rather than doing the dance of the whitening and then also then going into relapse surgery in the future. What do you think about that kind of a approach? [AJ]I mean, if you were in the, so a long time ago, wrote a paper on the class two div to patient with Martin Keller and Richard Porter, and that’s one of the things we talk about. I said actually, if we’ve got a retro client tooth, if it’s a purely additive approach, fantastic. I probably would still favor direct dentistry because I do, but on that patient, the first thing I’m going to do is I’m going to mock it up chairside and I’ll probably try the first appointment to mock it up with, because the shade of composite may need to be more opaque than you would normally expect. So in the gradient system, you might need to go for like an A02, an a opaque 2 rather than an A2. But if you can do that without the whitening bit, that makes perfect sense. [Jaz]And of course it’s instant orthodontics not in the old classic way of drilling away all the crowd into little pegs, but in a way that’s purely additive. [AJ]And I’m very comfortable with that approach. Yeah. Additive approach. Yeah, absolutely. I mean, but even with that, if you think about it, that’s a great quick fix, and it may be cost effective, but that needs to be maintained. There is no dentistry that you and I, Jaz will, that will do, will last forever. Unless it’s the patient who expires on the patients that we do who are living longer and longer, they have to factor in a maintenance cycle, and let’s say for a composite, that’s going to include repolishing and replenishing and eventually replacement. At the patient’s cost. Not at our. [Jaz]Well, let’s dive into the same tooth, upper left, central incisor. This time it’s a black tooth. It’s that patient who’s been walking around with a black tooth. I’ve got lots of good cases. I’ve actually done the past some good success rates, with this type of patient. Let’s assume they have a successful root filling. Healthy periapical structures now because of this successful root filling. Obviously if you’ve got disease, then yeah, no, it goes about saying, treat the disease first. Send it to your endodontist, get the re-RCT done, and then wait for that to heal. Now, any guidelines in terms of how long we should wait? That’d be a good question to ask in terms of you are waiting for post endodontic, when is there a time that you have to wait before starting whitening? [AJ]In my opinion, well, no, I don’t. If I’m redoing that endo, which I do myself, then my plan is on that appointment where I obturate, I’m starting the, so this is, we’re talking about inside outside whitening. I’ll be starting that obturation on that appointment. But perhaps we take a step back and say, because we’ve kind of talked about the spectrum endodontics, and you are talking about, let’s say asymptomatic tooth or with a poor root filling and there won’t be much controversy by saying that needs endodontic revision. That’s fine. [Jaz]And even did you say symptomatic or asymptomatic? Sorry. [AJ]So asymptomatic tooth there, there’s not going to be anything. But now here’s the tricky bit. What if the patient because the vast majority of the failures that I see and the failures that I’ve had in the past is actually not of the three people involved. It’s not the dental technician. It’s not the patient. The person who’s got it wrong or drop the ball is me, and it’s at the diagnostic phase because this patient may have a reasonable root filling, which has served them well, but the root filling is often part of the problem. So have they got reasonable root filling? Yes, but I don’t need them to have a root filling that a reasonable root filling to me, I’m afraid is not acceptable under for this particular circumstances. They need to have an excellent root filling. I’ll tell you a little bit about when I look at I, as you may or may not know, I’m not a much of a consumer of social media, and I certainly don’t put much on there, but I do look at other people, but my job isn’t to take pop shots at them. But if you look at things when people put up root fillings, everyone is obsessed with the apical third. Lovely ramifications. I’ve got a sealer spurt. It’s on purpose. It’s not, okay, fine. I’m always looking at the other end of the radiograph. I’m always looking at the coronal bit. Because we know that coronal seal is as important. Some of the data tells us more important, let’s say let’s forget the Ray and Trope studies and things like that. But let’s say it’s just as important, okay? But in the aesthetic zone, not only can it, it can’t just be enough to seal it. That gutter percha has to be sealed miles above where people think they are. And the first thing that I look at, these root fillings in outside of the aesthetic zone, I can see gutter percha into the pulp chamber of the molar tooth that is compromising the seal. Right? But if you put a crown on top of it, you’ll probably get away with it. And if it does become dark underneath, you can’t tell. You cannot get away with that in the aesthetic zone. So I’m really asking myself the question, is this tooth, which has a reasonable root filling and is asymptomatic, does that need endodontic revision? And almost always for me and my patients, the answer is yes. And not only do I have, I think the periapical is a minimum standard that you need, I almost, if it’s de novo endodontics, peral is fine. But if it’s not denova endodontics, if it’s endodontic revision, then I will have a code beam ct, a small field of UN cone beam CT scan, and I pick up far more pathology than you would think. Let me ask you the question, Jaz. Why is this patient got a single discolored tooth? It’s almost always trauma, right? [Jaz]Yeah. [AJ]So you’d be amazed how many undisplaced root fractures that I see on that tooth. Or the adjacent teeth. Awesome resorption. Now it might be surface resorption, it might be replacement resorption on the palatal aspect of this tooth. It then I’ve seen a few times when they’ve had re really decent palatal resorption on these teeth. Now this tooth, no matter how much I changed the color of it, actually isn’t going to last this patient’s lifetime. It might not last that long at all. So really then what I’m saying, this patient needs to spend a significant amount of their resources making a tooth pretty accepting that this is a short to medium term option because I cannot stop that replacement root resorption if it’s progressing. So can you see diagnostically, I think actually. Even as dentists, we focus on the outcome, which is a nice white tooth, which looks like the one next door, but I think that’s the wrong question. I’ve dropped the ball if I haven’t done a proper endodontic diagnosis. And my root filling needs to be of a very high standard, and it needs to be, and this is where there’ll be many people who disagree and that’s cool. And if you’re an, if you’re a student, please don’t quote this because for an undergraduate level exam, this is definitely wrong. You need to be minimum three millimeters below the CEJ or the gingival margin, whichever is higher. And for my patients, it’s often four millimeters or more than that. Right? Now if you just do the maths here, let’s say an upper central incisor, how long are you going to call an upper central incisor? Top to bottom. What would you say? [Jaz]22? [AJ]Perfect. 22 mils. Right? So how big is my root filling? 6, 7, 8 millimeters long? Hardly anything. Actually, if you think about it, you’d look at my root fillings and think he’s well short of the CEJ and the reason is the maths 22 millimeters, right? That’s the entire length of the tooth. Now do you want to filter the radiographic apex or do you not Jaz? [Jaz]Me personally, gosh, you probably don’t want to because the anatomical apex is before the radiograph. [AJ]Absolutely right. Yeah. Because the data tells us if you look at the lots of the data, including the Mitani study from 1992, the radiographic apex is not coincident with the apical term. That’s right. So your actual root filling is probably going to be, let’s say, what, 21 mil from the edge of the tooth, right? [Jaz]Mm-hmm. [AJ]Okay. How long’s the actual tooth, how long’s an upper central incisor? 10, 11 millimeters, right? So now often 22 millimeters, you’ve taken one off the top that leaves 21 millimeters. You’ve taken 10 off the bottom that it leaves 11 millimeters, right? And I want my root filling to be four millimeters short of that CEJ. So that leaves a seven millimeter root filling. [Jaz]Seven millimeters of gutta percha. [AJ]Of gutta percha. Now, okay, now that for me is very easy because I use a warm vertical compaction technique and then I back fill. If you’re actually using a lateral condensation technique, which the majority of our colleagues are, or you’re using a single cone with a bioceramic sealer, actually that’s quite a lot of effort and I think Serax Ferguson would say squeaky bum time, right? When you’re trying to now with a gates glidden bur trying to go back through and cut out the vast majority of this mohican of gutter percha that you’ve got. But if that bit is not done correctly inside, outside whitening, as I would describe it, is not a predictable process. But people jump ahead of that bit too much, you see, because without that bit, the primary curvature of the tubules, I’m sure you may remember that I just about remember that the dental students will remember that the primary curvature of the tubules means that there’s a sign of pseudo process, which means that the tubules actually are three millis of other CEJ, right? So any discoloration you get of your endodontic gutter perker, or the sealer, three or four millimeters above the CEJ will eventually present as late color changes the neck of the tooth. You have to leave room for the the GIC plug, if you place one. [Jaz]That’s exactly what I was coming to. So the relevance here for those young dentists may be unfamiliar with this, is that you want to leave that three to four millimeters of space below the gingival margin of CEJ because if you don’t, and if you finish at the CEJ, the neck of the tooth will still remain dark, right? [AJ]Yeah, absolutely. Or it will get whiter and then it’ll slowly darker. [Jaz]Yeah. And so, let’s talk about because this is a pain point for dentist in terms of the technique involved. Now you are probably using a scope, you got a lot experience in this, it can be quite tough to do to get right in this. So some of the best results I’ve actually had have been from the endodontist Caesar to work with Richmond. He’d do you under scope and he’d make this lovely seal for me. Perfect position, three millimeters below, including after the GIC seal there and he’d sent it back to me and I just have the easiest job ever and I get really great results because the seal was fantastic. But in the times in the past, I remember six, seven years ago doing something like this and with GIC, without a microscope, it can get very messy. And then if you get some up on the sort of the outer wall, then obviously you’re compromising your peroxide actually penetrating into those tubules. So 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. Jaz’s Outro:Okay guys, I’ve done it again. I’ve left you on a cliffhanger. So in part two, make sure you tune in to find out what is Dr. AJ’s preferred barrier material. Actually might surprise you, so definitely tune in for that. Hope you enjoyed this introductory episode so far. And episode two is going to have so much meat that we’re going to make a famous protrusive infographic with step by step with all the information from this one and the next one, but the next one really is the meat and potatoes of it all. If you’ve listened to watch as far and your Protrusive Premium member, you’re in luck. You get your full listening and watching time allocated as CE or CPD certificate. You just have to answer a few questions as you scroll down on the app. And as you know, protrusive premium. I’m adding premium content as I go along. I really appreciate you watching or listening all the way to the end, and I catch you in that killer next episode, you’ll absolutely love it.

Rochette Bridges are a popular option for interim tooth replacement whilst implants in the aesthetic zone are ‘cooking’. In this episode with Dr Pav Khaira we discuss his interim restoration protocols using Rochette Bridges and Dentures, as well as gaining an insight in to custom healing abutments. https://youtu.be/InBOBHfYxEA Watch PDP145 on YouTube Which cement is best for Rochette Bridges? How do you remove them? Ceramic or Composite pontic? When might we consider a Denture instead? We then expand in to soft tissue augmentation at the time of implant surgery to get the best pink aesthetics. This episode is packed full of gems even if you do not place implants – much of the benefits of soft tissue augmentation can be applied to non-implant fixed prosthodontics. The Protrusive Dental Pearl:  Steal my Resin Bonded Bridges consent form! It is a visual aid for patients and helps with information and consent for RBBs. If you are on Protrusive Premium, head to the ‘Protrusive Vault’ to download it. Otherwise you can request your free download here. Need to Read it? Check out the Full Episode Transcript below! 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 “It’s all about how you communicate the soft tissue grafting surgery to your patient” – listen/watch the episode to hear this absolute peach of a communication pearl! Learn Implants from Dr Pav Khaira Highlights of this episode: 3:40 Dr Pav Khaira’s Introduction 7:20 Interim Restoration vs Immediate Loading of Implant 10:12 TWO Golden Rules of Temporary Dentures for Implants 11:15 What is a Customised Healing Abutment? 17:40 Rochette Bridges Protocol 23:54 Temporary Implant Crown Protocol 31:36 Communicating Soft Tissue Grafting If you enjoyed this episode, check out Success with Resin Bonded Bridges. Click below for full episode transcript: Jaz's Introduction: If you've placed an implant or maybe your surgical colleague has placed an implant and now it's come to you as the restorative dentist, and you need to give this patient a tooth because they're not going to go for immediate loading, i.e, they're not going to have the temporary crown on this implant the same day. Jaz’s Introduction:We’re going to wait some healing, and therefore, how can you give this patient a tooth? It’s going to be a denture or a bridge of some sort temporarily. There might be some other ways, but these are the two most common ways to do it. Now, you might have heard of something called a Rochette Bridge. Rochette Bridge is basically like a metal resin bonded bridge with HOLES in it. It’s very popular way. A lot of the implant dentists use to TEMPORARILY have a tooth there so that everything can heal, the soft tissue can heal, the implant can osseointegrate, and then you can take off this bridge and continue on with placing a crown for that implant. But there’s lots of nuances when it comes to Rochette Bridges. So I’ve got on Pav Khaira today to talk about Rochette Bridges. Talk about dentures, like how do you make sure the denture’s not impinging on the soft tissues and on the healing abutment. Now if all these terms aren’t making sense to you, then I’ll make sure that Pav breaks down exactly what a healing abutment is. So really is the bare bones of everything and builds you up and we build up all the way towards the end. We talk about soft tissues and how in many cases soft tissue augmentation to get a nice papilla is so important and Pav will share with you a very interesting stat about the number of people that show their papillas. Have a guess, actually, if you don’t know this already, when people smile, when our patients smile, what percentage of them will show a papilla? At least a papilla, one papilla anteriorly, right? So what percentage of patients will show papilla, at least. Protrusive Dental Pearl:The Protrusive Dental Pearl I have you, is that you can steal my resin bonded bridge consent form. I thought it would be a good little gift to give to you guys. If you’re on Protrusive Premium, I stuck it on the download section already for you so you can download it. If you’re not on Protrusive premium yet, then you can now to protrusive.co.uk/rbbconsent. That’s RBB consent and I’ll send you my resin bonded bridge consent form, which I’m super proud of, because it’s pictorial. It’s got Images. Like images of black triangles, images of long connectors and how on one place you might have a papilla and the other place where the tooth was extracted, you don’t. Now, patients get to visually see this. And what metal show through looks like and just, it’s really, really good to have these visuals for your patients. It’s more like an information sheet, but this is a big hit. Every dentist who ever downloaded it as part of my resin bonded bridge course has always found this and the lab prescription form very useful. Now let’s join the geekiest implant dentist I know, Pav Khaira. Main Episode:Pav Khaira. Once again, welcome back to the Protrusive Dental Podcast. How are you mate? [Pav]I’m very good Jaz. Thanks for having me back and as we spoke about just a few seconds, I’m going to push this out on my podcast as well, so it always feels twice as productive whenever we do it. [Jaz]Excellent. Well, I’ve referred to you before as the ‘oracle of the implant world’, but the themes we’re covering today, and we’ll just get an instruction just in case someone hasn’t heard of the previous ones we’ve done and some of the group functions we’ve done, have been really well received because people message me saying, ‘Jaz, you’re covering these real world topics’. And what we covered in those topics, like how you probe periodontally around implants, right? Things like that. Screw loosening. We covered these really big themes and so today’s theme, but for those listening, all watching on YouTube is a twofold. One that will help every single dentist, I think, right? We’ll learn about rochette bridges. How do you take them on, how do you take them off? How do you put them on? What cement do you use? The selection criteria, that kind of stuff for like temporary, before they have the implant and while implant restoration, while we’re waiting for osseointegration and the grafting, et cetera. And how we can optimize our temporary implant ground to better serve our future implants and soft tissue augmentation. So something in it for those who are already doing implants. So this is going to be a bit of a beast. But Pav, for those who haven’t heard of you and the lovely work that you do, including your podcast, just give us a flavor about yourself again. [Pav]Yeah, thanks Jaz. So I am a full-blown Titani-nerd. I mean, to the point where when my wife and I went out shopping for wedding ring, she was like, ‘I want that one’. And she was like, she said to me, ‘why do you want that one?’ I said, ‘because it’s titanium’. And she was like, ‘why don’t you want gold or platinum?’ She didn’t realize until afterwards that titanium is what her implant, because she’s not a dentist. That titanium is what implants are made of. So I literally live in breathe implants. I have placed over 10,000 implants. I have been very, very fortunate to have been exposed to a lot of surgery. So I’ve become very confident and proficient at it. And, I still have a lot to learn cause I’m a great believer as soon as we turn around and stop learning. We do ourselves a disservice and we do our patients a disservice. And this is a philosophy that both you and I have in common. So I run the ‘Dental Implant’ podcast, which is kind of like, off the back of a discussion that you and I had a few years ago. And you were like, ‘Pav, you know so much, why don’t you run a podcast?’ And I was like, ‘I don’t know how’. And you were like, ‘let me show you’. So, you’ve been my sage and mentor in that context. And now I’ve also set up and I run the ‘Academy of Implant’. So I’m busy, busy training, mentoring and everything relating to implants. My daughter’s only two and a half and it won’t be long before I’ve got a motor in her hand practicing on models to place implants. So. [Jaz]Excellent. Well, I can definitely vouch for your geekiness, like when I was a newly qualified, I think maybe 10, 12 years qualified, that stage and the amount of knowledge that you had on occlusion and splints and obviously osmosis. I try to absorb as much of that as possible. And I’ve kind of run with that and I have seen you diversify into implants and how you really take into that. So I think you’ve got this personality Pav, whereby when you take something, you properly latch on. Am I right in that? [Pav]It’s obsessive. I can’t help it. That’s just me. And that’s purely from a point of view. I’m a great believer if you’re going to do something, do it properly. And in order to really help our patients, and it’s a personal journey as well. I don’t want to get to the end of my career and think to myself, I didn’t do this, I didn’t do that. I want to get to the end of my career and think to myself, actually, you know what? There’s nothing more that I could have put into this. Absolutely nothing. I’ve helped as many people as I can. I’ve trained as many dentists as I’ve could. I’ve gotten x number of, careers off the ground, and those people have helped more patients as well. And I think you have to be obsessive about it. And that’s just my philosophy. If you’re not obsessive about it, you don’t have to be quite as obsessive as me, but you at least need to have a passion about it. There’s a difference between passion and obsession. I’ve got an obsession with it. You need to at least have a passion about it. And the rewards that come off the back of that professionally, personally are just unmatched. [Jaz]Amazing. And I think that’s valuable for anyone in their dental journey the early or later on. That’s really great to hear. Now getting moving to clinical direction now. If you talk about Rochette Bridges, right? So for those who haven’t heard Rochette Bridges, I’m sure most of our colleagues listening and watching know this already, but, a resin bone bridge, for example, classically a metal wing with a ceramic pontic attached as we know so well, and then if you to get a round bur and poke holes through it, that’s now essentially a rochette bridge. Now, commonly when I think of Rochette Bridge, I think of those who place implants favoring this type of restoration to make sure the patient has a tooth to smile, to chew or maybe to chew with, smile with while they’re waiting for everything to cook. Now, before we get into the sort of ins and outs of this, I want you to know from you Pav in your protocols like anterior teeth, for example, what percentage of the time are you actually putting, like the day you place an implant, you’re putting some sort of an implant, temporary crown on top? And in what percentage cases are you then relying on a denture? On a bridge? Or some sort of prosthesis? [Pav]I’d say it’s about 50 50. And one part of that is some patients don’t have the funds to go for immediate load as well. And that’s purely from a point of view that it does take more time, which you have to charge for. And some patients like I’m happy with the denture. I’m happy with rochette. Whatever it is. There are also some instances where you can’t, from a biological point of view, while you’re waiting for everything to heal. But I like to go immediate load as much as what I possibly can. In fact, it’s probably a little bit more than 50%, probably about 60% of the time. And the reason for that’s quite simple is you get a lot of control over how things heal, assuming you do things properly. And in addition to that, patients really appreciate it, they appreciate a fixed tooth over a denture or having a space. So I think it comes down to biological factors and patient factors as well. But the more that I can do predictably, the happier I am effectively. [Jaz]And in those cases where you are let’s say it’s a lateral incisor, the patient may be used to have a denture and then you are now placing a tooth there implant and for the whatever reason, maybe patient can’t afford it or they want to space it out, or you want to give it more time to cook and heal. You can either, I guess just gouge out a bit of acrylic on the denture and then let them use that same denture. Is that any nuances to that you want to add to before we talk about the Rochette bridge? [Pav]No, not really. I think what’s really important is, so let’s talk about two different factors. Here is the patient who already has a denture and the patient who has a tooth, and you want an immediate denture as a backup. So the patient who already has a denture, yes, you can adjust it, but you need to make sure that there is no pressure on the healing abutment or on the healing site at all. So you’ve actually got to create a little bit of space about it, underneath it. [Jaz]How can you test to make sure you have got that? Because imagine after surgery, I mean, I’m sure your surgery’s very neat and you got the sutures on. It looks very good and probably you can eyeball it, but, I don’t know. Do you squirt some light body impression and just see if there’s space? I mean, how do you actually just be sure? [Pav]So I don’t like light bodied because it flows into the surgical site a little bit too much. What you can use is you can use a little bit of occlusal registration material. Because that’s a little bit stiffer. It’ll still give you the exact same information, but if you see any go down the side, you can just grab it with tweezers and pull it out. So you need to use something a little bit stiffer using a light body or pressure indicator pace you’re actually causing issues in the surgical site. If I’ve got a patient where they need to have tooth removed and we are making them a denture. In those cases quite often what I’ll do is I’ll ask the lab, in addition to making the denture, there’s two additional instructions that I give them. Number one, don’t suck it. And number two, don’t add a flange. So it’s literally a tooth hovering just above. And I tell them it’s specifically for an implant, and they normally keep it clear of where they think it’s going to end up by about a millimeter or so. And that ends up being really nice. But I always warn the patients beforehand, if we need to use this denture, you are going to absolutely hate it. And then when they hate it, it’s just I did warn you about this. But that again is one of the reasons why I try not to do anything removable. Another reason why I try not to do anything removable is unless you’re doing a customized healing abutment everything starts to collapse. So not only do you get the benefit of having a fixed tooth and that’s obviously easier than doing a Rochette or a denture when you haven’t got a massive amount of occlusal clearance, because you’re not relying on wings, you’re not relying on acrylic. But in addition to that, if you contour it correctly, it supports the soft tissues whilst the heel. So- [Jaz]Now you’ll have to explain Pav. Because a lot of younger dentists and students may be listening. Even experienced dentists who just are new to the implant world. Customize healing abutment like you’ve placed the implant. Really break it down like I’m five years old. [Pav]Fine. So on a very simplistic level, once the implant’s in place, you need something to protect the head of the implant. Whilst it’s healing, whilst it’s cooking, otherwise, soft tissue’s going to grow into the screw channel and it’s a complete mess. Okay. The neatest way to do it is with what’s called a ‘healing abutment’. That’s just something that screws onto the head of the implant. There’s two ways of healing. [Jaz]Is that same as a healing cap? Is that same thing as well? [Pav]It is. It is the same. It’s different to a cover screw. So cover screw is basically the gums will grow over the top, whereas a healing abutment slash healing cap is, it will protrude into the mouth. So you’ll see a little a little stud in the mouth, and that’s the healing abutment. So when it comes to healing abutment says two ways of doing it. You can use a stock one, which is just with your implant systems. When you’re ordering the implants, you ask the lab to send you whatever side. They come in different heights. Things along those lines. Different connections, depending on the implant system that you’re using. The issue that you have with that is, it doesn’t, it’s not really bespoke for the patient. It’s like getting what is it, you know there’s 3M crowns that you can get out of a packet and then you retrofit it. [Jaz]Yeah. [Pav]So it’s not really- [Jaz]Even like a whole crown as well, like hall crowns, like the preformed metal crowns for children’s teeth. They’re all, you have to make the tooth fit the preformed thing. Even like if I was to say like even sectional matrices, right? We have to, whatever tooth, whatever configuration the tooth is, you have to just select the appropriate sectional matrix, but it’s never going to be fully customized for your cavity. [Pav]That’s exactly correct. Now, imagine if you had something that’s fully customized. How much more predictably that soft tissue’s going to heal. And basically there are certain things that you need to look at when you’re doing this type of stuff. When you at the CEJ level and then underneath the CEJ level all the way to the head of the implant. There’s certain ways of contouring it, depending on the implant height and the position. So that it supports the soft tissue whilst it heals. And the whole point is, is you go to this length because at the end of the day, you don’t want to tell the difference between an implant and a tooth. This should just look exactly the same. It’s very difficult to do, like with all things in the aesthetic. If you’re doing a single veneer at the front of the mouth it’s very hard to achieve and this is no difference, which is why we want to go to the nth degree to try to maintain that control, to try to mold everything and keep in control of as of much of what we possibly can. [Jaz]Now I know we might be digressing from the main topic of the podcast, but I’m really interested in this, like, if you’ve got the stock abutment like, off the shelf and it’s not customized to a patient, fine, but then how do you actually make the customized, do you customize the stock one, like adding flow I’ve seen before? Or do you arrange this in advance by taking fancy impressions to do it? How do you actually create something that’s customized for the patient chair side? [Pav]You can actually do it both. So if you use guided surgery, quite often you can have a customized healing abutment made. I don’t see the need or point in that. I think it just increases cost for the sake of it really. Because it’s actually quite easy to do, chair side. So instead of using a stock healing abutment, you can use what’s called a ‘temporary cylinder’. And it’s, think of it like a tall healing abutment, but it’s actually a little bit narrower. So in that dead space between where the cylinder is and where the rest of the tip, that’s where you add your flowable composite. And then you can unscript on and off. You contour it to support the soft tissue correctly. You clean it, put it back in place, and then that’s kind of like it. And then what that does is it gives the correct contours, it gives the correct support whilst everything heals underneath. [Jaz]And then the presence of a customized healing abutment as you explained that, you made it just that you explained it really beautifully. Now, how does that influence the denture versus bridge? Or does it not influence which type of restoration you might go for as your interim? [Pav]So it doesn’t really influence. So if the implant’s gotten nice, really nice and stable, you do that contouring subgingivally first, and then you can just add more material on to make your temporary crown. Or you can get like a shell crown made and just stick that all together. It’s just gluing bits together. The other really nice way of doing it is if your tooth is relatively intact is cut the tooth off just below the CEJ, punch a hole into it, and then you can actually use the existing tooth as your temporary as well. [Jaz]Like the old living bridge kind of thing, but applied to a single implant. [Pav]Now there are histological benefits to that, which is a little bit too titanium nerdy for this. [Jaz]Clever, clever. But by definition, if you’re doing that, you are then going down the immediate loading pathway, right? [Pav]Yes. So you’re going down the immediate loading pathway. So if you are not immediate loading, once you’ve done that contouring, everything’s kind of like just one millimeter above the gum height. So it is not really encroaching too much into your restorative space for your temporary, although it is a little bit, and sometimes at the front of the mouth, in in a high smile line, you can see it. [Jaz]I was just going to say, it’s a nightmare in a high smile, a high smile line. How’d you, if you’re not going for a flange, how do you even cover that then? [Pav]This is why immediate loading is beneficial. And this is why patient communication is really important because sometimes you can’t hide it and you have to turn around and say to the patient, ‘I’m sorry, it’s going to look ugly and it’s going to look worse before it gets better.’ And what I say to my patients is, ‘look, I’m very, very good at what I do, but I’m not a genie. I can’t just magic things just because we want to. There are certain biological and certain biomechanical processes that we need to respect. If we disrespect those processes, we’re going to end up going backwards instead of forwards on one of those things. It’s healing time.’ And, I will always do my best, and I always say to my patients, even if I’m aiming to immediately load, give an immediate temporary restoration, I’ll say to ’em, ‘we’re having a denture as a backup, or we’re having a rochette as a backup.’ I’d rather throw it in the bin, but I’d rather have it and not need it, as opposed to going ‘mm-hmm can’t do this.’ and then not having anything. And then what? Walking away with a space at the front of their mouth. [Jaz]Well, we’ve covered already with the denture. Make sure that it’s not touching the soft tissues. Make sure it’s not a flange. You mentioned make sure it’s not socketed for anyone who doesn’t know what that is, that’s basically you don’t want an ovate pontic, you don’t want the tooth actually going into the socket, obviously, because there’s an implant there and there’s a healing abutment there. But, so in case anyone miss that, we don’t want that. So let’s now change gears and talk about a Rochette Bridge. Interestingly, Ken Hemmings, restorative consultant, I had a chat with him many years ago, maybe nine years ago now, and he was saying that, while he’s waiting for osseointegration or soft tissue healing, et cetera, et cetera, he didn’t actually like using Rochette bridges. He actually used the unperforated retainer with Panavia, because his argument was like, ‘listen, my patients, they’re barristers, they’re this, that and the other’. It’ll be a travesty if they lost their tooth. Thought I pretty much treated like a definitive. And then nine months later, or whenever I made a that number up. I’m sure you guys know the numbers better, but he will then remove the resin bonded bridge and then at that point you can actually design the resin bonded bridge to have some sort of a lip, which is going to be really super filled with cement. And then you can old sonic out and try and sort of lever it out. But I guess we can talk about techniques or removing bridges anyway, involving forceps, et cetera. But, colleagues I speak to implant, they use Rochette, which are perforated. So what is your experience of using resin bonded bridges as part of your implant protocols? [Pav]I prefer rochette bridges as opposed to resin bonded bridges. Actually, for quite a simple reason is when you seat it. Some of that cement flows through those holes onto the other side, and I can smear it a little bit. It actually gives me a little bit more retention and for that reason, I really, really like it. I do not like GIC to hold these things in place. I don’t think they hold particularly well at all. I’ll tell you what I have used very successfully before in the past. These are dual cure resin cements something like, RelyX™. I have used Panavia. The issue that I found with Panavia, it’s almost too good. Then removing it ends up being a real nightmare. [Jaz]I imagine like you’re trying try and trying, like, I’ve done it before. You have to just drill away the metal. Right? [Pav]Correct. [Jaz]You drill it away, right? [Pav]Yeah. Yeah. And this again, is one of the reasons why I like Rochette is because they’ve got that little bit of mechanical retention, you’re not relying solely on the adhesive, on the cement is they’re they’re a little bit more robust for a cement that fails, a little bit easier for when you want to remove it. I’ve also used Poly-F F before for these, which works really, really nicely, but like relyX dual cure or something like that. I tend to find, I get fairly stable results with, and I really like that. [Jaz]Okay. And then same thing in terms of the pontic being well clear of the abutment, the stock healing abutment in this case, for example, all customized, like it’s going to be away from that healing abutment, not putting any pressure. And you’ve checked this, any guidelines, half a mil, a mil in terms of how much clearance you want? [Pav]Half a mil, three quarters of mill, something like that. There’s actually two ways of doing this. Aha. Just to make it even more complicated. So you can put your customized healing abutment underneath. And then put your rochette on top. If you are putting a cover screw onto the implant, so you’re burying it, maybe the implant wasn’t as tight as what you need, you can actually have a slight ovate pontic on the rochette. The problem is, is you don’t always know which one you’re going to need until the implant goes into place. So you either make a judgment call beforehand, or you add a little bit of material to it, or you cut a little bit of material away. [Jaz]Yeah. I mean, that makes sense to me, right? If you go with a ovate and then drill it away, it’s just takes time and it’s annoying, and you have to go through the polishing. I’m assuming what nice, highly polished surfaces against your surgical side right? [Pav]A hundred percent. And this, again, is why immediate temporization and immediate loading is actually better. There are actually certain kits that you can get, which actually help you make those contours, subgingivally. But you can really quite easily do it freehand as well. It’s just a bit fiddlier. That’s it. [Jaz]And can you just add like flowable composite if you want to make it. Have you used flowable onto your ceramic as a sort of temporary shape builder? [Pav]Yep. Correct. That’s exactly what I’ve done. You just need an adhesive to get the flowable to stick to it or I don’t get the lab to make it in a ceramic. I’ll get them to make obviously the metal work. And then just get them to use composite, then it’s much easier composite. [Jaz]That makes sense. Actually using a composite pontic rather than ceramic. And the lab bill will be better as well. [Pav]Correct. It’s only temporarily that doesn’t, it’s not designed to be there for a very long time. [Jaz]Any other nuances that you think because I know you teach so much in your academy. I assume from the restorative dentist, new to this field, I probably have a lot of nuanced questions about rochette now. I know we’ve covered a lot there in terms of cement choice, probably a popular one, the design of the retainer, that kind of stuff. Any other nuances before we move on to actually, stuff that will be helpful to those who already are practicing implants and placing implants? Any nuances on temporization in terms of going for a delayed approach and you want to put a tooth there temporarily? [Pav]So a lot of the finesse comes into the next bit that we’re going to talk about, but normally what I do, as you stated before, because it’s temporary, I normally get the lab to add a little notch somewhere on the palatal, normally underneath the pontic where I can get the crown and bridge remover in, and I like those pneumatic or those slide drill crown of bridge removers. You generally tend to find that with a rochette. You just put it underneath slide one tap and it’s off. Comes off really nice and clean. Then it’s just a matter of just cleaning up the wings a little bit, cleaning up the excess cement, and then if you need to use it again, you can reuse it again. [Jaz]One thing I’ve done Pav is, removing resin bonded bridges is using some gauze over the pontic and then using some forceps like extraction forceps, supporting the abutment tooth. Okay. And then just give it a good talk and that can help. But yeah, you got to warn the patient going to feel a bit of a yeah. And you don’t want to use it on anyone who’s got maybe grade one mobility, et cetera, once nice firm teeth obviously, and you in a controlled way. But I know lots of dentists, I know Rajiv Ruwala taught me this actually many years ago, and I’ve used it a few times, but yeah, sometimes if you use Panavia, it’s really tough and then at that point you got to get the big boy burs out and really just thin out the metal. The interesting thing when you actually thin out the metal and you ultrasonic it a bit, it actually does come away. The last bit is it just pings off sometimes if you get lucky. So I’ve experienced that as well. Okay. Well, let’s switch gears now and talk about top tips with restoring spaces with temporaries before you move on, definitive crowns. Now, when you mentioned, let’s say, in a scenario where you are immediately loading, so you’ve got, either the patient’s own tooth that you’ve gouged out or temporary one. Now, how will that temporary one be made? Is that always a lab made thing? [Pav]So the easiest way to do it is to have the lab make a shell made temporary with just a couple of simple wings that sit on the adjacent teeth. And that can be single tooth. There’ll be multiple teeth. Because what’s going to happen is if you’ve just got a shell temporary without any wings locating it, it’s not as easy as you just say, okay. I’m placing an implant in the central upper, say, upper right, a one position, and then my lab will put a wing on the lateral and the contralateral one as well. That means once that tooth is gone, it’ll just kinda like drop into place and it’ll hook over the incisal edges and that way I can let it go without it falling away. [Jaz]It’s like a locating lug, right? It’s like index, like a locate seating lug essentially. [Pav]That’s exactly what it is. So it’s not a wing because you’re going to adhere to it. It’s a locating jig. So you get the orientation correct. So I used to do it where I just used to make the shell crowns and then you got a try and orientate it correct with your fingers. And then my big fingers are in the way while I’m trying to pick it up with flowable composite. And then I was just like, hang on, why don’t I just do this? That’s so much easier. And what I would do is I would get the lab to make the shell crown all the way up to the CEJ. So it is contoured nicely, but that’s not just contoured labially, but it follows the gingival contour from the labial aspect of the palatal aspect and then back around again. So it’s like the crown is fully formed. It’s not like flat, it’s not like a flat 360. What you do at that stage, once the implant’s in place, you then put your temporary, what we call the cylinder in place, and that should pop up through the hollowed out temporary. And if not, then you can thin it out more. Now with these hollowed out temporaries, I get my lab to really thin them out quite a lot because you’re going to add material and have it all picked up anyway. [Jaz]They should be see-through, right? Pretty much. This should be very, very thin. Like we’re talking acrylic, right? [Pav]Yeah, we are talking acrylic. If they’re too thick, all that ends up happening is you’ve got to create that space first and you’re never going to be as neat as what your technicians are going to be. So I get the technician to do as much the work as possible. And that’s partly because I want to be as lazy as what I possibly can be as well. Okay. [Jaz]Prav, I’ve been the scenarios, where I’ve done like, shell bridges and whatnot. And the technician has completely misinterpreted what I wanted. And they’ve pretty much milled these margins. Like one millimeter margin thinking I’m doing these one millimeter margins. I was actually doing vertical preparation, so I had to, I was there ages gouging out. Then I would get the GC fit checker, you know that silicon stuff. Put it inside, seat it on, pencil mark. Where is it binding? Adjust it. We don’t want any of that. Just get the lab, have that conversation with lab. They want it as thin as possible. Eggshell thin, as they call it. [Pav]Yeah, absolutely correct. So then what you do is you should have your implant in place. You put your temporary cylinder in place and the shell should just fit over the top so that’s the first check. And then what you’re doing is you build the contour below the gingiva. So you’re taking it on and off. You’re taking the cylinder on and off, you’re getting that contour correct. That’s a bit too technical for this because a lot of it is visual, so I can’t get into it too much. [Jaz]We’re talking acrylic. Are you using like acrylic hand mixed acrylic? [Pav]I’m using flowable composite for that. Okay. And I want a really nice flowable composite so I can polish it as much as what I possibly can. Once you are happy with that subgingival a bit, you put the shell crown on top. You pick it all up with flowable and then you cut off the wings and you polish it, so it looks like a screw retained crown. Okay, now let me throw some information at you. So Dennis Tarnow has done some research into this. Did you know that 98% of people have a smile line high enough that they at least show their papillae as a minimum? [Jaz]I didn’t know it was that high. [Pav]It’s very, very high. So 98% of people will at least show their papillae. The issue that you have is when it comes to implants, when you take a tooth out, it doesn’t give the same support to the papillae. It doesn’t have the same blood supply to the papillae, and it’s very, very common to have blunting of the papillae when you are doing an immediate implant. If a patient’s got a low smile line, then it’s not a problem. But what happens when you do have this smile on whether the papillae show or there’s a very high smile line. And the answer to that is really, really simple. You need to do soft tissue grafting at the same time as implant placement. So in anterior aesthetic zones, a lot of people say, ‘oh, we’re going to do immediate placement.’ We don’t raise a flap. You should be raising a flap. You should be raising a split thickness flap. Harvesting dense keratinized tissue from the palate. And there are certain ways of suturing, but effectively what you want to do is you want to augment over the sight of the tooth and the papilla either side as well. And what happens is when you do that . Augmentation and you push the soft tissue thickness to two millimeters, that those papillae they will infill. Okay, over time they will heal absolutely beautifully is you get really nice stable result. So in high aesthetic patients or in patients with a high smile on whether papillae is possible, it’s my opinion that soft tissue grafting in the anterior zone at the time of immediate placement and immediate alone. It’s mandatory. You can’t get away with it just by doing the temporary crown, it’s not enough because the biology changes. You need to give more strength, more soft tissue volume to the papillae themselves. So it’s not just augmenting over the site. You’ve got to augment the papillae either side as well. When you do that, that is when you don’t get papilla loss. [Jaz]Well, how does that translate Pav to your surgeries that you do in the sense that if 98% of people are showing a papilla, therefore are you doing this connection tissue graft in 98% of cases? [Pav]Yeah, pretty much. Cause it doesn’t take a vast amount of time. Or again, the other thing that comes down to is patient communication. So I turn around and I’ll say to the patient is if they’ve got a low smile line, I just turn around and say to them, look, in order to get a perfect result, this is what we’re going to need to do. The cost of it’s going to be X, but you’re not going to see it anyway. Patients go, fine. I’m not really bothered about it. There are other patients where you may see the papilla, but it’s not really a massive amount, or it’s the adjacent teeth are all, you can see composites on them and for those patients, you just have the discussion and you ask them whether we want to do it. The patients where it’s absolutely mandatory are those younger patients or patients with very high smile line or patients who are very aesthetically demanding. Then I turn around and say to them that, look, It’s not just doing the implant because I can get the implant looking right, but it’s that balance between where the pink zone is and where your teeth are. That’s what your eye’s going to be drawn to. I said, I guarantee you, because of the biology and the mechanics of what’s going on, if we just take a tooth out, put an implant in. You’re going to have a little bit, just small black triangle showing either side. I said the way to alleviate that, get around that is to do some very simple grafting at the time. That doesn’t mean a second surgery site. It’ll be like you’ve bitten into a pizza that’s too hot. It’ll be sore and sore in your palate for a few days, but it’ll heal. And when you explain it to patients like that is quite often they’ll go, yeah, I’ll have it. And whether they have it done or not comes down to how you communicate with them. So if you tell them that you’ve got to take a strip of gum from their palate and it’s going to hurt like hell, then they’re not going to have it done because in their mind, you’ve got to take a strip of gum from the pallet, it’s going to hurt. Whereas if you turn around and say to them, look, pretend you’ve bitten into a pizza that’s a really hot, and it’s burnt the roof of your mouth and it’s sore for a few days, but it settles down. It just had a big- [Jaz]So much more relatable, isn’t it? [Pav]So much more related and I say to patients, that’s what it’s going to feel. Like I said, it’s going to feel like a bad ulcer for a few days and that’s all that it is, and to be honest, is your harvesting techniques and your surgical techniques is, they shouldn’t really be heavy handed. I warn my patients of that, but very few actually come back complaining of pain. Because the amount of pain that a patient experiences directly related to how traumatic you are, which is not necessarily related to the surgery that they’re doing, but how you are doing the surgery. So using very gentle techniques plays a massive, massive role for a patient. [Jaz]I mean, you taught me Pav a while ago, just cause I follow your posts and stuff about the importance, like did you take it to a next level, like a blood test? Because most patients will be vitamin D deficient, like you taught me. That kind of thing. And to make sure that they, you optimize their healing. And all those Im important factors, their medical history. So I’ve absorbed that even though I don’t do implants, I’ve absorbed those details from you. But just interesting relating it back to the restorative dentist who may or may not be placing implants. Think to how important soft tissue is. Even for like resin bonded bridge cases, you’re doing a bridge conventional or resin bonded bridge, right? If you are replacing a tooth, it slightly doesn’t have a papilla there. And to get a really good result, you need soft tissue augmentation, even with bridges and stuff to get a nice papilla. So you can apply to those as well. Now, if you don’t, you need to show the patient that either we accept a black triangle or you get a long connector. So it’s also relevant in the restorative world as well. What I do love, Pav, I have to say, even though I don’t do implants, I love those photos of patients who, when you remove their temporary implant crowns, and just a beautiful tissue like with the scaffolding that you had in place, and they’re just perfectly ready for the definitive crown there. I do love those photos and I used to work as a DCT and restorative. I remember unscrewing, some screw retained temporaries, and just looking at that beautiful soft tissue that is a thing of beauty. [Pav]Yeah, it’s great. See, you are a Titanium nerd. I knew it. [Jaz]I just didn’t know it yet. Excellent. Well, Pav, you’ve covered things really well. I’m very happy how tangible we made it. I think for a lot of the dentists, some of those, the way you explain those certain things are brilliant. Even if you just take away that communication gem or hot pizza on the palate and how to talk about that. I think it’s great. How can we learn more? Now, I know you teach people who have zero experience implants, but also people who are doing a master’s at the same time. You teach them as well, and they all have something to gain. So tell us about how we can learn more from you. [Pav]So very simply is just reach out to me. You can go to the academyofimplantexcellence.com or you can find me on Instagram. I’ve got three Instagram handles, @academyofimplantexcellence and the @dentalimplantpodcast. And just reach out to me. I’m on LinkedIn as well, Pav Khaira just reach out to me. And what’s really important for me is I speak to everybody before they enter onto the academy. I don’t just let anybody on because I’m building a network of people where, as you rightly said, some of them have never placed an implant before in their life. And I’ve got other people who only place implants wanting to increase their knowledge and increase their skill. And I have to create a safe environment for everybody. So what’s important to me is those joining the academy, they are hunger. They’re hungry, they are keen to learn because when they have that attitude is they will love the information that I give them. Because if somebody comes in and ah, I just fancy doing the oral implant now and again, the amount of information that I dump in, it’s just too, it’s overwhelming for them. So you need to be a Titanium nerd, but if you want to learn I just love helping and I love watching. When you’re speaking to people, you see light switches going on and there’s these aha moments all the time. All the time. I love it. I love it. And in fact, I’ve actually swap switched recently. My working week, so I’m now focusing more on the academy and mentoring, but I’m still saying staying wet handed a couple of days a week as well, because I’m just at that point in my career now where I feel like I want to give back and I need to give back. [Jaz]I’m just thinking about the practicalities of this Pav, like, is it online only? Is it in person? Cause I’m thinking I got lost of this from the US, Australia, Europe. Is it only UK that you can help out? How does it work? [Pav]No. So the academy, the theoretical part is it’s all online because let’s be honest, you can learn everything you need to learn about implants from articles and textbooks. If you knew which articles and textbooks to read. Or you can learn everything by somebody telling you and from somebody telling you. You can either do that in person or you can do it online while you’re in bed in your PJs on a Sunday afternoon, whatever it is. So in that context, I actually have delegates from Canada, America, Austria, and Australia as well, and it’s a fantastic group with regards to the actual hands-on aspect of it. I do offer mentoring as well. That’s obviously easier in the UK than anywhere else. And you don’t need to be a delegate of the academy to get mentoring. Some people are just like, Pav, I’m stuck, or I want to learn how to do these complex cases, or I want to learn this. If I line up a day full of patients, would you come out to me? And the answer to that is yes. If you are a Titanium nerd, I’ll come out to help you. So, yeah. Jaz’s Outro:Amazing. Well, Titanium nerds there we have it. Perhaps your answer if you need mentorship or if you want to take that next level in your implant knowledge. Pav, thanks so much again for coming to the show and making implants tangible. There we we have it. Guys, thank you so much for. All the way to the end, I hope we made some aspects tangible, which perhaps no one explained what a custom healing abutment is and or if you’re already well versed with it. It’s good to learn Pav’s protocol of how he does his resin bonded bridges, using something like relyX cement and how he doesn’t favor GIC. And even just appreciating the need for soft tissue augmentation to get that ideal result. If you want to learn more from Pav, checkout Academy of Implant Excellence, so I’ll put the link in the show notes that can of course follow him on Instagram as well. It’s @academyofimplantexcellence, and while you’re there, I know you’ll also follow @protrusivedental. Anyway, we’ll catch you in the next episode. Thanks so much once again for listening all the way to the end.

No need for violins – this episode was to share our behind-the-scenes story of creating an online occlusion course. This year has been the most challenging for me and Mahmoud Ibrahim as we worked hard to make OBAB the most tangible, real-world, and comprehensive occlusion training on the planet. We faced many struggles, hardships, and sacrifices along the way. I want to thank you all for your support, your help and your feedback. You have been a great help in this journey and I am so grateful that we were able to accomplish it with your blessings. In this episode, me and Dr. Mahmoud Ibrahim were invited to the Dental Innovator Podcast to talk about the journey, challenges and sacrifices we made while working on OBAB. This episode will also inspire you regardless of your own situation. Whether you are starting a practice, buying a practice or starting a business within or outside of dentistry, this episode will give you inspiration and a perspective. OBAB One-Time Pre-Launch Deal is now SOLD OUT – thanks for all your support! Highlight of this episode: 2:27 Dr. Jaz and Dr. Mahmoud’s Introduction 5:52 Driving force in doing OBAB 8:56 Process in making online course 13:04 Online Course vs Live Course 16:48 Work-Life Balance 20:31 OBAB Journey 28:12 OBAB’s post course support 34:54 Responsibilities in Business Partnership 41:00 Qualifications of Dr. Jaz and Dr. Mahmoud to teach people occlusion 47:33 Dr. Mahmoud’s journey inside and outside dentistry 49:12 Marketing aspect of an online course 52:04 Advice for young dentists 55:42 Innovations in Dentistry If you liked this episode, you will love How to Win at Life and Succeed in Dentistry – Emotional Intelligence

As you may recall from the first part of this series, Dr. Wayne William is an amazing dentist in our community who has been kind enough to share his insights into local anaesthetics with us. Today we’ll be talking about the second half of this topic: The most commonly used anesthetic agents used by GDPs (and why we should ditch one) Is it safe to inject lingually? Adrenaline for Cardiac Risk Patients – is it really a worry? https://youtu.be/E9q4t5z7LdI Check out this full episode on YouTube 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 The Protrusive Dental Pearl: Do NOT use the technique of lingual infiltration that I did! There IS a better way! (Lingual Infiltrations are not bad – just the way I did them was not ideal) If you’re curious what technique that was, Protrusive Premium will get to see it in the middle of this episode including Dr Williams’ ‘live’ unedited, uncut reaction. This is GOLDEN content! Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 4:34 The Protrusive Dental Pearl  5:38 Large red headed people are difficult to numb. Is it a myth or is it real? 8:29 Lingual Infiltrations 17:02 Adrenaline being avoided for certain patients 23:49 Adrenaline for Cardiac Risk Patients  Occlusion: Basics and Beyond is the most tangible, real-world, and comprehensive occlusion training on the planet. Get the OBAB One-Time Pre-Launch Deal which SOLD OUT – the only way now is the Waiting List as IAS are preparing 20 extra starter kits. Be sure to watch the first part of this episode: Articaine ID Blocks and the ‘CIA Technique’ for Local Anaesthetic Click below for full episode transcript: Jaz's Introduction: Welcome back Protruserati to Articaine ID Blocks Part Two. How good was part one? Thanks to Dr. Wayne Williams. [Jaz]What I love about bread and butter episodes like these is the engagement it gets from the community. So you guys, Protruserati on the Instagram app @protrusivedental, had some really interesting things today. Like for example, Cony, Cony Caravotas we met in Brighton and also at the Finlay Sutton course. Hope you’re doing well. She said that she hasn’t done an ID block since 2009, so that was 14 years ago. That is bloody impressive, right? I told you I do about one a month. Coney hasn’t done once in 2009. She said, buccal articaine infiltrations all the way. And there were loads of comments just like that about how we’re all getting really good results with buccal articaine. But of course, Dr. Wayne Williams suggested that it’s only really appropriate for single tooth procedures. But I know many of you, including myself on many occasions, use it for quadrant dentistry in the lower molar. Now, I wouldn’t use it, like I said in the previous episode of people with large bones, large heads, big bony exostosis. But for the average person, I think it does work well in my hands, and that’s what it’s all about. Don’t change your technique if something is working well, unless there’s more efficiency, more safety involved, or lower cost involved. But if you’re not compromising a lot on those areas and something is working well in your hands, I wouldn’t change anything about your protocol as long as you’re safe, efficient, and cost effective. So more power to anyone who’s getting great success with buccal articaine. I personally will say that by putting it in the attached gingiva. Now, something that, @ohheyitsdoctoralbert also said on Instagram is the importance of attached gingiva. I find that the attached gingiva retains it, and probably by going in the attached gingiva I’m entering that coal area that Dr. Wayne Williams talked about in the first episode, and therefore, these em mystery canals, these holes in the mandible to allow our anesthetic to get in the right place. So if you are not getting good results like our colleagues are with buccal articaine, consider putting some in the attached gingiva instead of just going supra periosteal near the apical area and expecting it to diffuse into the bone. Like Wayne said in the last episode, it’s not as simple as that. One thing I have changed about my technique after talking to Dr. Wayne Williams is although I’m very slow with my anesthetic, I sometimes speed up towards the end, for a subperiosteal, which I won’t be doing so much anymore. But I think the key point was just always keep it slow and reduce the pressure. Another thing actually I will be changing because a lot of things I won’t be changing because it’s working well on my hands. But a big thing that will be changing is as a result of this part two, you’re going to find it pretty interesting what happens in part two. Just have a listen or have a watch if you are on the Apple, YouTube to this part. I’ve got a few videos I’ve taken of me giving a lingual infiltration and like if I’ve done a crap job and I’m doing something dangerous. Say it live on air. I mean, it’s, we’re not live, but you know what I mean. Say it on the podcast. It’s a learning thing for me. And I thought, okay, wow. I get to show someone who’s so experienced and written about local aesthetics and I get to show you this video. So, please, if I’m doing anything wrong, I want to learn and I want everyone else to learn if I’m doing something wrong, if I’m doing something right, please, please let me know as well. So a cool segment of this episode will be me showing you those videos, which I’m very excited and nervous about. So actually show Dr. Wayne Williams the technique of giving a lingual infiltration the way. I have seen a specialist oral surgeon do it. The story is that I was shadowing a oral surgeon and I saw him do his very interesting lingual infiltration where I thought it was at the time, and I’ve sort of copied him. Okay, he’s a specialist. He knows what he’s doing. So I’ve been copying him and I’ve been getting, yeah, okay results. But I had this doubt in my mind, is this something that could be made safer? And is it really respecting the anatomy in the best way? Is there a better way that I could give this lingual infiltration? Do you remember way back when if you’re a original Protruserati, you might remember episode 37. That was in, that was three years ago. My goodness. We had Dr. Shaz Memon and what we did is live on the show. I got him to critique my website. Right. And it was embarrassing because my website sucked and it still sucks cause I haven’t updated it. Right. But it was an interesting and cool thing to do and I was happy to do it. And it was embarrassing for me, but it’s fine. I’m happy to put myself out there for you guys. Now, I did the same thing here. But with a really high quality clinical video that I recorded showing him how I do my lingual infiltrations. Protrusive Dental PearlAnd so the Protrusive Dental Pearl is, don’t do what I did. The technique that I showed him is not a recognized technique and it shouldn’t be used. And even though that oral surgeon did it, Dr. Wayne Williams, whose opinion I highly trust, told me there’s a better way, which that’s why I certain I’m going to be changing my technique now. I’m not going to just expose myself and embarrass myself willy-nilly. This is only for Protrusive Premium members. So if you’re on Protrusive Premium, you’re going to see the whole bit where actually entire video, the same video that Dr. Wayne Williams saw his reaction to it and his feedback in terms of what I should change. Main Episode:And I’m happy to make a fool of myself and share that with you guys. So if you’re on Protrusive Premium, you’ll get to see all of that. If you’re not, then it’s okay. I still love you. I still respect you, but you have to understand the feedback that I got in the video that I showed him was absolutely golden and well worth the cost of a $9 per month. And to give you a teaser, this is the way that Dr. Wayne Williams reacted. [Wayne]I’m sorry, I’ve never seen that described anywhere. I’m not sure it’s needed. I’m not sure what the benefits of it are. Yeah, I’m not in favor of that technique. [Jaz]So let’s join Dr. Wayne Williams to continue on that cliffhanger we left you at, at the end of part one. Should we fear the large headed redhead? Is that true or false, that myth, or is that real? And any strategies to help the large headed redhead if it’s true. [Wayne]So I’m not aware of the redhead. The large I can kind of understand cause it comes back to an anatomy and physiology and understanding and that’s always my starting point on all the courses I present on all the teaching I do globally. It’s always going learn the anatomy, number one. Then understand the physiology, then the chemistry, and then we go to the techniques. But it has to be in that audio. Don’t try and go for the techniques and then work your way back. You have to have the anatomy, physiology, and pharmacology behind you. But, so there’s different ways I would approach a red head from now that I’ve heard you and Lincoln say that. And great program by Lincoln, by the way, with yourself as well. High respect to him and basically the guys I’d be more interested in for you and other colleagues in this country would be class three. People with Class three, mandible. Well described in, I brought this textbook along because this is what changed my life 25 years ago. [Jaz]Just for the listeners, can you just say the name of it for the listeners that were listening. [Wayne]Sorry because I know it’s Hazards of local Anesthetic Injections by Daniel Barnard. Same type of Barnard who did the first heart transplant. Possibly a family member, gentleman who I learned almost everything I know about local anesthesia from certainly the hazardous approach to it. A valuable, valuable piece of literature. But basically he speaks more about class three patients having a slightly higher lingular. And then certain racial groups, Chinese people have higher lingular, Asian type orientations in terms of their lingular position is slightly higher. And certainly some of our tribes back in Africa have different positions and much stronger class three mandibles and thicker bone of course. And of course you make your judgements according to that, but often what people miss is look at an OPG. If you’ve got an OPG of a patient, you can actually see the lingular often on that OPG, and you can then figure out from a cusp position in the mouth, you take a cuspal measurement on the OPG, say that the upper six, and you measure, that’s 2.3 centimeters. 23 millimeters. Then immediately you can then take your fingers and estimate a 2.3 milimeters. Put it in the mouth and say, right, that’s where the lingular is lying up at that point. And then get yourself to go in. Just giving yourself landmarks, local landmarks. [Jaz]That is a fantastic tip that someone could apply and that’s very useful. So really case by case. And so maybe not the redhead, we don’t know, but, you know, large anatomy, thicker cortical plate kind of thing. That may be a concern, but I guess the real clinical tip there is just aim higher because they probably have a higher lingular and that is a real applicable tip. [Wayne]Yeah. [Jaz]Now we talked about anesthesia failing. One of the reasons I do a lingual infiltration is to prevent that. Right? Now you’re probably going to say that don’t bother with lingual, it doesn’t work. Okay. That’s totally fine. I’ll stop my practice immediately if you say it. But, what are your thoughts on lingual infiltrations? To supplement and bolster your buccal. Is there any signs behind it? [Wayne]So again, if you’re using the mesial distal approach, then the lingual approach be probably becomes less utilized and less valuable. I think a couple of things with lingual. First of all, I’m not sure that I share concern necessarily about anatomy in the lingual domain. So yes, we’ve got the lingual artery. I think the more bigger concern is the access to the lingual area. So you’ve got a tongue in the way. You’ve got a a curve of Spee and curve of Monson with your teeth curving in and the lower jaw. So you’re trying to get under something rather than with clear vision if it’s directly in like that, whereas from the outside, everything’s open. On the inside, you’re trying to get, your visual access to the lingual is always limited, nevermind your tactile and dextrous access to that area is extremely limited. So I think your ability to deliver drugs successfully in the lingual, the main, certainly in the lower jaw is limited palatally in the maxilla. It’s a completely different ball game. I do predominantly palatal anesthesia that’ll shock you a little bit more. So I’ll probably do more palatal anesthesia than I do buccal anesthesia in the palette. And again, you know, if I ever get to share some of my anatomy lectures and work we’ve done, it is unbelievable how porous the maxilla is. But to come back to your lingual, I’m not scared of the anatomy. But I am more concerned about access. So the only time I would ever go lingual is if I needed the soft tissue anesthesia as opposed to dental anesthesia. So I would always use buccal infiltrations as you’ve suggested. And I still think that’s an excellent technique, but it has to be using articaine. I wouldn’t bother too much with lidocaine, lignocaine, and I definitely wouldn’t 2% drugs, and I definitely wouldn’t be bothering with a non-adrenaline Mepivacaine, Scandonest and others. It’s just got no value in my opinion. You need the 4% articaine for those. [Jaz]Amazing, well, should we do the bit where, I’m going to expose myself a little bit and honestly, it’s all a mentoring. It’s live. [Wayne]Go for it. [Jaz]I’ll show you it and if I’m doing something silly, please tell me. And I’m happy to learn. And we could talk about bending needles. Cause there’s one of them. I’m going to show a bend because one way I got around my access was, cause I don’t want to hurt the tongues, so I had to bend it. And I know that’s a big no-no. So please feel free to tell everyone watching this thing, don’t do what Jaz did, and that’s totally cool. [Wayne]Jaz, I can already tell you that. Don’t bend a needle. [Jaz]Never bend needles. [Wayne]Don’t ever, ever, ever, ever, ever bend a needle. [Jaz]Do as I say. [Wayne]Don’t Ever bend needle. [Jaz]Not what I did. [Wayne]The reason I have to say that is from a legal perspective, if I ever went on any platform and suggested even bending of a needle was safe, when it breaks off, I don’t want to be the one in court helping that person get outta trouble. [Jaz]Absolutely. [Wayne]Honestly. So again, the wand comes in, we bend the wand a lot. The whole hand piece can bend so we don’t have to bend the needle, but I would never, ever, ever bend a needle, ever. [Jaz]Great advice. All right. Have a look at this. Okay. So I’ll describe it for the audio listeners. I’m using my mirror to really keep that. I’m getting a good, good, sort of purchase of that tongue. And I’m really moving out the way. This is the case where I was doing a quadrant of dentistry, second molar restoration. [Wayne]Nice. Safe device. Very good. [Jaz]Yes, we’ve got the Safety Plus device. I’m keeping it out the way, I’m just entering sort of alveolar mucosa just adjacent to the mandible and lingually, I’m just going very slowly. And sometimes when the patient swallows it will actually assist your needle to go inside, basically. So sometimes it just that little swallow and then it allows it to go in. But I’m very, very, very careful to keep that tongue out of the way. I’m just describing for the audio listeners really. And then, yeah, I’ll just be here for probably about another 15, 20 seconds. So I’ll just keep that rolling. And there we are. I’m out. So that’s my technique for doing a lingual infiltration. I’ll now show the one for that we shouldn’t do, guys. This is the one where I bent the needle, so please don’t do it this way because this way I was really struggling with the tongue, so I thought, okay I give the buccal as I usually do, and I made a video about that. Here we are. Here’s the bend. So don’t do this guys, please. Right. But here’s what I did. Oh, let me just switch off the volume here. Okay, there we are. So, but same thing, and it’s clearer of you exactly what I’m aiming for. And I’m getting some soft tissue anesthesia. Here I was using a thermacut bur to trough through the lingual papilla because it was deep margin elevation and whatnot. So that’s what I’m doing. So some people get very worried about the anatomy. You are less worried about anatomy. You’re rightfully quite concerned about the access, which is tricky. [Wayne]Well, I’m now a bit more worried about the anatomy. I wasn’t quite sure that you were in the floor of the mouth when you used the term lingual. You’re actually in the floor of the mouth where you are right now, so that’s completely different to me. I was assuming you were on the attached mucosa in the lingual aspect. [Jaz]No, I was, as you saw, I was at the junction of the floor of the mouth. So what do you think? I’m happy to stop it like tomorrow if you tell me that’s- [Wayne]Jaz, I would never, ever, in my entire career, I’ve never given an injection where you were giving that injection. And I think the point I’m really trying to make there is you don’t need to. So maybe maxilla facial surgeons, if you’re taking a lesion out in the floor of the mouth, yes. If you’re taking something out where you can’t get to it through any other means, yes. But that as an adjunct or as a primary or even secondary anesthetic technique. I’m sorry, I’ve never seen that described anywhere. I’m not sure it’s needed. I’m not sure what the benefits of it are. And maybe someone, you know, would perhaps- [Jaz]The context of where it was taught to me is on the same vein of, you know, how far can we go with articaine infiltration, right? So, it was to, you know, it was first taught it to do extractions without an ID block, and therefore you don’t get that lingual anesthesia. So I would give the buccal, let’s say it’s a second molar. Buccal in the attached gingiva and then also the lingual. That’s where I first started to do it basically. And then now, and again, I might do it just to enhance, cause I was doing a quadrant there, so I was like, let me just get an, there’s a clamp and whatnot. We might be on the lingual gingiva and I haven’t done, ID block here. So its a way of me getting that lingual sort of anesthesia. But, from what you said, in terms of the other techniques that are available that perhaps is not necessary, but for an extraction, you were just given ID block anyway. Right. So- [Wayne]I would absolutely give an ID block. But again, only in my context because I know it’s going to be successful and in the 0.001% perhaps in our particular case, we fortunate. I’m very fortunate in the sense of if I do get a failure there, I just give the CIA technique as a supplement, by the way. So I would always give an ID block for all extractions in the posterior segment. Now it is very interesting because, and I’m sure you’ll find this interesting, so our perio visiting periodontist who puts in thousands of implants every year, he’s highly highly qualified and experienced. He was one of my teachers at university and now works for me, which is brilliant. I can tell him what to do. It’s fantastic. And basically when he puts implants into the posterior mandible, he prefers not to give an ID block. And the reason he doesn’t want to give an ID block is he wants the patient to be able to respond if he’s getting close to the inferior alveolar nerve. And that’s all, despite using CBCT planning and guided surgery and all the rest of this. But his view on that is he wants to give a very localized soft tissue supra periosteal, perhaps a slight lingual, but into the attached gingiva rather than the floor of the mouth where you were. The floor of the mouth where you were, I think does hold inherent danger. I think you can have going, there are spaces down there where if you’re going to press that needle too far and you made the point of the patient lifting their tongue and then you lose control of how deep that needle is because it then penetrates, Yeah, potentially more deeply. So, I’m not in favor of that technique. I’d much, much rather have teachings around the CIA technique and around supraperiosteal and around proper inferior. I think if people are trained properly in the inferior alveolar block technique, we should be using that with articaine. [Jaz]Well, I certainly feel much better today. I’ll speak to you about ID blocks in general, and you know, cause you see all the stuff that we talk about and what’s posted on social media and also in the BDJ, et cetera. People are dentists, young dentists especially, are more and more afraid of ID blocks. But I feel I can tell you now, I thank you so much. Cause I feel much better about it. I felt like this is the right thing to do to phase out of ID blocks. I thought that was the right thing, but from speaking to you, I feel way more confident about going back to ID block. So I thank you for that. [Wayne]Oh, pleasure. [Jaz]The next question I had is adrenaline being avoided for certain patients. Is that a myth or are there some patients that we should be avoiding adrenaline on? [Wayne]Very good question, and again, I think appeals predominantly to our younger colleagues, newly qualified colleagues. It’s just amazing going through this talk today with you, Jaz, about all the fear. I almost feel like we are in a political arena here for a minute, but you know, there’s just all this fear mongering and don’t do this and don’t use that drug and this will happen and that will happen. Well, the first point about adrenaline is I think we lose sight often of kind of where we are with that. It’s a produced adrenaline is produced by ourselves in our suprarenal glands. Our body produces adrenaline and tons of the stuff. Much, much more than you can ever imagine to be in a local anesthetic cartridge. So we produce a lot of adrenaline, so nobody in the world that I’m aware of to date is allergic to adrenaline. [Jaz]Yeah, I’d love to be a fly on the wall. Who told you that? That I’m- [Wayne]And who’s still breathing? So those are not breathing. They might not be, but they might have been allergic to adrenaline because then that’s what causes the problem. But the truth is no living human being can be allergic to adrenaline not one that I know of. So any patients that do tell you that at any point you need to probably run away because they’re a ghost or something else. So once you’ve told the patient that, I think we have to be highly respectful of the fact that a lot of patients will tell you that. As a result of a potential vasovagal attack previously with the giving of adrenaline. And what will have happened there was the patient will have a vasovagal, they’ll feel faint, they’ll pass out, they’ll feel all the symptoms related to that, and at the end of it all the doctor will go. The dentist will go. Oh, I’m never using adrenaline for you again. That’s what I used for this time in the dent, and the patient goes, oh, it’s because you used adrenaline, right? So that’s where the problem starts. The next thing is almost all of those, almost all of those cases, are intravenous or intra arterial injections. So because people are not aspirating and because aspiration is so non-effective in almost all anesthetic devices other than the wand, even all the quick sleeper, all of those, because they have a certain mechanical aspiration technique, the wand aspirates from a foot piece. So I take my foot off a pedal and the device aspirates, every other device has to have a hand attached to it. Some way or another, or a needle or a lever pulling. So you’re always going to have the potential for a false negative, but the point I’m going to make here is adrenaline if given at the right speed, go and look back at the textbooks. How fast, minimum times 60 seconds for any cartridge of local anesthetic. Time yourself, colleagues, time themselves. If you’re ever giving a full cartridge of anesthetic in less than 60 seconds, it’s a long time. Trust me, a lot of my anesthetics take me three or four minutes to give. And I warn the patient of that before the time. I say this is going to take much longer. However, when I take that needle out and my drill goes straight into their pulp. [Jaz]I’m going to replay this to my nurse. Cause I’m that slow as well. And then my nurse, sometimes they just, like every other dentist I’ll work with is just give the damn injection, you know, so – [Wayne]so if your needles in the wrong place, you’re into arterial or if you intraosseous even and you go in at speeds that these drugs are not designed for, you’re going to have vasovagal attacks. And it’s then when people go and it is then when the adrenaline will play a role. So the adrenaline will play a role in those cases. It’s less likely to be a problem. In fact, almost not going to happen. If you are using mepivacaine 3% or you’re using, you know, any kind of non-adrenaline drug, Citanest and Felypressin. And we need to come back to separate point in a moment. Cause that’s a whole different ballgame that I’m going to share something with you with. But the truth is with adrenaline, given safely, given correctly with good aspiration, making sure you’re not intravascular. Given over at least a minimum of 60 seconds for 1.8 milliliters of a drug. If it’s a larger cartridges, the 2.2 s that we have in this country, we need to go even slower. Minute to minute and a half, then adrenaline usually doesn’t play a role. Now, I have in my entire practice of thousands and thousands of patients, it come to me from all over the world. I have two patients who I don’t use adrenaline on, and neither of them are proven medical cases of not to use adrenaline, but I’ve experimented with that, if you want to use that word, where I’ve gone, listen, I’m the guru of local. I’m going to show you, I will get this right slowly and all the rest of it, and they still have some form of excitement or reaction. It’s not a vasovagal attack, but they don’t feel well. A lot of it could be psychosomatic. I can’t prove that it is or isn’t psychosomatic, but in two cases I say to the patient, look, we are going to use Mepivacaine or Scandonest 3%, no adrenaline. However, if you require a procedure that requires a long period of time that I need profound anesthesia, and you’re going to be jumping around in the chair. Then we are looking at sedation or we are looking at hospitalization or we looking at something else where I can then monitor your blood pressure and pulses rate to the pulse oximeter, and I can make sure that you’re not having some reaction to this adrenaline. But effective anesthesia, it has to be, and I think that’s a give. The takeaway from this concept is you have to always put good, profound anesthesia ahead of everything else. Now, even if that means that a patient has a mild tachycardia for 30 seconds, whilst you’re giving that anesthetic and you prepared for that, you monitor it with a pulse oximeter, the patient knows it’s going to happen. And it’s all over and you can control it. And again, slowly and small amounts, but I’m not aware of anybody who genuinely can’t have adrenaline. [Jaz]Well what about cardiac risk patients or cardiac health? Cause that’s a, the one where, if someone’s had a heart attack sometime ago. They have a stent and then automatically we think, avoid the adrenaline as a thing is. Is that a thing? [Wayne]Wow. Okay. So I want to just read something to you because this is something I’m faced with quite a lot. People ask this question, so I’m going to read you two things if I may. Citanest, is that something you’d possibly consider or would’ve considered in? [Jaz]We have that, yes. Absolutely. We were taught that if they can’t have adrenaline because they’re cardiac risk and maybe give a different type of basic constrictor. [Wayne]So Jaz, I’m going to hold up four cartridges, especially got these ready for this. talk [Jaz]Oh, amazing. [Wayne]Now two of them are the same thing. They’re just arctican in a 1.4 or a 2.2 mill cartridge. Only because manufacturers run out, et cetera, et cetera. And then the other two are Lignocaine, one in 80,000 adrenaline. And the other one is the Scandonest 3% Mepivacaine no adrenaline. You will not see Citanest or Felypressin in my clinic. And you haven’t seen that for at least 20 years, at least the last two decades. And the reason for that is, and I quote Felypressin – Citanest is the active ingredient of Citanest. Felypressin acts on the venular side of circulation with no significant cardiovascular response. It can be seen as a less of a risk in compromised patients. That’s according to respected colleague John Meechan in New Castle, Robb and Seymour in their book, pain and Anxiety Control for the Anxious Patient, however, according to Robinson Pit Ford and McDonald, in their book, local Anesthesia and Dentist. However, Felypressin has been shown to cause coronary artery, vaso constriction, and cardiac arrhythmia, and is thus not a benign alternative to adrenaline containing solutions in patients with cardiac disease. [Jaz]Wow, I had no idea. [Wayne]No Citanest. No Felypressin in my clinic. Forget the risks it holds for pregnant patients. If you’re keen on delivering a baby that’s use a bit of that towards the end of the pregnancy, that could help. But you know, the octapressin and felypressin in there. But the truth is honestly, yeah, I would- [Jaz]So we don’t want to give an alternative in Felypressin because of those reasons you mentioned, but in that patient who has some sort of a cardiac background, then also avoid the adrenaline by giving the plane. So there is a, there is, yeah. Fine. So there is a – [Wayne]Scandonest, yeah. Scandonest 3%. So for a patient with a known cardiac disease, and there are a whole list of those, I won’t go into all of those, but they’re well described in the literature. But for patients who are genuine or recent cardiac, major cardiac surgery and you’re having to do an acute procedure, you’re in a difficult position. Because what actually happens, and this is back to the point I made about effective anesthesia, is that every single time you hurt that patient, by not having effective anesthesia or long-lasting anesthesia, their adrenaline levels go sky high anyway by self induction. So their own body produces far more adrenaline into their body system than you could have injected. And therefore they’re having an adrenaline attack anyway, but it’s just self-induced, so profound and efficient. Anesthesia takes precedent in our clinic for all procedures and should I believe in most clinics, even if that means slow, careful, calculated deposits of adrenaline if you’re having to do a procedure over a long period of time. My point is, if you doing a small DO composite, Use your non-adrenaline containing drug irrespective. You know, I mean, I don’t use it. I use articaine and lignocaine for almost everything, but on the occasion where I’ve had the doubt, yeah, I’d use that. But if a patient’s coming to me for an extraction and I’m in a 50 50 doubt, they’re getting articaine in a controlled, calculated fashion. [Jaz]I’m just in awe. This hour’s gone so quickly. It was an absolute pleasure to speak to you today, Wayne. You were so hard hitting. You were so direct, and you really reassured me in lot of the areas, which me and the Protruserati already had some misconceptions, and that is fantastic. Wayne, please tell me, like you’re doing, you’ve done lots of teaching in the past. You’re getting into it again. Because I know you got busy with clinics and stuff. Where can, how can we learn more from you? [Wayne]So, yeah, contact me directly, Jaz. I’m happy for you to give out my details. My email’s usually the best way to get hold of me. I’m one of those guys. I get up at 4, 4:30 in the morning. You can always contact me between 4:30 and 8:30, but 8:30 I start with my patients most four days a week. But I do clear my emails on a daily basis, and you’ll know that from your experience with me. But I clear my emails every single day and if anybody gets hold of me by email, If you have my mobile number somewhere, you’re always welcome to contact me. I do in-house training courses for practices, but I don’t- [Jaz]What kind of stuff do you teach there? Like Akinosi gal, that kinda stuff? [Wayne]Yep. Gow-Gates, Akinosi, the CIA. A lot of it around the wand, of course, but a lot of what I teach will be anatomy, physiology, and pharmacology. That’s the basis of all the courses that I present. [Jaz]Wayne, I think any practice is looking for like a team day, right? In terms of something for the clinicians. Local anesthetic is such a, an underlooked at, but such a key thing, you know, rather than sending your associates to a composite bonding. And I think there’s enough of that going back to basics, local, an aesthetics. So do consider giving Wayne a shout because, I just, I’m sure you guys have as well. Absolutely love this conversation. Thank you so much. Anything else you wanted to add? [Wayne]No Jaz. As I say, you keep up your good work. I’m in awe of your work and all your Protruserati, I think is the term. I’m very proud to be one of those and please keep up the good work and thank you again for the opportunity. Jaz’s Outro:Thank you so much. Well, there we have it, Protruserati. I just realized at the beginning of the episode in the intro, I didn’t even introduce myself. So if you are new to the podcast, my name is Jaz Gulati and thanks so much for making it to the end. That’s pretty cool. Lots to be learned from that episode. Dr. Wayne William is full of cold hard facts, which might upset some people because you’ve been doing things and they’ve been working and then suddenly someone throws a bombshell of information, which kind of goes against your paradigm, but you have to respect the anatomy, the physiology, and the pharmacology. But ultimately, remember, like I said right at the beginning, it’s what works in your hands. So if you’re getting good results and you’re safe and you’re cost effective and you are efficient with LA, that’s what matters, right? If you can do it in a pain this way, all the better. So I’m sure you took away a few practice changing gems, but some things that you might just respect. But if because it’s working in your hands, that’s totally cool to continue the way that you’ve been going. Now, if you want to claim some CPD, then of course as a premium member, you can answer a few questions and get CPD for this episode and the last one and hundreds of others. Otherwise, I’ve got a lot planned this summer. In terms of podcast episodes, we’re expecting baby number two. Gosh, by the time this episode comes out, it’ll be a few weeks away, so wish me luck guys for baby number two. I hear it’s twice the lows and twice the highs. So if I do go radio silent for about 10 to 12 days, you know where I am at. So my team’s very supportive. We’ve got a lots of podcasts in the pipeline ready so that when I get busy with baby, there’s still your protrusive fix to keep you occupied in those long and lonesome journeys. Thank you as ever for being a Protruserati, and I’ll catch you in the next one.

There is a massive trend of Dentists ditching ID blocks in favour of articaine buccal infiltrations. For many that are still using ID blocks routinely, they are afraid of using Articaine due to fear of paraesthesia. Should we be doing less ID blocks? And when we do, is it ACTUALLY harmful to use articaine or is that a myth? I have to admit, the main reason I heavily switched to buccal articaine was to avoid ID blocks. Dr. Wayne William, our straight-talking, no-BS Prosthodontist guest will bust some myths and improve your daily delivery of safe and effective local anaesthesia. In this episode he taught us the Crestal Intraosseous Approach (CIA), a technique developed by Dr. Wayne to improve our buccal infiltrations. https://youtu.be/LbOxlXIZCkw Check out this full episode on YouTube 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 The Protrusive Dental Pearl:  Check out the couple of videos I posted recently on YouTube and on the app https://youtu.be/yFfKVLmSr5Q Robin Hood Dentistry – a careful and well-considered enameloplasty https://youtu.be/3QLby2U_W3E No More High Restorations 2023 Update – Stop Grinding Away Your Composites! “There is no such thing as a periodontal ligament injection” Dr. Wayne Williams Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 3:02 The Protrusive Dental Pearl 5:49 Dr. Wayne Williams’ Introduction 8:06 Buccal infiltration with articaine for lower molars 13:09 Crestal Intraosseous Approach (CIA) 22:28 ID Blocks – is it safe? 28:13 Hitting Bone while giving injections – safe or not? 31:04 Failure rate for ID Blocks Occlusion: Basics and Beyond is the most tangible, real-world, and comprehensive occlusion training on the planet. Get the OBAB One-Time Pre-Launch Deal before 21st March to get access to OBAB for two whole years and get a fully mentored case worth £550. Plus get £1445 of exclusive extras!!!  If you enjoyed this episode, check out Hot Pulps, Painless Palatals and ID Block Failures Click below for full episode transcript: Jaz's Introduction: There's been a huge trend in dentists doing less and less inferior alveolar nerve blocks and to be fair, I've been part of this, right? Jaz’s Introduction: I’m actually, I wouldn’t say afraid. I’m not afraid of doing ID blocks. I’m just do them way less because I’m afraid of some of the POTENTIAL COMPLICATIONS that you see in papers and in opinion articles about the potential risk of paraesthesia and other complications from ID blocks, and therefore I’ve been a bit put off. So what I did many years ago is I started to do more and more articaine infiltrations, buccally, and to be fair like I told Wayne, Dr. Wayne Williams, the prosthodontist who’s a fantastic straight talking guests. I love straight talking guests. Right? You’re going to love him too. And I shared with him that, look, I only do about one ID block a month. A) Because I’m getting so much success with my buccal articaine. But B) Because I’m being overly cautious, I’m really trying to prevent it. Because I think this scare mongering has worked on me. I am a little bit worried about the risk and the more ID blocks you do, the more you increase your risk or so I thought, because there’s so much we talk about in this episode in terms of the power of a buccal, articaine, but also, knowing when to respect and knowing when that might not be serving your patient the best, and why he should be perhaps doing some more ID blocks. And in fact, Wayne even says that he’s a huge advocate of articaine for ID block. So we’re going to cover a lot of controversial topics and as you heard already, Wayne is no stranger to controversy and I love that so much. One thing I really respect about Wayne is that he helped to develop the CIA, the Crestal Intraosseous Approach. I had to really, it’s a bit of a tongue twist. I had to really think about that. So the Crestal Intraosseous Approach and no, it does not involve drilling into the bone. It does not involve buying a quick sleeper or something like that, involves actually what he teaches us, is really cool about the anatomy and how there are these mystery canals in the bone. And we can actually utilize this to make our infiltrations with articaine far more success. And so because he started to develop and use this technique a lot, he actually would lecture many years ago and say that you don’t need to do ID blocks anymore. So he went through that phase himself, but now he’s gone a full 180 and he really believes in effective anesthesia through inferior alveolar nerve block. So I think you’ll really gain a lot from this episode, which is covering so much of bread and butter dentistry. Protrusive Dental PearlThe Protrusive Dental Pearl is related to a couple of videos I posted recently on YouTube and on the app. So this could gain a lot of attraction. So one video is called Robin Hood Dentistry. And so what this is about is stealing from the rich and giving to the poor. And what I mean by that is if you have a lower molar, for example, that’s completely beat up, right? It has exposed dentin, it has got cracks and it needs restoring. It will really benefit from restoring, but there’s no space because the upper plunger cusps sits right inside there. So what I talk about in this video, and I really encourage you to watch this video, rather than just go by this pile here, is the use of Robinhood Dentistry. Careful and well considered enameloplasty of this pointy sharp cusp to make it into a rounded cusp. It’s much better stress distribution and sometimes it’ll remove a bit of height, but you don’t want to flatten the cusp, right? You want to follow the cuspal contours so that you can then have space to restore the lower molar. And you can apply the Robinhood philosophy to anywhere in the mouth. And the reason I love it so much is because you show patients the photo and you say to them, you have a very aggressive opposing tooth. We have a very sharp corner of this opposing tooth, and we need to do some Robinhood Dentistry. We need steal from the rich and give to the poor. We are taking away from this arch and we’re giving to the other arch. So communication wise, patients really get it and it’s good to tell them before you do it. Otherwise it looks a bit sloppy. It doesn’t look very professional if you’re having to adjust the opposing arch after you’ve carried out some restorative dentistry, right? There is a second video that’ve also added. It’s called No More High Restorations, right? We replace those beautiful composites under rubber dam. We take the rubber dam off, the patient bites together, and we’re drilling away our beautiful anatomy. Well, if you want to watch the free version on YouTube, just read the show notes and click on or just type in YouTube, no more High Restorations Protrusive. You’ll find my 20-minute video, and if you’re on Protrusive Premium, there’s a 30 minute plus video of showing the adjustments after as well. When there are some adjustments needed, how to keep them minimal, and how to be efficient and very accurate in your conformative dentistry. Main Episode:Hope you enjoy this main episode with Dr. Wayne Williams, and I’ll catch you in the outro. [Wayne]Because some of the stuff will be controversial. A hundred percent. I can tell you now it will be controversial and I’m up for that as well. No, I’m totally up for that. [Jaz]Amazing, and I love that. So, without further ado, let’s actually welcome you on, so I’m actually might keep that bit in. Actually, Dr. Wayne Williams, welcome to the Protrusive Dental Podcast. How are you, my friend? [Wayne]Yeah. Very well. Thanks, Jaz. And, as I’ve said to you before, really delighted to be with you and part of the movement that you’ve started and that’s been going for so long now and doing so well. So thank you again for the invitation. Great to be here. [Jaz]Well, thank you for your kindness and thank you for emailing me that day and tell me about what you do, but also you are talking about skiing and how it could have worked out. You were in Morzine. The week before we were for that ski-PD trip. So hopefully next one we’ll make sure that you’re an educator for that because, I looked at your CV. I was so impressed. Wayne, you have a amazing CV. So for those listening, haven’t heard of you, please let us know what is the day in, day out kind of work you do. What are the things that drive you, I mean, from speaking to you before we hit record, you’re so fascinated. You got very, we’ve made multifaceted, but please tell us about what drives you. [Wayne]That’s very kind. The profession’s been great to me. Jaz, I’ve been very, very fortunate. Grew up in South Africa, had my undergrad and post-grad education at universities, two different universities in South Africa. Left those shores towards the beginning of 2000. Arrived, went straight into Harley Street. Did two or three years in the city and a bit of Holly Street, great experience and then decided the commuting wasn’t for me. Thank you very much. And I’ve set myself up in the countryside, in the Royal County of Berkshire and have a lovely practice. We’ve been here for almost 20 years. My wife’s a general dentist. I’m a specialist prosthodontist on the register here and very much still involved. I love what I do. I love doing all the prosthodontic components that we do implants, big full rehab cases. Lots and lots of specialist perio work in our surgery and just loving life. I was very fortunate in that early in my career. In fact while I was in my postgraduate program in South Africa, my Prostho program, four year full-time program, I was offered the opportunity to do some work in local anesthesia. And became very involved at that point with a company called Milestone Incorporated in the United States. The manufacturers of the wand, which you’ll hear a lot about in the next few minutes, I guess. And that took me around the world and I was able to, with a team of other researchers and people around the globe, but mostly in the states, develop techniques and study anatomy and physiology and understand what local anesthetics all about? So that’s taken me to, I think I’m at 31 countries now around the world that I’ve taught. Lectured attended academic institutions and conferences, and so very fortunate, but glad to be in Great Britain. [Jaz]Well, it’s obviously you have such a vast knowledge and experience and also your specialist prosthodontist at then day. It’s amazing. Like I said, multi-faceted man. So I’ve got so many questions. I’m looking at them now. And then while you’ve been talking about the wand and stuff and I realized, gosh, I want to ask you about intraosseous and that kind of stuff. There’s so much we can go in. So, yeah, this could be a very wild. So thanks for introducing yourself. Let’s start with the first one, right? Let’s start with the first one, which is, how far can you go with buccal infiltrations with articaine for lower molars? Is this the end of ID block? So your opinion, also what you practice and what you preach. Because for me, I give about one ID block a month if that, and I do, I treat a lot of low molars. What about you? [Wayne]Yep. So really interesting one, Jaz. So in 2000, 2001, I introduced a big, big international meeting in Israel, a technique called the CIA, wait for it. The Crestal Intraosseous Approach. And I introduced that because we found a skull and it happened to be in Israel at the Hadassa University that I only then realized what the bone in the maxilla and the mandible really really looks like. And to answer your question, if you’ve got thick buccal plates, and we know that the buccal plates along the mandible are of our thickest bone in the body because it’s our protective sort of zone to try and get local anesthetic to infiltrate through dense cortical bone. Not so easy. What a lot of people don’t fully appreciate either is, in my experience over these years, is we are dealing with a drug that’s been given in the buccal sulcus into what’s called a supra periosteal environment. So the buccal infiltration, the correct terminology is a supraperiosteal infiltration, an SPI. And you hoping that, that drug will go through the bone. And the reason people are using articaine for that purpose is it’s 4% concentrated, meaning it’s got double the dose not because again, you ask people, what’s the difference between 4% articaine and 2% lidocaine? And people go 2%. Well, it’s not, it’s a hundred percent, it’s a hundred percent more, 4% is a hundred percent more than 2%. And basically we are using articaine for a reason because we want that strong concentration. We kind of wish it to go through that buccal cortical plate. Not so much, sadly, to say. What actually happens is if you’re dealing with a young patient and it’s highly porous, it’ll go through and you’ll have a lot more success. And it’s a great technique and it’s one you should be using. So, I now use regularly. It depends on what procedure you’re doing. If you’re dealing with a hot tooth, less successful. Yes, if you’re dealing with a small DO or MO restoration, highly successful. Sometimes those restorations you could have done without the anesthetic anyway, so it’s kind of a placebo sometimes we don’t always realize it. What is guaranteed is the next time you get a chance, go online. If you come to one of my lectures, come to one of my presentations, you’ll see slides of many, many skulls on the crest of the mandible is a massive open area with holes in it and drop your anesthetic in there. It goes straight down into the medullary part of the bone and gets to the nerves of the teeth. So rather than coming in buccally, I’m going in Crestal Intraosseous Approach. So not going down periodontal ligaments. Let’s get that one out the way straightaway. There is no such thing. It’s a complete misnomer. There is no such thing as a periodontal ligament injection. Get rid of that. [Jaz]So intraligamentary, as they call it, right? [Wayne]It doesn’t exist, doesn’t exist. It’s complete misnomer. There’s a lot of literature to back that statement. [Jaz]What about that device, Wayne? You know that, I forgot the name of it. There’s Projected Press, what’s it called? [Wayne]There’s 12 of those at least. Yeah, there’s 12 of them. Okay. There’s Ligmaject, there’s Peri-Press, there’s sigmaject, there’s, and so we can carry on. There are 12 at least of those. Quick Sleeper, however, is different. A quick sleeper wants to draw through the cortical bone, which is what I’ve just told you. We need to get through the cortical plate. So to answer your original question, buccal infiltration is fantastic for single tooth procedures, not for multiple tooth procedures. So this type of intraosseous anesthetic works for limited times in my experience in research, 30 minutes. So you go in, you go out, you’re out. As soon as I start treating more than two or three teeth in an arch, I’m giving an ID block. [Jaz]But you said intraosseous a second note. Do you mean sub supraperiosteal you mean? [Wayne]No, so I’m still going. I never, I hardly ever give in the buccal sulcus unless I’m doing a very minor procedure. I’ll always put the needle intracrestal between the two teeth distal to the one that I’m actually an anesthetizing because the nerve comes from the posterior. So I use a technique called the CIA Crestal Intraosseous Approach for all my single tooth anesthesia in the mandible, in the posterior segments, and the anterior segments for that matter. Because the anterior segment is often more difficult to anesthetize because the cortical plate here is even thicker in some of these areas. So I think a lot of the time we do get success. In fact, the majority of buccal infiltration, supraperiosteal, albeit, but with limited timeframes to the success of that. And also if you’re dealing with hot teeth or teeth that require acute treatment, you’re less likely to be successful, but also I think one has to just be selective with which teeth you’re treating. [Jaz]Anyone with a large masseters, big square jaw. I’m going to be going for the ID block. And also for, yeah, multiple restorations. It has been my experience as well. And of course the hot pulp, all those things you mentioned. But if we talk about the crestal injection technique that you said, I forgot it already. [Wayne]CIA. [Jaz]CIA. [Wayne]Crestal Intraosseous Approach. [Jaz]Fine. So, you’re putting the needle in from the top and are you going into the attached gingiva or the muco gingival junction or the alveolar lining? [Wayne]Imagine the papilla. [Jaz]Yes. [Wayne]Into the so-called col area, COL. [Jaz]Yes, yes, yes. [Wayne]If you go back to periodontal- [Jaz]So you want to just see it blanche? [Wayne]It’ll start to blanche buccal and lingual. The spread of that anesthetic if it’s got a vaso. And that’s the other thing, you must use a vasoconstrictor. Yeah, for all those techniques, if you’re using a non-vaso constrictor, very limited five minutes duration on average. The problem with this technique is that because it’s intraosseous, it’s almost equivalent to intravenous or intra arterial, ie. it’s going straight into our main bloodstream. The biggest blood vessel in the body is the medullary bone, and it goes straight in there. And because we have arteriovenous shunts in the head and neck area, it goes to the brain without getting infiltrated through our lungs, which is where a lot of the pH modification of local anesthetic takes place. So this is one of the reasons people get vasovagal. This is one of the reasons people get edgy about it, and you have to just be aware that patients can have palpitations. [Jaz]Yes. [Wayne]When you’re delivering these drugs, intraosseously, whichever technique you’re using, quick sleeper, CIA technique. Tell the patient before the time, expect perhaps a couple of little alterations to the heartbeat can get a little quicker, but it’ll ease usually within about 30 seconds. The key issue here is to lower the pressure at which you deliver that drug. And the speed at which you deliver the drug. So Poiseuille’s equation, pressure, time, and volume. The slower you give the injection, less volume over a longer period of time, gives you lower pressure. Higher speed, increased volume, increased pressure. So without using the wand, good luck. Seriously. So just to put this in perspective and I need to get this out perhaps a little early on. I have no interest in the wand or Milestone Scientific haven’t for many, many years, although I was a clinical director early on in that company, I haven’t touched a handheld syringe of any type since November, 1998. And we do sinus lifts, full mouth perio, full mouth reconstructions, major implants, major grafting in our clinic. We only use the wand and have since November, 1998. [Jaz]Wow. [Wayne]So there are no handheld syringes. No clinician in my surgery in our practice is allowed to use anything other than the wand. So we’ve looked at all the other devices, quick sleepers, Peri-Press, Ligmaject, you name them all. The safety device from Septodont. Good product at least that allows some form of safety in dealing with needles, but the old, antiquated, handheld syringe, as most people know it, 1853, that device was invented, used by Charles Pravaz, a French veterinary surgeon. Veterinary surgeon, but everybody says they have a modern dental practice. I find that rather fascinating. We use a computer to give out drugs, but the point going back to the CIA is any intraosseous technique you’re using, you need to be controlling and you’ll know when you press on your syringe and you are in those areas. You have to press pretty hard. You’re going to develop carpal tunnel syndrome at some point. You’re going to have sore fingers and sore wrists at the end of that day. But imagine the pressure, and myself and Mark Hochman in the States have been the only publishers. We’ve measured all those pressures within the body for all these techniques. Wow. We generate some serious pressures and no wonder patients have postoperative pain when you’re using these intraosseous techniques. If you sub periostal, so in the palate and in the buccal sulcus, if you do go subperiosteal in the buccal sulcus and you manage to get that blanching and the pushing away of the periosteum from the cortical bone, that builds up a lot of pressure, Jaz, and creates some pain. [Jaz]Look, I agree with you and it’s something that I do, I must admit, and I might change our practice after speaking with you, but, you know, I’ve seen the downsides of this, Wayne, I’ve seen two ladies who came back with bruising down their neck before. Okay, so I don’t know if you’ve seen that probably because you are using the ones who probably have maybe pre-wand days, but you know, thousands of patients. But it’s still upsetting to me. So I did change my practice after that, really making sure that the pressure element is respected. But usually what I do is, I do give it in the suraperiosteal, as you said, but then also into the attached gingiva and also mesial and distal in those right cases that benefit. [Wayne]Fantastic. [Jaz]So, yeah. Is there any way that, so we can keep it safe? [Wayne]Drop the subperiosteal part because all that’s doing is it is giving you soft tissue anesthesia, so for your cord packing or raising a flap or anything of that nature. But the other bit will be the bit getting to the nerve of the tooth. Always remember where the nerve enters the tooth. That’s where you’ve got to get the needle. And so my whole start to all of this, 20 plus, 25 years ago was understanding flow dynamics in the human body. So I started studying what happens to that drop of liquid that comes out of the end of a needle, irrespective of what device you’re using. I started by studying the flow dynamics of those liquids, and that gave me the key to everything else that I’ve ever developed and known since. And if you think about that, when every time you’re giving an injection and you think about the direction that your needle is going in and where that liquid is going to end up. So what a lot of people, again, don’t really think about with this technique we are just discussing is you’re blowing that liquid out the end of that needle with your finger pressure and it’s hitting that cortical plate, bouncing off it, and going straight back into the soft tissue. It’s not actually going through the cortical plate to where you want it to go, where the nerve is inside of the apex of the tooth. So the only way to get it to the apex of the tooth is to go through holes in the bone. And that’s why the Quick sleeper was a good development, or the Stabident, which a lot of people know in this country. But people are drilling through cortical plates to get a needle tip through. Good luck to find that spot, however, if we look at the anatomy carefully and we should all go back and look at anatomy. If you want to think about good local anesthesia, then look at the crestal aspect of the mandible. There are holes waiting to be put through and that’s where we should be putting the needle. [Jaz]And how do you know when you’re through? Because you want to be your depth of needle. [Wayne]Again, if you are using the wand, you hand holding it like a pen. You have manual dexterity, you have manual tactile feedback with the handheld syringe. We lose all of that, Jaz. That’s why I’m not a proponent of the handheld syringe. It’s cheap and easy, but it’s not the right way that we should be delivering local anesthesia. It’s not possible for everybody to invest in more expensive technology. I get that. But the truth is to answer your questions, it only comes from tactile, perceptive ability to know when you’re in these right places. And with the CIA technique in particular, I was only able to evolve and develop that technique through the tactile feedback. I know exactly, literally the needle drops through. You can actually feel it. Pulsate it. [Jaz]And is this something that’s possible with a 30 gauge a needle, or does it have to be the something like the wand? [Wayne]Always 3-0 gauge. Well, the wand uses 3-0 gauge, we use 3-0 gauge half inch needles. We only use two needles in the wand, 3-0 gauge half inch, 27, 1 1/4 for blocks. But I want to go back to two things, If I may. Do you mind me jumping back? [Jaz]Please, please. I’m loving it. This is golden. [Wayne]The one that you spoke about, the bruising. The bruising’s really interesting. So when Hochman and I published and measured all these pressures in the human body, it is phenomenal for dental techniques. What was actually happening in your patient that had the bruising? You were rupturing venules and arterioles. You were actually rupturing those soft tissue vessels because you had such high pressure at the end of that needle with that fluid building up pressure and it causes rupture of those vessels. That bleeding then from those vessels, goes into the soft tissue and gives you the bruising and the only way you can avoid that is by reducing pressure, and the only way you can reduce pressure is by giving slow delivery. So the one whole mechanism is a drop at a time. So a drop comes out. If you imagine this being the bone, the drop hits that bone, the drop gets absorbed before the next drop gets there. That drops already into the bone. Then the next drop arrives. So drop for drop drip feed, almost like an infusion pump in a hospital. Rarely. And the second point I wanted to make was why, if I may ask, cause I think a lot of our colleagues will be asking this possibly, why would you choose to be doing buccal infiltrations? Are you somehow trying to avoid inferior alveolar blocks? And if. I’d be very interested cause I know the answers. I think I’ve heard them many times. Why are you trying to avoid an inferior alveolar block? [Jaz]Brilliant. [Wayne]That takes us into a whole new area. [Jaz]Yeah, yeah. Oh, let’s go to New York. Let’s go there. But just point on the point of bruising is really fascinating. Because this is the first time it’s happened to me, but it happened on two ladies the same week. It was strange. It really blew my mind. And I think maybe it’s because I’m very slow. I’m usually very slow injecting. But I look back and I think, okay, here’s what I do. I go very slow in tissues. So they don’t feel anything. Once they’ve got the soft tissue anesthesia, then I think I went too fast. Cause okay, they’re numb now. So I knew, I learned from that, that, okay, keep it slow even if they’re numb already, because it’s really good for them. So I think that’s what happened. And then, so why am I doing so many buccal infiltrations, is to avoid ID blocks. So why are we, the question is really, why are we avoiding ID blocks? I’ll be honest with you. I’ve read some of Tara Renton stuff and it scares the bejesus out of me, right? So, okay. [Wayne]Okay. [Jaz]So this is, well this is what it is. So for those of you who aren’t familiar with it, then you know, ID blocks may cause injury and Paraesthesia, et cetera, et cetera. [Wayne]You’ll have to give Tara my mobile number. She’ll probably have it already. And great respect to Tara. She’s done a lot of work in this field, and I respect her work and I get it, but if I’m honest, I don’t agree with almost everything she writes about this. I don’t agree with a lot of it. I probably only use non-ID block because of the type of work I do. Vast amounts of treatment and choosing not to use a CIA for a lot of cases. Probably 85% of the time I’m using an ID block still. There was a short time when I made the discoveries around the CIA that I went back and said, ah, want to now, you know, discovered this technique and now I’m going to use that a lot and put the ID block in. And in fact, in my lectures, many people in this country will have heard me say, oh, get rid of the ID block, blah, blah. I’m totally, totally back on ID blocks and have been for the last two decades, at least the last 15 years. So one, because I know they’re safe and every single ID block I give almost, almost without exception, is using articaine. So we need to get rid of that misconception. [Jaz]That was, yeah, that was one of the questions as you saw. So let’s hit that on the head. Okay. So we are medical legally. Will that be defensible? Is one of the questions I’ll ask you. [Wayne]Well, now we’re into quite tricky territories, so I’m going to be careful on this one. But in our clinic for the last two decades, and this is not a, this is anecdotal reporting, however, it’s also based on speaking to people in 31 other countries. Now let’s just go and start in Germany. Let’s start in Germany, 80,000 dentists, UK, 30,000 dentists. Roughly, 80% of all injections given in Germany are given using articaine. All injections. All techniques. Only 20% are not usually where they can’t use adrenaline or choose not to use adrenaline. [Jaz]Got it. [Wayne]That’s another subject. Their percentage. So you’ve got 80,000 people using 80% of the time articaine, 4% articaine. Why do don’t they report a single percentage remotely higher than we do for paraesthesia in the mandible with an ID block. [Jaz]Exactly. [Wayne]And my hypothesis on that is because articaines got nothing to do with it. What it has got to do with, and there are recently published papers on this without proof, there is no clear proof. If there was Jaz, hang on one second. If we knew for a fact, if Tara and her companies and people that she works with, if they knew that this was seriously dangerous, do you think we’d still be allowed to give ID blocks with articaine? [Jaz]Yeah, we wouldn’t. No. [Wayne]I don’t think we would. So I don’t think there’s sufficient evidence to say that is. However, there is sufficient evidence for people to be scared of that, but it’s because they don’t understand what the problems are with Paraesthesia. For one minute, think about what the primary cause of paraesthesia is. Traumatic. [Jaz]It’s got to be trauma. Trauma from the needle. Right? [Wayne]A long needle. [Jaz]Not the agent. Yeah. [Wayne]And I’m sorry, also to point out that predominantly the voice of anti articaine, anti ID block use comes from maxilla facial oral surgeon departments of which Tara may or may not be part of. I’m not sure, but the truth is, are they not perhaps looking for alternative reasons for the cause of that trauma? Or the reason for the cause of the paraesthesia? And how can we ever prove whether a needle has hit that nerve or not? And how can we ever prove whether it is with lidocaine, articaine, mepivacaine anything else, what actually causes that? And that’s part of the problem here. So I’m not suggesting for a minute that people should just at a whim, start using articiane for all their ID blocks. They need to checklist for themselves. In my clinic, after a long, long time, I’m 58 years old. And I work every single day, four and a half days a week now at predominantly six days a week for a long time, doing lots and lots and lots of ID blocks, only using articaine. And you know, anecdotally, I can tell you many stories of maxilla facial oral surgeon, one in particular who worked with me and alongside me for a long period of time. And when he first joined us, he was part of the group who went, I’m not touching articaine near an ID block and within a few months he only uses articaine. And two decades later he’s still using articaine for all these ID blocks. And the reason we use articaine is because it’s so much more effective because it’s doubled the concentration of Lignocaine. So the single most difficult injection to get a predictable outcome for, you’re telling me we want to be using the lowest concentration drug. I say no, the least predictable of all the techniques we use, we need to use the highest concentration of drug in a safe environment. And you have to be able to aspirate because that’s now the next domain we go into is, oh yes, but I have this reaction and people are that, and again, we’re going into blood vessels, but we are not aspirating. And if you’re aspirating with a handheld syringe, you’re getting false negative aspirations if you’re doing it. Because most people tell me they’re not. If we treat ourselves, every single case we do with a wand, irrespective of where we inject automatic aspiration. Automatic aspiration, which means we can keep the needle still and it doesn’t go back and forth in and out of the blood vessel. So we are getting two aspiration results. Does it mean we’ll never have a problem? Of course it doesn’t, but it reduces that risk tremendously. But to answer the point regarding articaine and ID blocks, I’m yet to be convinced. And I want to see clear research data before I’ll stop using articaine for ID blocks. [Jaz]That has been really eye-opening. I think that’s good to hear. Refreshing. So thank you for sharing that with the Protruserati. With Hitting Bone, I asked this on another episode as well. One of my strategies when I do give an ID block, which I feel in my head is keeping safe is I was taught to hit bone at dental school, but then I heard from this surgeon called Radislow guy, he says, don’t hit bone because that deforms this tip of the needle and that’s what could be causing the trauma. And so therefore, I stopped hitting bone. What should I do? [Wayne]Okay, so Jaz. One of the advantages of working with a microscope and using high magnification, as you’ll probably know as well, is honestly a lot of my injections, I examine the needle straight after infiltration or for ID blocks, and I’m yet to be convinced or see bending. And I do touch bone. I think hitting bone is probably a strong term. Forcing needles into bone is quite strong. But the reason I had to study this at the time and still do look at it carefully is because I used the Crestal Intraosseous Approach so much. There’s a distinct chance that my little 30 gauge, half inch long needle can hit a harder piece of the bone and deform even break. Dare I say, I’ve never seen one. I’ve read them in the literature and legal cases, but the truth is there is a potential for deformation. I take that point, but I think you have to hit it. Remember, these are a medically grade devices that are being constructed. If they were that weak and we’re curling around every time we touch something, I’m not sure they’d be released into the human body. But I’m not advocating that we press things hard against bone. I’m certainly not advocating, hitting things. But again, if you, and maybe again the wand comes to four because we just have that much more tactile sensation to be able to feel when we are hitting things or touching things. Cause we are holding it like a pen and all other devices are held as if we are holding, I don’t know, boxing glove or, so I don’t know what it is, but you guys do this stuff. But the truth is, again, I’m yet to see that, but I do share your concern if that needle does curl up and I’ve seen pictures of those, it’ll ripple the tissue as it comes back out as well. [Jaz]Yes. [Wayne]And the drug won’t go to where you want it to go, but are you going to ask at some point, sorry, was there anything more on that point? Because I was about to ask you, do you know what the failure rate of an ID block is across the world? [Jaz]Oh, wow. This is a really interesting one, Wayne. Okay. So my immediate guess would be 50%. But this is an educated guess because when I was in Vietnam, as a fourth-year dental student, I was with a very experienced dentist. He was in his sixties at that stage. And so, the protocol, we were in this Vietnamese rural area with these orphans. We were giving them dental care. And the protocol was that we give the kids two ID blocks because he said we know that half of all ID blocks fail, so let’s give these kids two ID blocks. Okay, how kind are we? And then we’ll do their treatment. So that’s where that number is stuck in. But I’m sure you have a more research answer. [Wayne]There’s a slightly more researched answer. So again, a publication because I like to go back to publications wherever I possibly can. And in some of these areas there aren’t, the articaine one is a difficult one, but the failure rate has to be a very high potential for 25%. And the reason it’s 25% at least, and that’s a least figure, I think you’re probably right, it’s probably closer to 50% possibly. There’s no publication on that number, but in a paper by Hochman and others in the states. Some years ago, they took x-rays by putting ID block in particular needles. So length, 27 gauge one and a quarter inch needles through bits of meat, and then they x-rayed what was happening to those needles. Bearing in mind that dental needles are beveled only on one side, whereas medical needles sometimes are beveled on both sides. So when you have an arrow, sorry, correction to myself, medical and dental needles are beveled on one side, but when you have an arrow, it has two sharp points like this, so when it goes through soft tissue, it goes through straight by cutting through on both sides, whereas our needle is only beveled on one side and orthodontists in the audience will know. If you push a beveled instrument of that nature through soft tissue, it will always deviate to the site towards the bevel. So they studied this and what that means is that when you’re holding a handheld syringe and you aiming for the lingula, because you always have to be above, or at least in line with the lingula to get anesthesia for the inferior alveolar nerve. If you are using a straight instrument and that arrow’s going straight, the needle’s going straight, but then curves down as you’re doing it. And there’s lots of x-rays that we were then able to show with this curved needle. And it dips below the lingula. That’s a failed anesthetic. So when people aim low, or when the needle curves low, so even if you’re aiming Gow Gates style really high, which is what I advocate, go really high, go too high rather than too low, but then aspirate because you’re getting close to the pterygoid venous plexus lots of things to be scared of. So you go up high, but if your needle then bends, you’re still going to fail because 25% of the time it can either go up 25% down, left, or right. It can go four ways that needle, depending on where your bevel is. So with a wand, what we then discovered was if you rotate that needle back and forth, you change the position of the bevel and it goes dead straight every time exactly like an arrow. So you’re creating bevel there, bevel there, bevel there by rotating just 180 degrees. And that’s the reason I can honestly hand on heart, tell you I cannot remember when last I gave a second ID block or when I had a complete failed ID block. Decades ago. Literally decades ago. [Jaz] Amazing. And so the question I have now, I mean, to visualize the needle bending in that way is fascinating. I think. [Wayne] Take a piece of meat. Put it through, and then take some x-rays, don’t, I don’t know how you’re going to get around the x-ray radiation part of that, but yeah. And stand outside the room and all the rest. Or read up Mark Hochman, H-O-C-H-M-A-N Publication, probably early two thousands. Mark Hochman Bevel translation in needles. [Jaz] Which is why sometimes, I see my patient’s notes and there’s a note saying, difficult to, aim higher because it could be that. Now my next question is, you mentioned about the technique with a one in terms of rotating, would that work with a handheld traditional anesthetic? You can’t do that, right? [Wayne]I’ve challenged people to do that because there’s always somebody in an audience somewhere. And that’s global by the way they go, I don’t hurt patients. You know, I do thousands of inject. I don’t need the one, I don’t hurt people. All my patients tell me they love me. I’m painless. I’m the best in the world there. And they also tell me I don’t have failed ID blocks and et cetera, et cetera. And I say, well, that’s great. You know, tell me how you do it. Cause I can learn something. But. Then you always get someone also that I don’t need the one because I can do that with my handheld syringe and I say, well, show me. And it’s just physically give it a try for yourself. If you can let me know. Cause I’d love to learn that technique and, you know, put myself wrong. But, honestly, it’s physically impossible. And whether that’s a safety injection or whether it’s a handheld syringe, whichever, especially the 1853 Charles Pravaz one, that’s impossible. Jaz’s Outro:Brilliant. Next question, I guess in the theme of anesthesia failing, I was at a lecture by my friend, Lincoln Harris, and he mentioned interesting things about redhead, which I knew already. Red people with red heads, they’re more difficult to numb, but also, large heads because large heads have large bones. So should we fear the large headed redhead? Is that true or false, that myth, or is that real? And any strategies to help the large headed redhead if it’s true. Well, there we have it. Guys, thank you so much for listening all the way to the end. And because you made it through the end, if your Protrusive Premium, answer a few questions based on this very engaging, very real world episode, and you can gain some CPD, how good is that? So if you’re not already on the app, head to protrusive.app on your browser, sign up and get CPD and watch exclusive content. We of course, left you on a cliffhanger. So there is a part two coming where we finally find out is it a myth or is it real, that red-headed large headed people are more difficult to numb. And also find out which are the three types of anesthetic that Dr. Williams keeps in his practice. Okay, so I’ll give you a clue actually, out of Mepivacaine i.e. Scandonest, Lidocaine, and Citanest, we already know use articaine. Okay? Out of those three so Citanest, Lidocaine, and Mepivacaine, one of them he thinks is absolutely useless and we shouldn’t be using it. So you’ll find out which one that is next time as well. And if you’ll listen to this, and it happens to be before the 21st of March, then this is your final chance to get access to OBAB for two whole years. And get a fully mentored case worth 550 pounds. Thereafter, you’ll have to pay for mentored case support, right? So in the discussions, yeah, we’ll support you all day, all night, but if you want us to spend time to go through fully your case and give you structured feedback, then we will do that. But that’s a paid feature. If you one of one fully mentored case, then that is available if you enroll before the 21st of March. So hope to see you there and we’ll catch you in part two of this episode.

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After the cliffhanger from Part 1, Dr. Sandra Hulac is back to share more information about Frictional and Constricted Chewing Patterns (CCP) with cases shared and explanations given. Check out the Full Episode with a Free membership on Protrusive.App 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 The Protrusive Dental Pearl: Overjet is King. We don’t want tight bites. We want a bit of overjet that gives chewing space – this will reduce the chances of a functional attrition and avoid ‘too much anterior guidance’ or locking the patient in. “It’s important to know why things fail and try and avoid failure the next time” Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 0:28 PDP141 – Stop Blaming Bruxism Part 1 Recap 6:34 The Protrusive Dental Pearl: Overjet is King 6:56 The role of pre-restorative orthodontics 9:24 Case #1: Extremely traumatic deep bite 14:10 Case #2: Crowding of the lower anterior segment 19:41 Case #3 Lot of wear on the front teeth  23:54 Case #4: Chipped and worn front teeth  27:06 Case #5: Worn front teeth  32:41 Case #6: Patient had an extraction ortho Dr. Mahmoud and I are also excited to share the occlusion that we learned over the years –  in a way that you have never seen before!  Occlusion: Basics and Beyond is the most tangible, real-world, and comprehensive occlusion training on the planet. LIMITED DELEGATE SPOTS DUE TO STARTER KIT STOCK – AVOID DISAPPOINTMENT! Occlusion Online Course Be sure to watch Part 1: Stop Blaming Bruxism! How to Spot Frictional and Constricted Chewing Patterns (CCP)  Click below for full episode transcript: Introduction: Hello, Protruserati. I'm Jaz Gulati and thanks so much for coming onto the app for part two or what was quite a brilliant part one with Dr. Sandra Hulac. Her energy is just absolutely amazing. Jaz’s Introduction:Now, just a recap, we left you on a bit of a cliffhanger last time. We talked about, I asked Sandra about orthodontics. You know, how often does orthodontics come into it? Is it every single time? And the answer she gives is really pragmatic. So you’ll hear that or see that in just a few minutes. But I just want to do a bit of a recap, what we talked about last time, right? So, a constricted chewing pattern is someone who really wants to bite here, but the teeth meet together here, so the condyle gets sort of pushed back, if you like. Right. So for this patient, the centric relation is actually further forward. So who’s at risk? People who’ve got upright or retroclined upper incisors, right? And their jaw wants to be further forward, right? Maybe cuz of growth, the jaw wants to be further forward, which is why Sandra said that people who’ve had orthodontics and upper pre-molars extracted. The maxilla gets smaller if you like, and mandible start continues to grow and those patients may be at risk. So if you see those kind of traits, then maybe we shouldn’t be using like a leaf gauge for centric relation on those patients. We should be using like a deprogramming appliance Lucia Jig or a Kois deprogrammer. If you fancy that one because that’s what Dr. Sandra does. And what you find with these patients with a CCP is yes, their jaw gets shifted back, but you might get more wear on their edges. And that’s not from bruxism. That’s because the outside in movement. Right? Their jaw wants to be further forward. Now, this is similar. The cousin of this is the frictional chewing pattern who their condyle isn’t getting forced back, right? Their MIP is okay. It’s just that as they’re chewing the outside in is causing this. So, let’s say that’s normal, the incisal edges are not worn here. Can you see? They’re a bit jaggedy over here, right? It’s just, to over here and over here. We see this all the time and let me show you some photos actually on the screen or what this might look like in a 75, 80 year old person throughout their life. And you’ll notice here, the upper right central incisor in this patient is actually more worn than the left one. Why is that? Because the upper right central incisor is more palatally positioned, right? It all starts to make sense, okay? There’s not enough chewing space. And we also see this glassy thin structure of tooth. We see this glassy thin enamel. Now, in bruxist, we don’t tend to see glassy thin enamel because their side to side teeth grinding destroys it, right? So if they’re destroyed their canine, then they’ll come onto the centrals and they’ll make it really flat. So, it’s a clue that, okay, maybe it isn’t so much bruxism, maybe it’s more functional. And we call this pathway wear. We see it on the facials of the lower incisors. And the lingual of the upper incisors. The problem though is, in dentistry, there’s always different opinions. And so whilst I respect this opinion, the other school of thought that we need to consider is, This patient, right, who we’ve decided that has got a frictional chewing pattern. Their upper incisors are more retroclined, and when they bite together, maybe they’ve got a bit of fremitus, a bit of vibration, right? They’ve got pretty much too much anterior guidance, right? There’s not enough space, there’s not enough overjet. So when the patient bites together on their retroclined upper incisors in the lower teeth, come together. Now, imagine this patient also happened to be a bit of a bruxist. A bit of a bruxist, because Sandra, she introduces term that true bruxism, you know, your heart starts racing is generated centrally mediated, which is true. But there is something called rhythmic masticatory muscle activity, right? So, we know that bruxism is a muscle behavior and there are normal bruxist, right? 60, 70% of us will grind for a couple minutes every night. About three minutes on average, and that’s normal. Okay. Three minutes a night based on some evidence that we’re just going to be grinding left and right, three minutes a night, even grinding. This is a cool bit. Okay. Even bruxism or muscle movement without tooth contact. So imagine someone’s opening the mouth and going side to side that counts as bruxism. So the bruxism that we are concerned about is people who are clenching their teeth together and grinding at the same time, right? So moving to the side with their teeth together. So imagine someone’s doing that for three minutes. That’s different to a patho bruxist. So kind of what Sandra is doing to these patients may be patho bruxist. They’re grinding for 18 to 20 minutes per night. They’re doing significant muscle contractions. They might be in different phase of sleep when they’re doing it. So these are the dangerous beast, basically. And I completely agree that for those patients, yeah, you get this flattened appearance, but think to the normal grinders, or even a pathological grinder who seems to have a lack of overjet, right? So yes, the outside in is affected, but as soon as this patient wants to grind left and right, the front teeth will get in the way. So what I’m trying to say is, yes, there is this functional attrition happening, right? The outside in, but it’s not helped by at any time in this patient’s life if there is any bruxism or parafunction happening as well. So just think about that, right? Sometimes one compounds the other, and what I’ve done is, I’ve often taken photos of my patients who’ve got this pathway wear, or this frictional chewing pattern. I’ve seen photos of them and I put article in paper and I just get them to grind left and right. I don’t get them to do the test that we’re going to show you with the blue paper 200 micron. Yeah, we show that in this video. Sandra will show that, and I’ve got videos of that as well, which I’ve put on occlusion basics and beyond. But let’s think about checking the inside out. Let’s check the left to right grinding. The color, the ink that’s rubbed off kind is similar and matches the wear pattern, which we say is from outside in. So really my argument is, do you really need to get into the semantics of the diagnosis? What’s causing it? Is it bruxism? And this is, they just have too much anterior guidance. Is it bruxism on a really retroclined upper teeth? Or is it this functional attrition that’s happening? So is it function or is it parafunction? My argument is the treatment for it is actually the same, right? The treatment for this is actually the same in the way that we open the OVD. We procline the upper incisors, we gain some more overjet. So it’s important to consider, okay, this could be a friction chewing pattern and plus a minus bruxism, but the way you treat these two conditions is very often the same. The only thing that might differ is if you truly believe that this patient is a frictional chewing pattern, and you think a night guard is going to solve that. Then yeah, it’s not. Right? So just some food for thought and I hope I didn’t lose you there. I want to, I’m going to crack onto part two with Sandra. Protrusive Dental PearlSo Protrusive Dental Pearl is, overjet is King, overjet is your friend, right?We don’t want tight bites. We want a bit of overjet, gives you that chewing space. And also if there is any grinding left and right, it gives space for that as well. So Overjet is definitely your friend, and that means orthodontics is your friend, which leads nicely to the episode where we pick up from the cliffhanger. Main Episode:So let’s join Sandra Hulac for that right now. The role of pre-restorative orthodontics, because what you’ve shown there is a wonderful case where this was managed purely restoratively and finding this new joint position, which is going to be in her case, slightly further forward because it’s now no longer distalize. And by increasing the OVD you now had some space. Tell us about, what percent of cases A) would you like to, in an ideal world. You know, have a wand and say, okay, this patient’s going to have orthodontics and go through the pain and misery of that and B) what actually happens in terms of what percentage actually get on board with that and what is your cutoff point? At which point you say, you know what, if you don’t know ortho, no treatment. [Sandra]Okay, so my answer to this is what, like I told you before, not enough patients will accept the pre-treatment orthodontics, and there are cases where I will say, absolutely, I’m not going to treat you unless you agree to this. Okay? Which, you know the case I’m going to show you now, I said to the patient, no, this is absolutely not possible in your way in without pre-treatment orthodontics and, you’re going to break your teeth very soon. And he said, well, I’m not willing to have this orthodontic treatment. He started breaking teeth, so he had the orthodontic treatment. In that case, took from start to finish about two years because it was very complicated orthodontics. Now what I have is really, it’s like very often, is the juice worth the squeezing. So in this case of the last case I told you, whatever I did, even if we had pre-restorative ortho, her teeth are actually in the right position in her face. What are we going to do? Are we going to intrude her lower front teeth? Now we can’t do that either, right? Because, you know, we can’t intrude the teeth so much that we get them away from her palatal surfaces and have enough restorative space. Plus, we do know that, you know, lower intrusion is the most difficult treatment of all orthodontic movements, and it’s also not very good for the teeth. And let’s not forget that the two of these teeth actually are have to have implants anyway. So, and it’s very complicated ortho and she needs restorative dentistry anyway. So I will not go and go and say like, if a patient has a bombed out posterior occlusion and needs onlays on everything anyway, and I can’t achieve the same by just opening the occlusion vertical and I don’t need to put them through orthodontic stent, the patient will not even get proposal of orthodontics. So what is my biological burden? I will say, and I will show you a case, for example, where I found the biological burden acceptable. And the first case where the biological burden was basically that there was, you couldn’t do it without, so maybe now let’s just go and have a look at the first case, which I’ve treated a very long time ago. I saw this patient, I think for the first time in about 2010, that’s when we started and he came to me and you can see it here. Beautiful case. Obviously we have an extremely deep overbite. It’s a traumatic deep overbite. The patient had these crowns fitted by a prosthodontist in boston four years prior, and you can see that already. [Jaz]I’m expecting for the next slide to show me like completely bombed out, lower incisors. [Sandra]I will, I will. But I also want to show you how the right canine is already broken off and see how the canine tip has broken off of the right canine. We also can see even just by looking at the patient at the picture, that there is a significant cant, and this was obviously the times before DSD and before everybody was Christian Coachman’s best friend when, you know, people really did dentistry without looking at the faces whatsoever. And obviously Christian has changed this, but I like, I would like to say that John Kois created, facially generated treatment planning 25 years ago. We just didn’t have a smart tool like DSD. We had to do it with, you know, a face bow and levelers and literally water weights on the face bow to get the stuff straight. But you know, he made sure everything still was straight in the face. Anyway, so here we have this and yes, we have totally bumped out front teeth, lower front teeth. I’m going to show you that more in the next slide, but we also have a completely mutilated. You know, occlusion, you can see there’s over options there, teeth missing. And you know, and the patient comes to me and like, I want you to just treat my lower front teeth. And I’m like, you’ve got to be kidding, right? Yeah. But they’re so warn, can’t you just put veneers on them? And I’m like, no, we cannot. And I said, you my friend need comprehensive orthodontic treatment. And if you don’t, You will break your upper front teeth pronto very soon because all these teeth were root canal treated and many had large posts in them. And you can see, I don’t know if you can see that under the right side of the screen, but you might see when you look at that right central, you can see how the porcelain is cracked in the cervical area of this tooth. Can you see that? The porcelain fracture in the cervical of the one one? [Jaz]Not so clearly from my screen. [Sandra]Okay. So there is little crack lines going through that porcelain on the cervical, and that shows you the enormous amount of torque this teeth gets. These teeth get, from the constant banging of the lowers against it. So I said to the patient, so you’re going to break one of the teeth off very soon? And he’s like, okay, well I don’t want the orthodontic treatment, so goodbye and two weeks later. He came back in and this had happened and I’m like, ah, gosh, I hate it when I’m right. So when, then he said, okay, so we have a broken tooth there. He is like, okay, well I understand what you’re saying and let’s do the orthodontic treatment. So first what we did, we actually put him in long-term milk provisionals because we needed to open up the vertical for us to even get to those lower teeth. Cuz I mean it, it looked so bad. And so these are actually long-term milk provisionals, which were already big, big, improvement. And most importantly looked at were actually straight in his face. Then we did comprehensive orthodontic treatment for two years, starting in the lower and then going to the upper closing the spaces. And this is the case in 2012, so that’s 10 years ago, finished. Now I don’t really would say this porcelain work is something I’m very, very proud of. I certainly, you know, but the patient wanted a very American look, very bright. And this case is holding up beautifully. We’ve lost one lower tooth because it was so bombed out and had a large post. So he has an implant there now. And one of the upper canines also, pain subsequently became an implant. But the patient knew this was going to happen, so this wasn’t entirely surprising to us, but this case basically is, you know, you must have orthodontic treatment, otherwise I cannot do the case. Okay. [Jaz]So was this upper and lower orthodontics or was just lower? [Sandra]Upper and lower. [Jaz]It’s impossible to do with lower? Yeah. Mm-hmm. [Sandra]The upper also had it, because, you know, there were all these spaces, the teeth had to be moved in the right position and that once we were finished, we basically just, you know, went into very, pretty poor, not very pretty white person work. We’re done this case is holding up beautifully. So, it’s quite a successful case. So the next case is a case also where I did ortho. This was much, much less comprehensive ortho, but we can see for example here that the patient has a little bit of crowding of the lower anterior segment, particularly on the lower right hand side. And we can see subsequently that there is a lot more wear on tooth number one, one and one two, because these lower front teeth are coming out a little bit more now. So again, to this patient, I say, if we want to do this right, we have to sort of, do a little bit of aligner therapy first. We are going to do a bit of stripping here and get those teeth a little bit down and back, which is exactly what we did. So at the end of the treatment, you can see the teeth are slightly more intruded, everything is much more aligned, and we can do 10 beautiful veneers. And this was done without any, you know, opening of the vertical or anything like that. And this is, and again, you know, looking now, there is no contact on these teeth. We’re just doing all that. And that’s also a successful case, you know, with a tiny little bit of aligner therapy. Now here’s a case where I didn’t do- [Jaz]Can I just ask you, Sandra, on the previous case, just cuz some dentists might be thinking as they’re listening and watching is for, so we don’t have a maximum intercostal position contact and definitely, as you could describe, it will not be holding shim anteriorly, but how do you account for it in, from the in the inside out? Do you still want to have your lines at the front and dots the back in your inside out? Or are you not so fast about that? [Sandra]No, I don’t want any lines on the front teeth. Ever, particularly not on my porcelain, you know? In the final position and I don’t want any shim shock on the central and laterals. Okay. Yes, in my final position I can have a little bit of a spot, you know, but I don’t want that on the edge of the teeth. Okay? I don’t want them to come in a fully seated position. Yes, I can have a occlusal contact, but I don’t want them to come into an occlusal contact and rubbing over the teeth while they’re going into the- [Jaz]You don’t want a line being formed outside in. [Sandra]That’s right. That’s right. [Jaz]But what about the lines inside out? So what if this patient decides to become a bruxist? [Sandra]Now remember that real bruxism, they don’t decide that. It’s a neurological thing, you know? There might be clenching a little bit. Okay. But there’s a distinct thing, but real bruxism is lateral and posterior. They don’t go over, therefore, they will be going over their canines maybe, but they don’t go over their front teeth. In the 30 years that I’ve had that I’ve been in this profession, I’ve had exactly one person bruxing anterior posteriorly. And Dr. Kois said the same. So people don’t brux forward and backward. [Jaz]I agree. I do a parafunctional analysis all the time, and I see it’s always left to right, yet to find that unicorn going forward to back. But, I guess because you have treated these patients in a position where you’ve given them that space, even if they were to go left to right, the anteriors are not getting in the way. [Sandra]Correct. They’re not getting in. [Jaz]Because of the setup. And so essentially it’s in harmony. They’re in harmony. Essentially all these people, you know, Kois, Dawson, they all teach. Everything should be in harmony. The inside, out and outside in, yes, outside is very important, but often it’s in harmony. When you treat one, you almost help the other. [Sandra]Well. Yes and no. I mean, as I say, you know, you always will have people that clench their teeth a little bit. Okay. But this is not bruxism. They go like, they don’t go, very rarely. Yes, yes. You will have the odd patient that does it when they really have a lot to drink, for example, because then it’s again, it’s up in the brain, but your average patient doesn’t really brux. Only the real bruxer bruxist and the real bruxist gets a mouth guard. [Jaz]The pathological bruxist, absolutely. [Sandra]They get a mouth guard, but a patient like this doesn’t get a mouth guard. No. Why? He doesn’t really brux. So, I’m a lot less generous with my mouth guards. If I suspect that the patient, so if I, and this can happen, this happens all the time, you know, when I have not so much in chewing constrictions because chewing constrictions are actually, I don’t want to sound blase, but if I have a constricted chewing envelope and a patient’s that willing to do treatment, this is my ship has come in. Because this is actually an occlusal problem, which in my honest opinion is a little bit easier to get right. What’s really hard to get right is a proper chewing dysfunction, because some people, they just chew all over the place. And to find, to get now you have to be a real visit to fine tune those occlusions. And sometimes you can’t cure him. Even John Kois and he is probably the best equilibrator out there, will tell you that sometimes some patients you can make it better. You can’t cure them. And these patients will continue to maybe clench around a little bit at night, constantly going around and looking, you know, very often then if they’re under stress, this kind of throws them out and puts them in an episode where everything, you know, can’t find my teeth, blah, blah, blah. Everything is terrible. Yeah. And these people, you need to definitely, if you treat them a mouth guard needs to be part of that, because it’s a security, it’s like the belt and suspenders thing. You know, you just do it for every option. [Jaz]Oh, thank you. I’m going to explore your philosophy there. Please we’re going to show one more case, I think. [Sandra]Okay. So what I wanted to show is here’s a case where we should have done ortho really. It would’ve been so much better, but the patient just didn’t want it. So there was a small biological price to pay here, because the only way we could get this right was by opening the vertical. So this is the patient that I showed before. So we have a lot of wear on the front teeth, and you can see the palatal surfaces of the upper front teeth are worn out. So this patient, I again, was one where, you know, I actually used a jig. Or like a bonded platform. I’m not a jig person. I like to bond platforms and I took a centric bite like that because some, I have a lot of patients, you know, Hong Kong is kind of, you know, a city of professionals or used to be, and these people say, I’m not going to run around with an orthodontic device in my mouth for best part of the day, I need to be able to talk. So we do this. And in this case, I’m also a secret waxer. I actually like to wax up these kind of cases myself. So this was, you know, what I wanted, again, a case done before DSD, this is what I wanted to be, this teeth, you know, like on the top. And then what we did, we put the patient in long-term provisionals based on my, not long-term, but into provisionals for a little while based on the wax, the bite that we had that we wanted to do, and we find to the occlusion in that this is like, you know, my wax up temps, which, you know, are nothing to write home about, but at this stage they’re all additive. So these teeth actually haven’t been prepped at all yet. Okay. I want to make sure that everything is okay. Before I actually start prepping the teeth. So, and then, you know, you can use your temporaries as a prep through guide, which, you know, this whole Galip Gürel concept. I mean, typically when we do veneers we always use now an additive wax-up as a prep guide because you want to make sure you are maintained as much enamel as possible. [Jaz]Begin with the end in mind. [Sandra] Exactly. And then here what you can see is how much I had to prep the back teeth in order to get the minimum thickness for these pressed emax, which in those days, I think now they say you can press it to 0.3, but you know, not really. So these were like 0.5 thick or something like that. [Jaz]Wow. Still very thin. [Sandra]Very thin and we- [Jaz]But you got a lot of enamel there which will help cuz you’ve got so much enamel there that which is the key indicator really. [Sandra]Yeah. So apart from the seven and funnily enough, because the seven had quite a bit, I had a composite in there that one actually broke and I had to redo this one and I had to make it a bit thicker. But you know, the others have held up very nicely and this is the case. These are, this is a German patient. These are German hyperrealistic teeth done by a wonderful dental technician of mine in Hamburg. And you can see this is actually the case a couple of years out. I only restored the lower front teeth with a little bit of composite and there’s a little bit of chipping of that lower composite because it’s so thin. Because it’s less than a millimeter in thickness there. But other than that, that case has held up very, very nicely. And yes, we had to do eight more teeth that we wouldn’t have to do without ortho, but with a minimal biological cost. But yeah, so ideally this would’ve been better off with ortho. Some patients don’t want to do it, so, and then if they don’t want to do it, then they have to do something else. I mean, I have to get the restorative space and I have to get the right restorative position. And if they don’t worry, then they very often it happens that they just don’t want to do any treatment. And then they just want some, they just want prettier front teeth, right? So what are you going to do it? You’re going to let them go to the next [unclear] who’s going to basically drill these teeth down and slap, slap on 10 veneers that then break and the patient comes back to you crying, but now can even afford you less. Or, what are you going to give these patients? You know? So, and this is maybe what we can talk about next. [Jaz]Yes. Oh, I’d love to. I was going to say, you’ve covered a nice range with ortho, which showed a great case. Without ortho opening the bite link, the mandible will come forward. So what about that patient who is unable to go through the whole hog? What is a halfway house that is going to make you happy and hopefully save the patient some tears. [Sandra]Okay, so what a halfway house, for example, is a patient like this, you know? So here we have her. She comes and she has these kind of chipped and worn front teeth with a fair amount of palatal wear. Now, I don’t know, the patient had orthodontic treatment and then she is Asian. And very often when you have Asians patients after orthodontic treatment, they end up with ginormous, black triangles. And she had some composite work done on these teeth to correct the black triangles, and it was obviously done. Done quite poorly. The teeth are not the right proportion and the composite heads aged very badly. So she really wants to do something about the front teeth. Now when I examine her, she, I see like, you know, I’m like, hang on. This is all very tight and very weird and do you know how your teeth fit together? And she’s like, yeah, I’m not really sure. So I said, really what you should have is a comprehensive occlusal analysis that we actually know how your teeth going to fit together cuz you can also see, obviously there’s something going on here. Is she bruxing to the left hand side? She says she doesn’t brux. There’s a lot of wear on the left canine. Is that because she has an enlarged chewing envelope? So, but the patient is like, no, I don’t want to find this out. I want pretty teeth. So what I then say to the patient, okay, here what I can do. We forget about all that, but the only thing I will give you is four composite veneers. I’m going to remove the old composite of those teeth, and I try and pretty-fy the teeth a little bit. I make them a little longer, and most importantly, I’m going to build the edges out. So I want these edges out of any kind of functional envelope that can possibly get into. Now, can she still break them? Of course she can. And that’s not my problem. So we have a clear understanding that I recommended something else. But I understand that the patient wants pretty teeth, so I will do this pretty teeth at zero biological cost. I will not touch these teeth whatsoever. Okay? You will get four composite veneers that are going to give you a cosmetic improvement. They’re not going to be as wonderful as porcelain would be. But I’m not going to hang porcelain off those teeth and ruin them. Forget it. So here is the composite veneers done. [Jaz]Very nice. [Sandra]For composite veneers doing, trying to get a little bit better, a more kind of nicer shape with rounded edges, with classic Asian two shape, and just making it look all a little bit better and it does look better. It’s not ideal. But it does look a hell of a lot better. So, I have these kind of patients all the time, so this is another one. You know, he has been- [Jaz]Just to share under a key lesson before you share that. Okay. The key lesson, in case anyone missed it, everyone was multitasking, they didn’t hear you is, you did the veneers, the composite veneers at minimal biological costs. But the main thing there is that you built them out. The incisal edge was slightly further forward to not exacerbate this issue. So again, it doesn’t interfere with the outside in. So if anyone missed that, that was a real important gem there. [Sandra]It’s super, super important. So very often I will actually wax these cases up beforehand and then make my lingual matrices like that. But here I have another case. So this is a patient that has worn front teeth. He wants them to be longer. He doesn’t want to go through, that’s actually stable wear. He doesn’t want to go through the process of occlusal analysis. So I’m like, okay, let’s do four composite veneer. So I look at these edges, I go like, okay, well opposite at 2-2 the left lateral has been built up for a very long time with a lot of composite, and that’s still there. Nothing’s chipped there. So I’m quite happy to leave that edge in exactly that position. The rest, I’m not leaving like that. So here what we do, we do a very, we do a quick and dirty intraoral mockup, and you see how much I actually add to those edges in length, but also how much I built them out facially. Okay. And then we just go through the process of removing the old composite whatever is there. And first, as this is just, I like to build my cervical outlines first because it makes the placement of the rubber dam so much easier. So then we put the rubber dam on, and then we start the process of four composite veneers. And it certainly does look a lot better. [Jaz]Beautiful. [Sandra]And I haven’t seen him. I’m a fellow of the American Academy of cosmetic dentistry. And we are also known as, you know, the Academy of Pretty Composites, so we do. If I’ve done something a lot in my life, it’s composite veneers, it’s like, ugh. I love doing composite veneers. It’s my favorite day in office. [Jaz]Yeah, it shows. [Sandra]I really like that. So, yeah, and this is a very nice way and here’s the fun thing with a case like this. If you have a patient like that, this can actually be a diagnostic restoration at the same time. Because if this patient comes back now in a couple of years and he hasn’t broken anything, I’m like, let’s do veneers. We’re just going to copy this. We’re just going to copy this incisal plate, this exact incisal position. We are doing exactly this, and we say to our technician, under no circumstances are you going to go back here? You know, you’re just keeping it where it is or if anything, you know, if you want to, you can go even a little bit more forward because we liking that position, we know that works. So if the patient wants that in a couple of years, and I do that a lot as well, that people will then go like, oh, I like my composite veneers. But you know, they stain a little bit and they will stain even if you do everything right. You know, I do all my composites under rubber dam and I pay a lot of attention to the polish, but it stains. I mean, and that’s patient dependent. It’s not your fault. We have to stop always going like, oh my God, I’m such a bad dentist. Your composite has stained, you know, oh my God, I’m such bad dentist, [Jaz]It will stain as you say. And you’ve noticed that it’s the smokers, the coffee drinkers, that kind of stuff, who’s going to be affected more. So it’s part of the aftercare and the warnings that you give. [Sandra]Exactly. That’s one. It’s like, this is an upkeep restoration, okay? If you want something that’s not going to stain, then you have to go for the porcelain, but for various reasons, you’re not going to get it in my practice unless you do X, Y, and Z, you know? And because I’m not going to be that person. So, and if you do the composite and you break it, it’s not on me. I can repair it. I can easily repair a broken composite veneers, and I certainly, I won’t do it for free. If you break the edge. I told you, you know, this is a classic, what we call the red dot scenario not being on my forehead. You know, literally, I mean, this is not an Indian reference, but at Kois we have a green dot, yellow dot, red dot, and red dot means there is a big problem, but I’m not going to have that dot on my forehead. It’s the patient’s problem. It’s not my problem. You have to stop making patient’s problems, our own problems. [Jaz]Oh. Preach. Preach it. Absolutely. [Sandra]There’s so many people out here that are just so, they’re like, go home. They’re so depressed. You know? And you know, I will say that it’s good. I very often go home and I’m still very depressed if things don’t go my way. And I will wake up in the night and I’m like going like, oh my god, what have I done here? It’s like, because stuff like that happens and that makes you, I think, a good and a conscientious- [Jaz]Because you care. Because you care so much you care, but you don’t want to care too much more, especially more than the patient. [Sandra]Exactly. And it’s the patient problem. The patient has to own it. [Jaz]I think everyone must rewind two minutes and listen to the exact spiel that Sandra gives to the patient and how she just said it to us now. If you break the edge that’s on you and to make it clear that yeah, guess who’s paying for it? Yeah. Not me. It’s going to be you. And it is just very clear that you are rehearsed in saying that to the patient, your patients, and the clarity in which you convey your message of patient’s understand and they get it. [Sandra]And, let me tell you, I’m not just saying that once, I will say that in the initial appointment when we make the veneers, when we decide that we’re going to do composite veneers, I will say it after we’ve done the composite veneers, and I will say it at third time when the patient comes back for a shade check. Make sure everything is okay, just checking the occlusion one last time. So these are, you know, three appointments where the patient gets told it all the time, and guess how many, like, oh, I wasn’t aware that this could break. And I’m like, are you fucking kidding me? You knew that but yeah, so, I just quickly want to, I mean, show you how important it is that you, when you do restorative dentistry yourself, that you check the position of these edges. And it’s, and as I say, I’ve been doing this for a little while now and it happens to me still. So here I have a lovely lady, she is a work colleague of my husband, and she had, you know, basically she had extraction ortho, and it’s so the kind of the classic ortho, which just the upper arches get way too trunked. And the anterior posterior position of the centrals can’t be maintained. So these teeth basically fall back in the patient’s faces. And in her case, there was actually a shitload of composite on these teeth. And still, you know, they weren’t really visible. You can see, I mean, maybe you can see the step here in the right picture. You can see the difference in the buccal corridor width, particularly on the right. So you can get an idea how much composite is on those teeth. And this lovely patient, she hated it. So I’m like, okay. Now let’s do some proper veneers here. And then everything was wonderful. And then she wanted lower veneers as well cuz she didn’t like, so I’m like, okay, let’s do the lower veneers. And then this happened. So- [Jaz]Oh gosh, yes. Upper left central. [Sandra]And this is, I didn’t do anything. I was just chewing. And you know, if you look, and you can’t really see this now, but you could see that if you could blow up the picture, you can actually see that there’s a tiny little bit of black marking on the right lower central, and this is the classic porcelain friction. You actually get little black marks on the porcelain. So when you see something like that, you go like Uhoh. and guess, I mean, I did check this for friction. I thought I had adjusted it enough, but clearly I didn’t, you know, so here I am, you know, doing two more centrals free of charge, because once you have to, you can’t just redo one, you know, and these are done by a porcelain technician in Australia, and he’s not cheap. And I have to pay for that because I did not do my job. And obviously, you know, I’m then 100% sure and see what’s happening. See now you can see actually on the, you can see \ on the edges here, you can see the little bit of black hair. And that is what’s happening. She’s coming in still way too forward. So I actually had to also adjust and you can see here that there’s way too much. Smudging on these edges, you know? And I need to get rid with all of that. I need to get rid with it. Now. I can keep the big contacts on the bottom. Okay. When she goes into full seat, I can keep those. But anything that’s on my way in, I need to eliminate because that’s what’s going to lead- [Jaz]And in this case, when your decision making, would you be adjusting those areas on the upper or would you be now looking to the lower, facial to try and not have to compromise so much. [Sandra]I actually, in this case, because the lowers were veneers already, and you know, they were just pressed emax, and I can’t polish this back up. I had to do both. Okay. Because I obviously don’t want to hollow up my edges too much. And this is like, I mean, there she is. She’s a very pretty girl. And I mean, as I say, I don’t want to do this one more time and luckily she hasn’t broken it since then. So, you know, we are not fairly happy that this is not going to break anymore, but, you know, happens. Happens and happens to me too, and then no, if it happens, it’s my mistake. This is my mistake, I’m going to pay for it. If the patient breaks a composite veneer that I did, telling them that they should do something else, that’s not my mistake. I’m not paying for it. [Jaz]I love that because you’ve shown both sides. Sandra, you’ve shown the side where you know what, actually, it’s on the patient, but it was so much humility and you’re so humble to share your own mistake and say that, you know what, when I cock up, it’s because I did cock up. And then that’s when his ears is on me. It’s so refreshing to have that. And I love clinicians always value clinicians who share their mistakes and failures. And actually you actually blew it up in front of us and showed us. Exactly. And that for us, the learning is just so, so, so much here. So thank you. I also now learned that you spent some time, you did time in NHS, which is, wow. I can’t believe that. That’s amazing. So there’s hope for us all. You showed so many signs today and so many great cases that you showed as well. [Sandra]Thank you so much for having me. I have to say I’m on one hand I’m jealous that at the younger generation that there is so much out there and you have this, you have this amazing choice and you can see everything on the internet and everybody throws stuff out there. I mean, you can learn more these days that, but looking at somebody’s Instagram for a little while, somebody good, obviously, and following them, you can learn more. Probably then you could have learned until like in one month in dental school. The disadvantage of you guys, what you guys have is now obviously to distinguish yourself, you need to have a rocking CV with a lot of continuing education. It’s so much more competitive these days. And yeah, it’s got them hard. [Jaz]And there’s so much, it’s information overload as well? Like, you know, there’s from every angle? There’s this, who do you listen to? You know, how do you form your own philosophies? Who do you pick as a mentor? So it’s almost like too many mentors out there available. Yeah. So who, you know, you got to pick your best. [Sandra]It’s too many, too many chiefs, not enough Indian scenario. So I would always go, I guess it depends where you are. I just felt 15 years or 14 years in that I just wanted something that was very comprehensive, that really started at A finished at Z and wasn’t ever done. Because you know the Kois Center as well, one of the very few facilities where we go and we have an annual symposium where we have continuous, you know, updates on treatment planning, on everything. Cause John will actually read all the stuff, all the literature that has come out. So he reads about 25 articles a day, every day without fail. And if there’s an article in the last 30 years written in English, he will have read it. Okay. And he has a, when it comes to that, he’s like a little bit like a rain man. He can really get all this information out and he will very often change treatment. Not the system, but he will tweak it. It’s never dogmatic. So it’s not like, oh, we have to do it like that, because that’s what I told you 10 years ago. We actually do many things completely different now. [Jaz]Because the evidence is better. And the case come back absolutely. [Sandra]Because the science has changed and because nobody is infallible. And actually, if you want to see, if you want to see treatment, taught and philosophies is taught, showing failures. That’s where you go cuz he can show you failures up to a zoo and then he will explain why it failed. I mean, the most frustrating. [Jaz]Just like you did as well with that last case. It was so good. [Sandra]I know why it failed. And that is what’s so wonderful is because you will still have failures. Okay. And some failures are your failures. Many failures are patient failures and failures. And patients have to understand that even with the most meticulous planning, there is never a hundred percent guaranteed there can be undesired treatment outcomes. And so what’s the most frustrating is to see something fail and fail again, because you don’t know why it failed. That is really what’s soul destroying, and that is when dentists just give up and will actually not prescribe any treatment anymore. Cuz that’s your classic, you know, dentist that’s just not even doing fillings anymore because they don’t want to have post-operative sensitivity. And you will go, like my dentist said, everything was okay. You know, I guess that’s where you get to, because you simply can’t take the failure anymore. But, nothing is without failure. Nobody is infallible. It’s important to know why things fail and try and avoid failure the next time by changing your bonding protocol, by doing this different, by doing that different, you know, by knowing also that despite your best efforts, you can have a postoperative sensitivity. You know, typically the worst 40 hours after the procedure. So very often if I do large composites. Big cases, these patients go on painkillers for three days afterwards. Best combo would be, you know, 800 milligrams or 400 milligrams of ibuprofen with a thousand milligrams of paracetamol on top as a nice cocktail. You know, get them over that post treatment inflammatory bump that happens on day two by day three, typically they’re gone. They’re good. You know, so, I mean, it’s going to happen, you know, but you just, you need to know how to deal with. Okay. [Jaz]Absolutely. I think it’s some such great real world advice for a lot of the young dentist listening who have that fear in them. Sandra, I know you do the demonstration at Kois, do you do and you run any courses in Asia or Australia or anywhere. How can we learn more from you? Please share with us all the channels we can connect with you because I’m sure you’ve inspired so many dentist today to start looking, taking a step back and instead of blaming bruxism. Look out for these constricted patterns and frictional chewing patterns and maybe to now think that actually maybe the knowledge that we have wasn’t enough and we need to learn a bit more. [Sandra]Okay. Let me just see if I can, so this is just a lecture. I do online lectures. I’m part of the Australasian College of Dentals, so, but I do online lectures for them. and my Instagram handle is here. It’s @sandrawholikedentistry because my Instagram is private. If you want to connect with me, you have to send me, you know, you have to ask for me to accept you, and I will, and then you can ask me stuff. I’m very happy to answer it, you know, so- [Jaz]It was so refreshing that a superstar, like your staff even replied to me. So again, thank you so much and like, the amount you give away, the amount you share, you know, you don’t hold anything back. And that’s what we love about educators like you, you know? Thank you, thank you so much for all the time and the expertise and the humor and everything today. [Sandra]Well, I’m very happy to share this with you because I think if you’re at some stage in this profession, to be perfectly honest, It becomes a little boring. So you need to find something that that helps you recreate the passion. And I constantly, and during Covid, I haven’t been able to go and go on continuing education. For me, I find this is very, very important to avoid burnout. I need to constantly, I’m a bit of a CE junkie. So the next best thing is if you can actually share something you do know. I’m a wet glove dentist, you know, I’m not really a teacher, but I do like to share whatever wisdom I might have to share, you know, and I’m very happy, you know- [Jaz]And there was plenty of it today. Thank you so much. [Sandra]That’s very nice of you to say. [Jaz]You not only met my expectations, you exceeded them greatly, and it was so great to learn about your journey as well. Sandra, thank you so much. I’m going to put the Instagram handle on the show notes well, so people can connect with you, expect a barrage, people reaching out to you, and hopefully they’ll keep your dms too busy. [Sandra]Okay. No, I’m looking forward to that. So, as I say, I share copious fashion advice and dentistry on my Instagram. So there’s a lot, there’s a lot of, so I can tell you everything about shoes and handbags and, you know, teeth. Jaz’s Outro:I’m specifically going to tell my wife not to follow you. Thanks so much. Well, there we have you guys. Hope you found that really helpful. I really enjoyed speaking to Sandra. So do give her a follow on Instagram @sandrahulacdentistry and do tell her that you heard about her from Protrusive and send her some Protruserati love. That’d be great. If you’re watching, and it’s March, 2023 and it’s before 21st of March. There’s a few days left probably for you to join the pre-launch deal. I know I’m banging on about it, but look, this is the most important thing I’ve done in education and I’m so proud of it. I just don’t want you to miss out on a really good deal. So if you want to check that out, otherwise afterwards, it’ll still be a bargain. It’ll still be worth it. But if you’re going to catch it at the best time, it’s part of the pre-launch deal. Anyway, I’ll catch you same time, same place. And if you’re new to the app, you know, have a little look around and let me know what you think. Thanks so much. I’ll catch you around.

Do you blame bruxism for every time you observe attrition? As you know, I’m no stranger to occlusal appliances, but often they may be inappropriate for the patient who is causing their wear during FUNCTION and not so much during parafunction. Maybe it’s time for us to start looking at different aetiologies of attrition and this is what the wonderful Dr. Sandra Hulac breaks down for us in this banger of an episode. We also discussed the differences between frictional and constricted chewing patterns, which are often confused with each other. We share some case examples and discuss how to correctly diagnose these types of chewing patterns. https://youtu.be/ao0sqY6lXZ4 Check out this full episode on YouTube 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 The Protrusive Dental Pearl: Acknowledge, understand, and believe the fact that often our patient’s centric relation (CR) is NOT more distal/posterior to their maximum intercuspation (MIP) – it can actually be anterior to their MIP! Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 2:43 The Protrusive Dental Pearl 6:01 Dr. Sandra Hulac’s Career Journey and Inspirations  18:22 What is a Constricted Chewing Patterns (CCP)? 25:43 How to spot for CCP (Constricted Chewing Pattern)? 30:12 Frictional envelope vs constricted envelope 37:31 Case Discussion Dr. Mahmoud and I are also excited to share the occlusion that we learned over the years –  in a way that you have never seen before! Occlusion: Basics and Beyond is the most tangible, real-world, and comprehensive occlusion training on the planet. LIMITED DELEGATE SPOTS DUE TO STARTER KIT STOCK – AVOID DISAPPOINTMENT! Occlusion Online Course If you enjoyed this episode, check out How to use Injectable Composites to Treat Toothwear Click below for full episode transcript: Introduction: Hi, my name is Mahmoud Ibrahim, and I'm Jaz Gulati, and we wanted to make the best occlusion course in the Universe. Now we know that sounds like a big task and a huge ask, but we did it. I think we did it. OBAB:We did it. We finally made OBAB, Occlusion Basics and Beyond. And we’ve really, really worked our butts off to give you an occlusion course that is gonna be applicable to real world dentistry. So, what’s included in this pre-launch deal? We’ve got five different things for you. First of all is the OBAB starter kit. We’re gonna send you a starter kit so you can start implementing the concepts we’re gonna teach you straight away on Monday. It’s got a Huffman leaf gauge we imported from the US and this is our favorite leaf gauge. It’s also got a pack of shim stock in it, so you don’t have to use your fat fingers every time. We’re gonna send you a pair of Miller forceps as well. The start kit is worth a hundred pounds and we’ll start shipping it once the course access begins on 7th of April. I think really anyone interested in occlusion, whether you are at the beginning of your career in the middle, or even getting towards the end would learn a huge amount from this particular program. The second benefit of this pre-launch deal is we’re gonna give you 500 pounds off of the cost of the course, and you can take our word for it, that we are never gonna price it this low ever again. And this course truly has an unbelievable return on investment. The third benefit of the pre-launch deal is that instead of getting 12 months of access, we’re gonna extend that. So you get two whole years of oab and that’s a no extra charge, and we’re gonna be adding lots of new cases and content as we go. I felt like I finally understood topics that I just struggled to wrap my head around for years. And that’s purely down to the way in which the content’s delivered. The fourth benefit of this pre-launch deal is you’ll get one fully mentored case with us included that I think is massive. So we’ve set up a case forum and you can submit your cases for mentorship so you get one fully mentored case at no additional cost worth 550 pounds. We are here to help and we wanna help you through your cases and wanna hold your hand through some of these cases, and you have the opportunity to do that without feeling bad as part a structured and organized way. Now last but not least, it’s the OBAB Book. Now this is gonna be a fantastic companion to the online course, and it’s got the world’s first visual glossary of occlusion. This is gonna blow your mind. This is gonna explain occlusion to you like you’re five years old. Fairly advanced, five year old. Yeah, very, very intelligent five year old, but you get the point. We are so confident that you’re gonna get an amazing return on investment because understanding occlusion unlocks so much of restorative dentistry, and you’ll start taking on bigger cases and you’ll start having more fun in dentistry. Now, this pre-launch deal ends on the 21st of March. So what are you waiting for? If you are finally ready to say that occlusion doesn’t confuse me anymore, and you wanna go from assessment, diagnosis, and delivering high quality dentistry, because that’s what occlusion allows us to do, then let’s take a giant leap towards predictable dentistry. It is the best course that I have ever done, and I would recommend it to any dentist. Whether you have a basic understanding of occlusion or even an advanced one, you will still gain a lot from this course. Take advantage of this pre-launch deal ending on the 21st of March. Sign up at occlusion.online. Jaz’s Introduction:In this episode, we are gonna discuss a type of wear, a type of attrition that would not benefit from an occlusal appliance. There is no place for a splint in this type of wear. Now the way I got the guest Dr. Sandra Hulac on today is, I was on a Facebook group for dentist, I believe it was DPR, and someone posted a photo of some anterior wear, and so many people suggested occlusal appliance, splint, occlusal appliance, or something of that nature. But you see, this type of wear was not due to parafunction. The type of wear exhibited was functional, and therefore, in these patients, we need to stop blaming bruxism and start looking at different etiology of the wear. And this is what Dr. Sandra Hulac will break down so well. Some of the key themes that we really cover well in this episode. Hello, Protruserati. I’m Jaz Gulati, and welcome back to the Protrusive Dental Podcast. This episode will change the way that you see the tooth wear that you observe in your patients. We’ll go on to describe the terms later, like frictional, chewing pattern, et cetera, but not only does sandra describe it. We show a video as well of one of our patients who exhibited a constricted chewing pattern. So all these terms might be new to you, might be familiar with them, but essentially it may fool you. It looks like bruxism. It almost, you know, you look at it and think, yeah, yeah, that’s bruxism, but it’s not bruxism. So it’s really important for your diagnosis so you can start getting predictability in your treatments. I was really stoked to have our guest today, Dr. Sandra Hulac. She is just absolutely brilliant. She’s so giving and she’s so passionate, so, so good to have her on the show. This is one of those really big episodes, which might take you a while to process because we do go into the deep, dark world of occlusion. My favorite place to go to, and there are two ways that this episode may just twist your mind a bit. One is with a whole, you know, think of bruxism as something else and a frictional chewing pattern as another thing. So, functional wear versus para functional wear. We’ll talk about that. And that itself can take a while to wrap your head around. And the other thing which is really crazy, and for me it took me years to realize, only when I saw it in my own patient or in occlusal appliance, that I realized the following, right? Which is that centric relation is not always more retruded, or the other way to say is centric relation is not always more distal to MIP. Centric relation is not up and back in the joint. And there is a case whereby some patients, their centric relation is actually anterior to their maximum intercuspal position. So for those of you who are new to these terms, are getting a bit confused, we go into it a little bit, but not so much. So you might wanna check out some of the more foundational episodes of Protrusive or check out OBAB. Protrusive Dental PearlBut let me just explain this concept, because this concept is your Protrusive Dental Pearl today. Every main episode, I’ll give you a Protrusive Dental Pearl. So the Protrusive Dental Pearl is to acknowledge and to understand and to believe in the fact that sometimes your patient-centric relation is not gonna be more distal. It can be anterior, and the mechanism to think about it is imagine the mandible is a foot, because a foot can move, right? And the maxilla is a shoe, the shoe doesn’t move, it’s the foot that moves, right? So the foot fits inside the shoe. So, in our case, the mandible fits within the maxilla. Now, if you are wearing really tight shoes, right? So your foot, you say it’s your normal, usual foot. So you go through the shops, you buy some shoes, and the person gave you the wrong size of shoe. They gave you two sizes too small. So you try to put it in and you’re really having to force your foot within your shoe. So imagine having to force your mandible within the maxilla and the maxilla is too small, right? And so to make it fit, the mandible might have to go back a bit in the same way that maybe you’d have to curl your toes in. You have to really force your toes and curl them to allow you to get inside this shoe, and it’s not a comfortable position to be in, but you can still walk in it and over time you might even adapt. The shoe might stretch a bit in a way. The foot may adapt chronically to that scenario. But the drive home point is that sometimes the shoe is too small, or rather the maxilla is too small for the mandible and the resulting bite means that the condyle actually goes further back in the glenoid fossa and therefore it’s no longer in an anterior superior position. And that’s the whole point of centric relation. It’s no longer in centric relation. So for that individual whose condo is further backwards for them, their centric relation actually is further forward. So I hope that made sense and maybe you have to listen to it a couple of times. But basically, these patients do exist and so we do mention that as well. And that is your Protrusive Dental Pearl. We’ll talk about how to diagnose that through occlusal appliance therapy or a jig, or, as Sandra describes it, the Kois deprogrammer. Now enough for me, blabbing will join the most wonderful Dr. Sandra Hulac. Main Episode:Dr. Sandra Hulac, welcome to the Protrusive Dental Podcast, longtime fan of yours. Welcome. How are? [Sandra]I’m good. Thank you. I’m glad to be here. It’s such an honor. [Jaz]It’s so great. I mean, today’s a very cool day for me. I’ve got yourself, just about an hour ago I had Gregor Slavicek, from Europe talking about some really cool occlusion things here. So today we’re talking about a really important topic and I’m just amazed that I’m with you recording right now because, you know, you look at your heroes and you are very humble on Facebook, and I messaged you. You’re so incredibly humble, but it’s amazing now. I know there’s so many negative things about social media, right? About, you know, mental health and where it is too much. But one of the greatest things about social media is for young dentists to be able to message anyone in the world. Anyone, they look up to for mentorship, for advice. And we connected because on DPR Facebook group, someone had posted a photo of a particular type of wear, and about 80, 90% of people, were like bruxism, you know, watch this, para function, et cetera. But you are the first one. And I was thinking, wait, why has no one mentioned the ccp? And then you’re the first one who mentioned it. I was like, oh my God. It’s Sandra Hulac. So, I was like being cheeky. I was like, you know, I, I don’t think she’ll reply to me, but I messaged you. And then you replied. So, God bless you. Thanks so much. And now here we are to spread some knowledge to share with our colleagues. So for those of you who haven’t heard, and guys, please check out the work of Sandra Hulac, online contents. Amazing. Tell us a little bit about yourself, because I know you’re in Hong Kong. You’re my first guest from Hong Kong. Where you trained, what inspired you? All those things, please. [Sandra]Okay, so I actually come from a family of dentists. So my father is a dentist, my brother is a dentist, and my cousin is a master ceramicist. And both my father and my brother actually also started out being dental technicians. So it’s kind of a family thing. And I knew fairly early on that it was a profession that I really wanted to go into. I was, you know, not the least bit surprised in dental school. Like many of my colleagues that had thought it would be something altogether more different and more glamorous. I was like, okay, well that’s just how it is. And yeah, I never regretted the choice of becoming a dentist. Now what I regretted is when I got out of dental school, although I knew that, you know, you’re not done learning and- [Jaz]Where did you do a training? Because I know you’re in Hong Kong, but where did you actually do a training? [Sandra]I went and studied in Germany and I studied at a very, very small dental school in the north of Germany, called the University of Witten/Herdecke. And it was at that stage, one of the very few private universities in Germany, but it wasn’t fee paying. You had to apply and you got in and, you know, so I actually decided to go there because my brother had gone to a very large state university, Erlangen, which is one of the foremost dental schools in the country in Munich, sorry, in Bavaria in Germany. And I was close to home. But it also was quite brutal because they accept about twice the amount of students they can have in pre-clinic, and by the time they’re going to clinics, they need to get rid with 50% of them. So my brother, because he was a trained dental technician, much of the stuff they have to do in pre-clinic, like, you know, the waxing, all that kind of stuff, that was, you know, nothing for him. But I didn’t have that training. I didn’t wanna go into a large dent like where this could happen to me. So one of the things that Witten had was that it much moral in the kind of, you know, American way that they went into clinical training much earlier than your average university where you wouldn’t really see a patient before you’re in the fifth term. Now, we started seeing patients in term three already. Our whole thing was like, the whole patient. So you, when you were doing your cons assignment or your prosth assignments or your, I mean, you had to treat the whole patient. You had to go and develop a treatment plan for this patient. This patient needs this to that, and even for your finals patients, you know, we had to do, by the time you do the finals, you had to do like X amount of crown preps, X amount of this, X amount of that. But that all had to happen in a patient that you had started from start to finish. So finding your final exam patient was really, really, really challenging. Because you had to do a fixed prosth, you had to do a removable prosth, you had to do crown preps and all that. [Jaz]Very comprehensive. [Sandra]So very comprehensive. So we’d say, I’d say I’ve come from a comprehensivity kind of training. We were incredible. It’s just like we didn’t really know why. I mean, well, our course coordinator, Dr. Reynaldo Ramirez also would say like, any monkey can learn how to drill a tooth, you need to know why you do it. So, but still, you know, when I came out of dental school, it was 1993 and I knew that, I knew nothing. This was another one. You know, nothing. You know, nothing. You know nothing. I knew that I knew nothing. So we certainly weren’t a dental school that trained you very well in the art of Dunning Kruger. So it was- [Jaz]Just to get perspective. How many classmates did you have, Sandra? [Sandra]We had 20. We were 20. Max 20. [Jaz]That’s amazing because one thing I really resonate with there is, the book by, I dunno if you’re read the works of Malcolm Gladwell. I’m a huge fan of his. There’s a book he wrote, David and Goliath. And he talks about it’s sometimes better to be a big fish in a small pond than a small fish in a big ocean. Kind of thing. And I think with your training, I think I definitely hear those vibes that you had a lot more smaller class sizes and therefore perhaps a better learning experience. [Sandra]Well, you know, I don’t know. When it comes to, one of the things that we had a problem with is that there wasn’t that much time for theory, so to speak. And because it wasn’t like big established university, yet many of the lectures we had weren’t really lecturers. There were people that worked in the field, so they knew how to do, but they didn’t know how to teach, or they’re taught with a lot of passion. But there was, it was a lot. It was quite chaotic to be perfectly honest. I know it’s not like this anymore. I noticed the university has come heaps and bounds, but in my time, boy, it was, it was so chaotic. And we suddenly got a new dean and it was, ugh. Anyhow, it was like five years of lovely chaos, seeing a lot of patients. And so one of the things that I always find when it comes to like knowledge, for example, particularly when it comes to removable prosth, which I know nothing about, you know, material science and stuff like that. So I’m sometimes sitting there scratching my head and people go like, yeah, it’s like blah, blah, blah. And I’m like, how come I don’t know this? Yeah, because nobody ever taught you that in university stupid. On the other hand, because we were doing pre-clinic with the medical students, you know, it wasn’t separate. Because it was big medical faculty there as well. It’s actually much, much more famous for its medical faculty. And so I can still, you know, run circles around many, like when my partner ask me something medical and I’m like, well, it’s because of this and this. It’s like, how do you know this? And I’m like, because I went to university, you know, the same thing you did. But so my training was great in some aspect, totally lacking in other aspects, but the most important thing is that you gotta understand when you do dental school, you come out and it’s very good to know that you know nothing. You know nothing because, and you know, you can do dentistry for years and you still know nothing because you’re never done learning. Never. [Jaz]Sandra a hundred percent agree. But the difference now, Sandra, is that yes, we still know nothing when we come out, but the danger and the real sad thing now is not only do we do nothing, We have done nothing. i.e., we’ve done, like, you know, we’ve done like one root canal. [Sandra]Exactly. [Jaz]In my class, in my peers. You know, the amount of the volume is not there. Sounds like you had a bit more comprehensivity as you called it, and a bit more volume behind you, which I think is a real danger or a real worry about new graduates. [Sandra]Yeah. So, no, and it quite right, so, and I think actually, so it’s a double-sided sword on one kind. Well, I think when you’re coming out as a fresh grad out of university, you know, in most countries you paid an extraordinary amount of money. Not in the UK, but in the US you have, you’ve received, or what you think you have received very comprehensive training because that’s obviously what they tell you. That you know, you are the best trained and then you go out in the real world and nothing is like how it was, you know, for once you find out, you can’t take the teeth out of the patient’s mouth like it could do in the phantom head. And you can’t sort of pull the cheek away when you have a difficult cavity and all that stuff, so, and if you haven’t done it, then I think it’s very hard. You just have to then many people make the decision. It’s like they stop even trying and then, or maybe they try and do their best and they still clinging onto a notion that they were so well trained. Or they realize that they have to go a completely different way and become extremely conscientious and really then look at, for example, my God, on Instagram, what’s available, and these people tend seek out mentors. I mean, I did not grow up in the time of the internet, so for me it was, it took me a little while to, I always had an inkling that I needed to know more. But then, you know, I started working in London. I actually worked in London for nine years, and I worked first in the East end. That was pretty rough. Like, Four months in bio next to the Royal London Hospital. Whereas, I mean, in a full on NHS practice, you know, where we had- [Jaz]No way. [Sandra]Where we had portable suction units, you know, the ones you rolled around, which you had to empty at 10 of today. Yeah. [Jaz]Wow. [Sandra]It wasn’t an- [Jaz] I would never have thought that you spent time in (beep) NHS Dentistry [Sandra] No, totally. And the building I was working at, the Bow Dental Surgery on Bow Road, naturally was allegedly once owed by the Kray twins. So, it’s like, and it had no heating in winter. It was just miserable. So I worked there. But you know, I saw volume, you know, I saw volume again. And then I started working in a kind of semi-private practice and I stayed there for a little, I stayed there for four years and then I opened a private practice for Bupa in Tower Hill. But I always felt, you know, I needed to know more. And when I then started working in Hong Kong in 2001, it was the first time that I worked in a big group practice. And I suddenly had- [Jaz]I just want to know, what took you to Hong Kong? Was it family? Was it love? What was it? [Sandra]Yeah, it was my husband’s job basically. So he got offered a job with Citigroup to go over to Hong Kong and we thought we were gonna stay for like maybe three years max. And I was gonna go back to the university and I wanted to do maybe a master’s in endodontics, believe it or not, which I really loved at that time. And now I haven’t done a root canal in years, obviously and, but so that didn’t pan out. So I took my licensing exam. I passed my licensing exam, and then I started working and this practice was suddenly, you know, there were so many good dentists there. They were all like, they knew so much more than me and I was just, and I knew, they knew much more than me. And then I started working there. Then I had a couple more children. And finally in 2007, when it comes to big decisions, by which time I had been working for 14 years. Which is one of my biggest regrets that I didn’t start this earlier, but 2007, the time was right. My youngest children were just two years old. I could finally, literally leave them and I took myself off to Seattle, to John Kois. Yeah. So I went to Seattle to train and I started taking the whole curriculum of John Kois. And when it comes to post-graduate education, I still think, oh, I think it’s the best in the world. If you want to have a comprehensive program that teaches you literally the alpha to omega of dentistry and gives you, you know, I don’t know. And also puts you in touch with a bunch of great people and mentors. And it opens really, it opened, it opened the world to me. I am so grateful to, to Dr. Kois and everybody in the Kois Center. And you know what happens when you are finished, then that Kois center, typically you start mentoring other people and eventually you become a mentor and eventually become a clinical instructor. And that’s what I am since this year. So I will go back in September and actually, you know, be clinical instructor on my first course, which doesn’t mean I really instruct, but I’m just really there to help Dr. Kois to facilitate the best learning process. I mean, it’s really amazing. [Jaz]I mean, everyone who’s done Ko is said such wonderful things, is a gentleman and a philosophy and a camp that I respect so much, so much time. And I’ve got, behind the scenes, those who are listening. Can’t see the screen right now, but I know you’ve got the checklists and stuff, which is so comprehensive and thorough that they put out and it’s just great that we are, it’s lucky in dentistry to have the institution. [Sandra]And John Kois will be the first one to acknowledge that there are many, many ways that lead to Rome. What he has just tried to do is to give everybody an easy entry point. You know, it doesn’t mean that this is a cult, and you have drunk the Kool-Aid. He doesn’t want you to stop thinking, but what he wants to do is give you a system. And systems are not recipes. Systems create foundations. Recipe creates ceilings, you know, so there is no recipe to this. It’s just a system of record taking, a system of diagnosis. Because if you don’t have a diagnosis, what are you going to do? And when it comes to wear, it’s not a diagnosis and you don’t need to go to dental school to tell somebody, oh, Mrs. Brown, your teeth are worn. Yeah, I know that doctor. I can see it, you know. So you don’t need to, you need to know what is the origin of wear. So what is the wear, it’s a symptom of an underlying occlusal disease or- [Jaz]Which leads so perfectly to the exact issue I wanna talk about. You time that really well. That was, you know, you rehearsal this. So it was wonderful. So, we saw that photo on that group. And so you identified it and so did I, but I was surprised that no one else did that you suspected that this wear was a CCP or a constricted chewing pattern. So now for those listening, what are, and they may also have looked at it and say, oh yeah, bruxism, we see some wear automatically assume it’s bruxism. So this episode’s called Stop Blaming Bruxism, because there could be some other diagnoses that we can make. So what guidelines can you give to equip dentists listening and watching to be able to now change their perspective and facilitate them to make such a diagnosis. So what are the classic features? What are the classic signs that we see that may lead to us? So just give us a, the background on this type of wear. [Sandra]Okay. So I wanna start out with to tell all our listeners that bruxism is the most overdiagnosed disease in dentistry because everybody will immediately jump to bruxism as soon as they see any kind of wear. Now, real bruxism is actually an extremely rare beast because it’s a neurological issue. It’s an above the nose problem. So it comes from the basal ganglia and what the patient will do he will go sideways. So in my bruxism is always lateral and posterior. And if you give these people a mouth guard, you will actually see, you can read that mouth guard and that mouth guard looks like a Zamboni machine has gone over it. You will see the tracks on the mouth guard. This is your classic bruxer. What people then, very often they see anterior wear and they say like, oh, this person is a bruxer. Now, anterior wear will only happen in bruxism if the patient has flattened the posterior so much that he will or his canine so much that he actually can get onto his anteriors. Okay? And the wear in the anterior wear in bruxism will be flat because the patient goes over the surfaces all the time. Now, if we see anterior wear, solely anterior wear or anterior wear that looks different like little spicules, little thin wear on the palatal where you know the enamel, where you really, patients are hollowing out this palatal surfaces. This is never wear from bruxism. This is where that happens in function, and this is what people don’t understand that wear can happen if the function isn’t functioning properly. So if your occlusion, if you can either have, you know, something called occlusal dysfunction where your chewing envelope is so large where your envelope or function is so large because your brain can’t find a back teeth. And, this is a completely different pattern, but, we call this occlusal dysfunction, or you have something called constricted chewing pattern, or frictional chewing pattern, which are two different things. Whereby because of dentistry, or very often because of orthodontics, by the way, or because the patient grew wrong. You have just during chewing too much contact between the facial surfaces of the lower anteriors and the palatal surfaces of the upper anteriors because these teeth actually in function should never touch. And one of the things and that’s why, for example, unfortunately many of these problems are, or you see many, many constructed tune envelope patients that had previous orthodontics because orthodontic cases are very often finished in the growing patients, say 14 to 16 years old, we’re done. The young orthodontist is, or the orthodontist is taught in orthodontist’s school that the front teeth have to touch. The facial growth isn’t finished, particularly in the male. If your growth pattern is somewhat brachyfacial. These people literally grow through their front teeth and destroy them. And so this is why, my orthodontist and I always like, leave me room there. I don’t want any touching on the centrals and laterals. Never ever do I wanna see a extreme stock contact on a central or a lateral ever. If I’m doing restorative dentistry, I check this out in static and, you know, in functional, I don’t wanna have much contact on these teeth because they don’t have to. And even, even, you know, you can go and look at all kind of occlusal concepts, but there are certain things we have decided to unilaterally own. And even Dawson writes, you know, in the big book that one of the biggest mistakes a restorative dentist can make is to constrict the envelope of function. Okay? And very often this is also done with restorative dentistry, you know, your bulky surfaces of anterior crowns and so on. But the technician looks at it in the articulator. It goes like that looks fine. Lots of room, but he doesn’t know how does patient choose. And even you can have all the functional analysis, you can do all the anterior incisal tables in the world. Still, it’s probably different in the patient’s mouth and you gotta check it out in the mouth first. [Jaz]So it’s fair to say that bruxism is inside to outside. And then when we see the type of wear that you described. Now it’s function, so it’s outside to inside. It’s the hollowing out of the palatals of the upper, against the facial of the lower. [Sandra]You have said this, this is a very important outside, in an inside out. So this whole thing, when we are sent, when we are checking the envelope of motion, so the limitations of the chewing envelopes, right? Working, left, working intrusion, you know, I’m just doing this for our listeners so people don’t chew like that. This is an inside out movement. It’s completely useless. I mean, it’s great. You know when you do it on the patient and you go like, oh, now move your lower jaw to the right, to the right. And they go like, which jaw do you want me to move? Because actually, they have no idea what you mean because this is not a natural, this is not a natural movement. So the only people that know how to move their jaw to the right or the left under tooth contact immediately are dental students or bruxists. So this is, by the way, very interesting. So when you have somebody in the chair that knows immediately what you wanna do, like that’s somebody where I go, oh, this might be a bruxer. It has the memory- [Jaz]Muscle memory. [Sandra]The muscle memory for the movement, cuz this is a difficult movement, means like you have to contract like two muscles on one side, release, three muscles on the other side. So yes, but chewing doesn’t work that way. Chewing is an outside in movement. So it’s causing a completely different wear pattern as you will ever figure out. And left working, right, working, and so on and so forth. [Jaz]Could you now show us some photos because you’re sharing screen. Do you have any photos to show us this type of wear? And then perhaps just describe it for the audio listeners in case we do end up having to spin there for the audio listeners as well. [Sandra]Okay. So let me just do my share now. This is what I’m showing here is a classic test now, for constriction. So this is for our audio listeners. This is a patient that has very thin and worn upper front teeth, and they’re also quite short. And when we look on the inside, we can see distinctive wear on the palatal surfaces of those upper front teeth. And what I’m doing here, and I do this a lot when I see anterior wear, I let actually people chew on a piece of 200 micron thick horse shoe paper, because that’s precisely the amount of space we wanna have between the teeth during mastication, between the anteriors, during mastication. And during any kind of functional movement, like talking or swallowing. So that’s the minimum amount of space we need. And if this paper shows us a lot of tracking marks on the anteriors, very often we know that there might be a problem. Now, it’s not solely that. This is a CCP now, or a functional chewing envelope. This could be also a dysfunctional chewing envelope. That is why we need to have more diagnostic tools. But very often this is first thing we see when it comes to how we show it to the patient. [Jaz]But before you come to that, Sandra, can you just explain the difference between a constriction and a frictional chewing pattern? What are the key differences? [Sandra] Okay. Actually that’s why I wanna quickly show this video, but basically a frictional chewing pattern means that, okay, the teeth are hollowed out, but the mandible doesn’t get distalized in full MIP which is, you know, basically maximal intercuspal position. So when you close fully, the mandible doesn’t distalize in a CCP, in a real constricted chewing pattern, in an active chewing pattern, the mandible is actually pushed back when you close. And that is, you know, now we’re getting into the whole thing. But centric means the mandible is always going backward. No, it isn’t. Because very often in centric, the mandible actually wants to go forward because the mandible is for reasons- [Jaz]It’s being forced by the maxilla. There’s no space. [Sandra]It’s actually, yeah, exactly. It’s being trapped by the maxilla. So it’s actually distalized in full seatings. So what I have here, just quickly show that for our people that actually are. So what you see here, you need to look at the, you can see the constricted chewing pattern, how the patient is first when he goes in hitting on the front teeth and now distalize. And you can see what happens to the disc as well, that, you know, the disc actually is anteriorly positioned when the mandible is fully closed because the condyle is pushed so far back. [Jaz]Sandra, I’m gonna share my video if you don’t mind now actually. [Sandra]Oh yeah. Oh, wow. [Jaz]Can, can you see this? [Sandra]Yeah. Oh, yes. Okay. [Jaz]Let’s watch the video. [Sandra]That’s classic. Yeah. [Jaz]But then what I do is I make it in slow motion now and watch it in slow motion. I think it goes like this. This is really, and then it really gets forced back. [Sandra]Oh man. Yeah. That is unlucky growth here. [Jaz]Yes, exactly. And, but I think it’s a nice little clinical demonstration to supplement your animus. [Sandra]Did this patient have premolar extractions on the top? Just wondering. [Jaz]I don’t know. Yeah, I’d like to know as well. I don’t remember. So, back to you, Sandra. So I hope that was, would you agree that that’s exactly, that is a classic CCP? [Sandra]That’s exactly, that’s pretty much a classic CCP. And I would think that this patient because there’s actually not that much wear on the teeth. Okay. She’s probably very adapted. I would think that she’s completely off the disc and she might be a little, she might be quite symptomatic. What we typically find in that, that females don’t really wear their teeth, their everything else hurts, but because the muscles are weaker than they will typically end up with a lot more pain symptoms while men, they just destroyed their teeth. You know, they don’t have any pain. The muscles are so strong, they’re just destroyed their teeth. [Jaz]Yeah. Very valid observation. Do you wanna share again, your screen? [Sandra]Okay. So the important distinction between a frictional envelope and a proper constructed envelope is that in a frictional envelope, the mandible isn’t distalized in full closure, but in a frictional it is. So we used to call a frictional envelope an adapted constriction. So thinking, and sometimes it is an adapted constriction whereby, you know, the patient has worn away so much of their front teeth that you know, they now they can seat into that no further wear will occur or whatever wear is going to occur future in future to the teeth won’t, won’t be due to friction, but will be due to chemical issues. For example, because once you’ve worn away all the enamel from the pala of the upper front teeth, you know your dentin is going to erode. Once it’s exposed, that’s just gonna happen, but that’s not gonna happen because of friction that’s just happening because of mastication, because of acidity of food and so on and so forth. [Jaz]Well when you’re looking at these two different patients very similar, but different, diagnoses clinically. I think the key distinction factor is actually seeing that mandible, distalize and getting a hint that, okay, there’s a mandibular distalization happening, but it’s very difficult to diagnose clinically, right? [Sandra]Correct. And you, in order to diagnose it clinically, you gotta actually, you know, put this patient in. Yeah. You have to get a centric registration record and see where does this mandible actually wanna go, and where does it wanna be? Okay. And how far is it gonna come forward or, or backward or whatever. And one of the problems, and this is where people, old school, gnarthology, go like, this is bullshit. This doesn’t happen. The mandible will always goes back, it’s a fully seated joint. It’s always distal to MIP, blah, blah, blah, blah, blah, blah, blah. This is where, for example, using a leaf gauge is gonna bring you, give you a big problem if this is a true constriction. Cuz the only thing, leaf gauge- [Jaz]I was just gonna say this exact point, Sandra, that I’m a huge fan of the leaf gauge, but when I suspect this diagnosis, I might then go to a acrylic jig. [Sandra]Yeah, exactly. You cannot, because a leaf gauge will always distalize your mandible or you are running in a big, big trouble to push that joint back even further. And so you don’t wanna do that. So what I do when I suspect this, and what I do with most of my patients is I put them in a so-called Kois deprogrammer, which is your acrylic jig. But it’s basically an appliance that can be worn, it needs to be worn for a very long time because particularly when it comes to construction cases are much easier. But when it comes to occlusal dysfunction in a brain that’s utterly confused and has no idea where the bite is, where everything is, you need to let the what we call the motion generator, the general pattern generator. Forget, so to speak, how everything is supposed to fit together so that the joint can seat and that the muscles are relaxed. And for this, you need time and patients cannot run around with a jig forever because I mean, it’s annoying. So here is where the Kois deprogrammer comes in and I’m just gonna show you a quick case. So now here for our listeners, we have a case here with a patient. I did that a very long time ago that kept breaking her front teeth and there was a fair amount of lingual wear on those teeth as well. And she also had a fair amount of wear on her back teeth and basically no more occlusal home because of poor restorative dentistry. So I wasn’t gonna go and restore this case before I knew actually where she wanted to be. So on the left, we can see now this is a Kois deprogrammer in action, so it’s basically like a holy retainer. But it’s got a tiny little, what we call platform behind the upper front teeth, so it can be worn during the day and you know, people can talk with it. It’s a little bit annoying these days. We can make them without the wires in the front and you just scan them and you just have an appliance that really just sits palatal. But basically what. You have with this patient, wear this as much as possible, and they only take it out for brushing teeth and for eating. And you want the patient to wear this for a good solid week and get back to you. So every morning when they take it out, you want them to sit up, tilt their head back about 45 degrees and close. And eventually you will find that when they say is, oh, my teeth meet in the same spot every time I take this appliance out. And that means that they are now deprogrammed. And that’s what you then wanna see when you actually mount the models in the bite you have taken with the appliance in place. By the way, this is what’s so smart about it, because when you take a jig very often or any other centric registration, if you guide the patient into something, you have to remove the appliance. Okay? With jigs you don’t, but this has the advantage that it can be worn for so long, and in my opinion, is sometimes really necessary. So when you then take the bite registration, you have much more security that the patient is really gonna give you the centric bite, and then you mount this and you analyze the model. In a constricted chewing pattern or a frictional chewing pattern, the patient will say, my front teeth meet first. Okay? Or I have my heaviest frontal, and in a dysfunctional chewing pattern, the patient will typically say that the first contact happens on one premolar or so, or can be a lower seven or something like that. You very often have premature contacts on those. So, yeah. So this is how a Kois deprogrammer looks, basically a Hawley with a little platform, but, it’s my tool of choice. [Jaz]Do you use this like routinely or only when you suspect a CCP or a friction chew pattern, for example, do, is the leaf gauge still in your drawer for a more straightforward case for you? [Sandra]Abso-bloody-lutely. I love taking a leaf gauge, but only when I’m 100% sure and even when I use, I always look if I put my patients, cause I do a lot of quite complex, full mouth rehabilitations because I specialize, or I’m a specialist when it comes to, you know, restorative cosmetic and wear cases and stuff like this. So I put my patients in temporaries for a long time. I’m not going straight into porcelain, you know. Because I wanna make sure that this does works before we do this. So I’m these days, I mean, in former days, you know, I used to, I used to, let me just show you a case. In former times, I used to put people into milk provisionals, and these days I do everything. I do everything with injectables because I’m a big, so here I have a case I just did recently and for our viewers, you can see, you can have an extremely deep bite situation. The patient keeps breaking a front teeth at all. Everything also looks pretty ugly, and you can see now in the middle of the screen how this patient is hollowing out. The inside of her upper front teeth. I mean, that’s like that Left central is about to break off. I mean, that’s, that tooth is so bombed out and this patient like pretty much everybody has no money and doesn’t really wanna do anything. [Jaz]So I mean, while you’re having a drink there, you could see how the central incisors there have not got so much talk. Right. And that’s part of the diagnosis part of the issue. [Sandra]Yes, yes, yes, yes. They’re like, you know, slightly upright. [Jaz]They’re slightly upright. [Sandra]Very upright. And the lower incisors will be very often pretty retroclined because they already have been trying during growth to get out of the way. But, you know, not enough. So, in her case. So here we have a pretty much bombed out occlusion as well. And so here, actually here, I did take the registration with a jig that I bonded behind her front teeth because she wasn’t gonna, she’s a head hunter. She needs to talk all the time. She wasn’t gonna wear the deprogrammer. Okay, so this is what I did. So I don’t know if you can see that, but there is actually a small bonded platform on the back of these teeth. This is how I take my centric registration. They sit in the waiting room for like 20 minutes and constrict chewing patterns. They did program very, very quickly because their lower jaw wants to come forward. [Jaz]They want to come forward. [Sandra]Yeah. What we then do, we wax these cases in centric, and I don’t know, is injection is the kind of ejection molding technique, is that a big thing in the UK already or has that not gone? [Jaz]Yes, it’s growing. Yes, absolutely. Using the gc injectable resins. [Sandra]Injectable, exactly. [Jaz]But it’s great to hear that you’re using it as I’m loving the direction, you’re going in is that you moved away from the mill crowns to this, it sounds great. [Sandra]If I need a patient if I need to get the patient out of this pronto. I mean, who can afford? We are talking about, you know, this is basically a full mouth case. We are looking at about 150,000 US dollars worth of dentistry. Who can afford this? Just like that. But I know if I don’t get this patient off her front teeth pronto, she’s gonna make them unrestorable possibly within a year. I need to get her off her front teeth. So that’s where injectables are. Great. So here we have the classic thing where we have a wax up and we duplicate the first wax up model, and then we knock off every second tooth because we’re using alternating matrices, two matrices per arch. And then we go and we start. And so I’m going here through this. This is this for me. This is a fun day. Took me six hours. But it’s basically all the teeth. [Jaz]And for those listening what’s Sandra’s showing essentially is that Sandra’s doing injection molded long-term, direct temporary crowns, like composite crowns is what you’re doing. Which is great. See? [Sandra]Yeah, exactly. And I know I give the patient, I said, look, I don’t know how long this is gonna last because it is pushing the material to its limits. And if you talk to GC, they say, yeah, you know you can do it. But it’s also, yeah, we good for occlusion. But this is like, really pushing it. So I say to the patient, look, now I’ve gotten you off your front teeth. And you, and here we have, we do the same thing. You know, we make the patient chew and we see we gonna get rid with all those little contacts we have. But you know, she’s not on those front teeth so much anymore. And now you have the finish case. Basically you can see that as a significant bite opening we have done, but we don’t just have open to bite by letting the patient, by rotating the mandible open and distalizing it more, we actually have allowed the mandible to come forward. So this patient has been in these provisionals now for about eight months and she’s actually moving to the UK. So I’m gonna finish off her upper front teeth because I want, I obviously want to give her the biggest bang for the buck. I said, when you are in the UK, because she needs some implants down there. Those two lower front teeth are toast. The ones that look a little bit gray, she is opposite. She needs a lot of dentistry, but the nice thing is now she has time to sequence this treatment out to a point, you know, where finances and time allow, because at the end, yes, she added a little bit of cost to the treatment, but it bought her the luxury of time. And as I say in this case, although I know that this is most definitely a constricted chewing envelope, I’m much more comfortable in doing this just with a jig bite because, but I still would’ve never taken a leaf gauge with a jig bite because I know I’m gonna temporize her like this. And so I had these kind of patients you then bring back for short appointments and adjust occlusion, you know, make sure there’s no streaks on those front teeth. Make sure when they chew that you know, their back teeth really crisp into a very nice occlusion because you don’t want them to chew too lateral. Now this is a different topic, when it comes to occlusion equilibration, but you want despite to be like, where they go like, wow, this feels really good. And then you’re done. And now you can segment this case out because hey, I’m not Frank Spear. I’m not John Kois. I’m not gonna prep, I don’t know, 28 teeth and you know, do a jig bite and then do, I don’t know, cross mounting and stuff like that. Nah, no, no. I’m not doing, I dunno. I’m doing it like this. [Jaz]I love to see that and I think everyone’s gonna love to see this. Just a technical question on the posteriors, were the posterior temporary, PMA crowns or were they also injection molded? [Sandra]Yeah, that’s all injecting molded in that is stuff strong ass [Jaz]Yes. Yeah. So you got, that’s all pretty much posterior injectable resin crown. [Sandra]Good. Exactly. [Jaz]Posteriorly as well. [Sandra]Exactly. [Jaz]Amazing. Yeah. Wow. They look so great. [Sandra]Yeah, I mean that’s because it’s a nice wax up and it’s good matrices. So yeah, it’s pretty nice. And as I say, you can do this quite reasonably because the lab cost at least for me is not that high, and the material is not that expensive. So you can do this for a fraction of a crown price. And what I very often say to the patient, look for me, this is also easy because now the only thing I have to do is, you know, I’ve obviously removed the decay. This stuff is also my core buildup already. I can just prep these teeth now to ideal. So it’s properly bonded on there. So now, when I prepped her, her 10 upper front teeth there was a doddle. You know I just have to get the margins back to tooth and do my stuff. But I’m quite happy to leave much of this is core built up. It’s a very strong resin material. Okay. [Jaz]Restoratively, it’s a dream, this scenario, actually very good. [Sandra]It’s very nice now, but I have patients also with constricted chewing patterns and stuff like this for much longer. I have one case where I completely changed to occlusion. He’s three years out now, and I brought him forward and gave him the bite he was happy with. Now, when the material wears in the ideal case scenario, your teeth are going to erupt into occlusion. You know, that’s the whole DAHL concept in, in many so to speak, because obviously you still wanna have a supported occlusion. What you don’t want is, you know, big pots. That’s why I personally never DAHL because I think it’s too much, it’s too many teeth. But typically if you just one posterior tooth is out of occlusion, you still have a supported occlusion. These tooth should erupt in occlusion and to occlusion. Jaz’s Outro:Just a few different side questions. I wanna lead you down now based on the case showed me that one of the questions that we are going to discuss is the role of pre-restorative orthotics, because what you’ve shown there is a wonderful case where this was managed purely restoratively. And finding this new joint position, which is gonna be in her case, slightly further forward because it’s now no longer distalize. And, by increasing the OVD you now had some space. Tell us about, what percentage of case A) would you like to, in an ideal world, have a one then say, okay, this patient is gonna have orthodontics. And go through the pain and the misery of that and, and B) what actually happens in terms of what percentage actually get on board with that and what is your cutoff point? At which point you say, you know what, if you don’t know ortho, no treatment. Well, there we have it guys. What does Sandra say? Well, we have to find out in part two because I’ve left you on a bit of a cliffhanger. Now, part two, it will be on the app, on the premium app and the free app. So, you know, download the Protrusive app if you haven’t already, and you could actually get it for free by the way. You don’t have to pay. If you want to get CPD and watch the premium videos, then yes, you should subscribe to Protrusive Premium, absolutely. But you can watch the episodes for free as well. So this part two, because it’s so visual, she shares cases and examples and how she uses the articulating paper to diagnose these issues. And even sharing a failure and how she rectified it. You always have to respect clinicians that share their failures. So the way you’ll be able to access part two next week is on the Protrusive app only. It’s not gonna be on YouTube, it’ll be on Protrusive app. It’ll be on free version as well. Part two will be a free version on the app. That will be the premium version, which can get the CPD and the premium notes, but it will only be accessible through the app. So you can go on your browser, for example, www.protrusive.app, and you can actually check out all my content via your browser. You don’t have to do it on your phone. Some people don’t like the idea of learning on their phone. That’s totally cool. You can do it on your laptop. Thank you so much once again for listening. All the way to the end. I’ll catch you same time, same place next week.

Dr. Mahmoud Ibrahim and the host discuss occlusion philosophy, longevity, predictability, and the impact on restorative work. They cover different schools of thought, failures without conforming to occlusion, and the importance of individualized treatment. The episode highlights the OBAB course, emphasizing its practicality and comprehensive training on occlusion.

Dr. Karl Walker-Finch shares his journey of pain to passion as he reveals the secrets to finding YOUR passion in Dentistry. We started by discussing our crippling imposter syndrome as we left public Dentistry to practice privately. Along that theme we highlight the importance of taking control of your own destiny. Karl’s new book, ‘In The Loupe‘ raises money for Confidental (emotional first aid for Dentists) and is a powerful book for Dentists that wish to practise without fear and establish the right work-life balance. https://youtu.be/YPv71yr62tE Check out this full episode on YouTube 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 “We do not need thousands of specialists in full mouth rehabilitation” – Dr. Karl Walker-Finch Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 3:12 Dr.Karl Walker-Finch’s introduction 5:48 Experiencing Imposter Syndrome 11:40 Private Practice vs Public Practice 16:31 Finding Passion – Ideal work for dentists 20:59 Top tips to help dentists find their ‘whys’ – Dr. Karl’s pathway before niching down 29:34 Taking control of our own destiny 39:32 Implementing the power of atomic habits in Dentistry 44:12 Dr. Karl supporting ‘Confidental’ – helping dentists with their mental health You can now grab a copy of In The Loupe: The Secrets to Finding a Passion in Dentistry by Dr. Karl Walker-Finch! If you enjoyed this episode, you will love Passion and Values in Dentistry with Dr. Dhru Shah Click below for full episode transcript: Jaz's Introduction: n this episode, I'm joined by Dr. Karl Walker-Finch, who's the author of the book called In the Loupe, the Secrets to Finding a Passion in Dentistry. Hence why the name of this episode. Now, some of the other titles that are also considered were GDPs, just Want to Have Fun. Jaz’s Introduction:And the other one that describes this episode really well, which I almost considered was Fall in Love with Dentistry all over again. Hello, Protruserati. I’m Jaz Gulati and I’m the host of Protrusive Dental Podcast. This is a non-clinical interruption. We call this an Interference Cast. If it’s your first time listening, thanks for joining me. I appreciate it. It’s a whole three or four years worth of content that you need to explore, but if you are a regular listener, thanks for joining us again. This episode is a bigger picture episode. This episode is kind of like a feel good and an emotional exploration of your why and your purpose in your life and in your career. Some of the themes that we cover are things like imposter syndrome, my goodness. So I do get imposter syndrome less now than I used to, but when I get it, I get it in a big way. So we’ll talk about how Karl experience is and how we both overcome that. We also talk about our journeys in moving to private density and how we actually felt bad about leaving the public health dentistry and what that kind of looked like. Our little roadmap. The other thing we discuss is how we both want to, we’re both on a mission, Karl and I to infect you guys, you listening right now with enough positivity that you can head into work with excitement. In fact, the thing I love about protrusive and what it’s become and you guys is the messages I get are kind of like in this vein here. I’m just going to read a message out to you from, oh, hey, it’s Dr. Albert, Albert, thanks so much, for freeing a listener. You sent a really lovely message. He said lots of nice things and I’ll cut to chase. He said, I’ve been practicing for seven years and have been stuck in a lot of routine, mundane mindsets that have been holding me back. And watching PDP episodes on YouTube has gotten me so excited about all sorts of new things. Thank you again, and please keep up the great work. So, these messages, which I get saying about how you’re feeling more positive towards sensory, this is what it’s all about, man. This is what it’s all about, and this is such a huge part of what me and Karl discussed today. We talk about finding your why, but also why Karl does not like goal setting. So if you listen towards the middle to end, you’ll find out why goal setting is not recommended by Karl. And a big part of this is mental health and not feeling like you have to be like every other Instagram dentist. Like you don’t have to do that to be happy. There are other ways of defining your values and living your life and working your career in tune with your values. And what I love about Karl and his book In the Loupe is that all the profits go towards ConfiDental. ConfiDental is a charity which is emotional first aid for dentists. So Karl, I applaud you, my friend. I think what you’re doing in spreading positivity in our profession, much needed, positivity is absolutely fantastic. And if you guys enjoy today and the conversations and the themes that you should definitely pick up the book, it’s out from the 27th of February. Show Karl and ConfiDental your support. I hope you enjoy my chat with Karl today. I hope that you’ll feel inspired to take control of your life and take a massive stride towards having a fulfilling career. I’ll catch you in the outro. Main Episode:Karl Walker-Finch, welcome to the Protrusive Dental Podcast, my friend. How are you? [Karl]I’m fantastic, Jaz. Thank you so much for having me on. It’s feels like it’s been a little welcoming, mate. [Jaz]It’s been great to see you because you’re such a great member of the Protruserati. You are the one that came up with a term Protruserati. So for those who want in the background, it was on the Facebook group and I was like, ah, our group needs a name. It’s just called Protrusive Dental Community. I think that we can do better. And there were so many different suggestions. There were some obscene ones. I’ll have to figure out, I’ll to find that little thread on Facebook. But I loved, I love Protruserati, so thank you so much. Which is why you’ve been sent a hoodie. Just show off your hoodie, man. [Karl]Yeah, I’ve got Marty, here. It’s not got baby stain all over it of anything. So yeah, it’s, it’s been- [Jaz]Mine’s usually got coffee stains on it, so you’ve done well. No, again, thanks so much for contributing to the community in that way. Tell us a little bit about yourself, buddy. Tell us your origin story. I want to talk about something. I want to talk about a large part I talk about today is your book and what you write in your book. Cause I love that so much. And the charity you’re supporting, and the great content is the best dental book I’ve read in my life. I’m just telling you right with that right now. Okay. So, I’ve read a lot of dental books, is the best dental book I’ve read in my life. So I want to say that right now. Make it public. But tell us about you, Karl. For those who don’t know you, tell us your origin story. [Karl]Yeah, you’re very kind. You’re very kind. Thank you. Well, yeah, so I grew up in Wilmington, moved over to Liverpool for my undergraduate, my BDS, and qualified in 2010. After some ups and downs job in university, got out into the big wild world of dentistry. Started practicing in the NHS, did five years in the NHS to start off with, married a Yorkshire lass and then moved over to Yorkshire. And when I moved over to Yorkshire, I was looking for these jobs. I was looking for NHS jobs and every NHS job I could find was in a corporate. And I’ve never worked for a corporate, so I can’t really comment on what it’s like to work for a corporate. [Jaz]It’s crap. Sorry, sorry. I’ve got a frog in my throat. Really bad frog. My, awful frog. [Karl]You’ve got. But I’d never worked for, and I didn’t, I hadn’t heard great stories and I didn’t fancy it. And so, I thought, well, what else is out there? And there was a private job going practice in Woodfield, well, a couple of factors in Woodfield. And because of my background in dental implants, cause I’ve done a few dental implants by that point, it fit really well with whether principal dentist wanted to take the practice with regards to offering more things in-house. And so, I got the job there and I started working in a mostly. Private practice. [Jaz]Can I just ask you; can I just stop you on that Karl? When you were applying for that position, did you get like something that I experienced when I was going fully private is, this imposter syndrome. Like you feel like you’re not ready to go into private. Did you have, did you battle with that? [Karl]I get imposter syndrome most days at the moment. Still, it did. Absolutely. Yeah. I had this trepidation about getting into private dentistry. I mean, I kind of had this loyalty to the NHS. I wanted to repay the NHS for, you know, all the help and support and the funding that got me through university. And, you know, I’ve done five years, but I felt like I still wanted to give more. But yeah, I thought, right, well, the standards going to go up. I’ve got to do better. I’ve got to do more than, and to some extent that’s true. Yeah. You know, people are paying a lot more money for this service and yeah, you’ve got to offer a le a better level of service. But it came to a choice of like, well, do I want to sacrifice me and what I’m doing and the work I’m doing to go and work for a corporate NHS style environment still? Or do I want to push myself and raise my level to fit in and go, yeah, you know what, I’m going private and it’s not going to be perfect straight away. Nothing ever is. But I thought, you know what? I’m going to push myself and if private is all it’s cracked up to be then great. I’m going to push myself to be at that level. I got in there and I was surprised at how quickly you adapt to the working style. More time, more talking with patients. It’s great you get, actually have proper conversations with your patients and connect- [Jaz]Proper relationships as well. [Karl]Yeah, and you know, there will be those that can argue, you can do that on the NHS to some extent. And, you know, I always tried to connect with my patients when I was working mostly in NHS, but I really get to dedicate pretty much as much time as I want to or need to, to every patient. You know, if they’re anxious, they’re just getting more time and that’s fine. Yeah. Whatever it just, you can do whatever you need to do for your patients. [Jaz]The thing that I found most liberating is not being confined by what the system can dictate you can and cannot do. And just like forgetting about it. So now when I’m on Facebook and I’m scrolling through the dental groups, Anything that’s about what does the system say can be done, or what the system is allowed or not, I can just, I can smile and just skip right past that. I’m not giving that any of my time attention. So in the same way, it felt liberated, like the shackles have been broken because now I wasn’t thinking, okay, this patient needs, three root canals, four crowns. I might as well work at Tesco’s versus also trying to then unfortunately, this, I’m just speaking the truth and trying to think, okay, how can I work smarter here so that it puts me in my practice in a better situation in terms of how much time is spent in the chair. Those are kind of real thoughts that happen every single day and let’s face it. So having to not think about that and having to just to think, how can I help the patient? Now, of course, in the real world, in private, you have budgetary constraints that every patient carries with them, but that is part and parcel of any service that you provide. But that is much nicer challenge to have and a nicer problem to have than working in a confined environment. That’s the biggest benefit I thought. [Karl]Yeah. I think the other thing for me was not, I had this real difficulty doing what I felt was sales selling private treatment to patients when I was on the NHS. And I’d be like, well, I can do this crown for you for 200 and was it 246 pounds or something when I was last in the NHS? That’s, I don’t know what the band three is now, but yeah- [Jaz]Hashtag inflation. [Karl]I go in, well, yeah. But then going, well, I could do it privately for you for 400 pounds. Well, why would I do it privately? I don’t know, it might be a slightly nicer crown. But the reality was I wasn’t nearly likely to be doing an awful lot more than I wouldn’t. And I just, I felt really conflicted by it. [Jaz]I hated that so much, Karl. And same with the root canal. Now, I don’t know how our colleagues do this and some are great at doing it about, oh, you can have the NHS root canal now you can have the private root canal in the private, I get to use. This fancy equipment, the electric equipment. Wow. I mean, that is a shaky territory. And I didn’t want to go in that. I’d never ever have done a private root canal whilst in mixed practice I just couldn’t do it. Because for me it was like, well, you either do the root canal or you don’t. So anyway, that’s why me And you didn’t make great NHS dentists, [Karl]Yeah. And I don’t know. And you know what? I enjoyed my time working as an NHS Dentist. And I enjoy my time working as a private dentist and I’ve had highs and lows in both. But now I would really struggle if I had to go back into a fully NHS or a nearly fully NHS environment. I honestly would, I don’t think I could do it. I couldn’t do the job justice, and I have a great deal of admiration for anybody who can’t. [Jaz]Hundred percent. [Karl]It’s a hard job. [Jaz]You guys, the dentist that and you know what I should give myself stuff on the risk because James, I’m not going to say a certain, I’m not embarrass you, but James, had a nice beer with you one day and you told me off in a nice way for calling out NHS dentist and calling him NHS dentist. And you’re not, you know, just a dentist who chooses to work under a contract. So, give myself something. There’s no such thing as an NHS dentist, such as a dentist who chooses to work under that contract. And you’re right. And for those dentists who choose to work an NHS contract, are doing an amazing service, keep it up in a good way. But if you feel as though you need to change course, then you should. And maybe this episode will inspire you. Maybe Karl and my experiences is going to hopefully help you along the journey. We’re always easy to reach on the Protrusive Dental community. Check us out on Facebook. But I want to take this direction of the podcast. I just want to do a little bit of celebration of your book, Karl. So please, tell us about your book and then I’m going to pick apart because a few of my favorite chapters, a few of my favorite sentences. I want to just get you to speak a little bit more about that. So just tell us about, your book because at the time me and you connected, I was also writing a book. I’m happy to share the name of my unwritten book. It’s called, The Bit Between Your Teeth. I was really proud of it. Tell us about your book, Karl, because you’ve done far more than I ever could. It’s really good. [Karl]Yeah, I mean the points of the book, I’ll say, just to segue in from the last point, I’ve not differentiated you between NHS and private within the book, you know, dentist. And my career, as I said, has been up and down as a dentist. I’ve been qualified like 11 years now, and I’ve had times where I’ve had that feeling, that dread all weekend about knowing that I’ve got to go back into work on Monday morning and get flew another week of work. And you know, I’m not relating that to any NHS or private. This is just, I had this dread that thought. I’ve not always loved being a dentist. I’ve not always loved being in dentistry. I do now. I love the fact that we get to help people every day. I love the fact that, you know, we’ve got to have this knowledge, this skill, this passion, this intense attention to detail, the perfectionism, the challenge that every different case brings, and the fact that we can make a big difference to people’s lives. I love it. I really do. But it’s not always been that way. A few years ago I started listening to these personal development books on audible reading and a lot of stuff. All these great people, Stephen Goldin, Daniel Pink, Austin Kleon I’m looking up at my bookshelf now. [Jaz]Simon Sinek. There’s a lot of Simon Sinek I can sense in your book. Yeah, absolutely. [Karl]It is. And all of these things say, wow, this is amazing stuff. This is really powerful stuff. But so much of it isn’t really relevant to me. I’m doing all this reading and I’ve read the dental books as well and all these, and I said, you know what, wouldn’t it be great if I could take everything I’ve learned my journey from disliking, hating, not wanting to be a dentist, the fear of going to go through another week, the fear of patients complaining about me getting sued, the GDC, all of that fear and anxiety about being a dentist. What if I can show people how I’ve built myself a career that I love and you know the thought once upon a time think, oh God, I’ve got to do this for another 40 years. To now going, great. I get to do this for like another 30 years or longer if I want to. How have we gone from A to B? And if we can bring in all of this stuff from all these personal development books. I mean, my audible, I had a look before to just check. I want like two and a half months of listening time on Audible now, and I’m like, well that’s bonkers. [Jaz]What speed do you listen at Karl? [Karl]One and a half to two times, depending on the speed the innovator talks. [Jaz]Yeah. Okay. That has a strong bearing on it. You’re right. [Karl]But yeah. What if we could get all of that into like one book that’s relevant to dentistry and that can make a difference to some dentist lives and, you know, help other people love what they do. I mean, there’s that fear of everything that doom scrolling that we do through Facebook, reading everybody else’s horror stories and the, and how unreasonable these patients have been to them and all of how reason reasonable the principles been to them or the nurses. All of this stuff, all of these problems that we encounter. You know, what if we could find some way of helping people overcome these issues and grow stronger together and really build this career, this passion, for helping people with dentistry, for doing what we love, because I’m not the only person who loves what loves what I do. I know you do. It’s obvious the moment you speak to you or listen to one of your podcasts. And there are thousands of other dentists who love what they do as well, but there are many, many other dentists, possibly many more dentists that don’t. And you know, this is not like a switch. It’s not like you’ve either born to love dentistry or not. You know, this is a journey you can go on and you can build this amazing career for yourself. And what I wanted to do was take everything that. I’ve learned in my career so far and used that to maybe help other dentists get to the same place, that same feeling that I’ve got of going, great. I’m back in work tomorrow. I can, I’m going to do this and this and this, or, you know, I’ve got a new assessment. Awesome. What’s this patient going to be like? You know, it’s a great feeling to have, but it’s not something that a lot of people do have. [Jaz]It’s so true. And I think that’s the number one thing going forward for the mental of dentists with something we’re going to touch on as well. and I’ve always said, I’ve always been the vocal about being about okay, not rather being, but sometimes to know which direction to head in. You have to understand which direction not to head in. And the kind of direction we as dentists should not be heading in is the kind of dentist. Now as you’re like curing, you’re looking at the clock. Not because you’re counting down how many seconds you are waiting for the like you to finish, but you are actually genuinely waiting for the day to end. Everything that we should do should help us to deviate away from that, I think. And definitely your book is, does that, and I’ve just chosen a few things now. You talk about finding your passion, and that is such a big part of it, and I just wanted to say that, or read out, or just some segments of it. It’s just to put it in your context so you can explain more about what is the ideal work ferry dentist? So, you, you talk about how the work can sometimes be on one end of the spectrum can be done in laborious and on the other end it can be overwhelming and exhausting. So, I’m just reading for certain parts of your book. And I love this term that you’ve used, which I’ve never seen related to dentistry before, and use this term emotionally expensive. And that is something that I really loved and I reconnected to. So just explain a little bit more a about that in relation to finding your passion in dentistry. [Karl]Yeah. I mean, dentistry is exhausting. I remember that feeling that I still get tired at the end of the day today, you know, don’t get me wrong, but that feeling earlier in my career when I wasn’t quite so used to talking people and engaging with people at such an intensity and forming new relationship, it takes a lot of energy in your mind to really focus in on exactly, you know, what each patient needs, what each patient wants, and you have to make all these decisions through the day, these diagnoses and everything about every step of the treatment that you’re providing. If you are early in your career, you’re not used to doing that. Your brain hasn’t strengthened its muscles. Cause our brain’s a muscle in a lot of ways. Like anything else, you know, if you want to get stronger, physically stronger, you go to the gym and you push yourself to your limits. You stress your muscles, and you stress your muscles and they recover and they come back a little bit stronger. And our brain’s the same. You know, you go to work every day and you stress your brain. You push your brain, you push yourself just out of your comfort zone, and you engage with a few more patients and you on a deeper level. And that’s emotionally challenging at the start of your career when you’re not used to doing that. You can’t go from zero to perfect straight away. You have to build it up over time. The key with finding your way is when you are getting exhausted and when you’ve been, you know, on the NHS I’ve maybe seen 30 patients. As in getting towards the end of the day, it’s having that resilience to get back up and go again and say, you know what? This next patient is now the most important person. It’s challenging yourself to push yourself up to that next level again, to go again and to connect with that next person. [Jaz]How did you find your passion, you think? So just taking bits and book like everyone’s got their own journey. So how did you figure out that the implants, the cosmetic dentistry, the rehabs, that was your calling. And what do you say then? And then we’ll move on to the fact that the happiness doesn’t necessarily come from just doing the kind of work that you do. Because the next bit I really loved was, I’m just going to read the bit I absolutely love, was that, ‘If you enjoy doing checkups and routine dentistry, the levels of challenge that brings the stability, the income, and the freedom of not needing to constantly attend the next course, then embrace it and run with it.’ Man, I love that so much. I think a lot of people need to hear that. A lot of people who see Instagram dentistry and everyone’s posting all these full mouth rehabs and people are swimming in Invisalign liners and stuff like that and setting up all these boxes of Invisalign. But really you are just happy to provide a good level of care, which in some people’s eyes might be basic, but yeah, you love that and you don’t feel the pressure of having to go on these complex courses all the time, then there is a place for you in this universe. It’s the message I got from that. And I think so many people would love to hear that. [Karl]You know what, it’s not just a place, it’s not just a place for you in this, it’s actually, that’s the bulk of what we need in dentistry. That’s that. You know, we don’t need 40,000 implant specialists. You know, you can’t, we’re not specialists, but you don’t need 40,000 people who can place dental implants. You don’t need 40,000 people who can do Invisalign. What you need is, you know, maybe 30,000 people, 30,000 dentists out of the 40,000 dentists in the UK who are really good at being general dentists, who are really good at looking after their patients and caring for them and keeping them well maintained, preventing general dental disease, and that’s the most important part of dentistry. [Jaz]And I think that needs to be said. So I’m so glad we said that. And then on the opposite side, if you don’t enjoy the routine stuff, there are many different pathways. Or if you don’t enjoy dentistry at all, you go into that as well, in your book. Cause there’s only so many other pathways with dentistry you can take from specialism to hospital community, research. But it’s about realizing that your happiness doesn’t come from whether you are in NHS, or you are in private or how you’re remunerated. There’s far more to it. So what I want to ask you is, Karl, when you were going through this journey in yourself, how did you realize that okay, just doing the general routine dentistry didn’t quite cut the mustard for you and you wanted to put yourself in these extra courses, uncomfortable scenarios, complications, because with doing a high level work comes high level complications, more sleepless nights, that needs to be said. So how did you decide that, okay, this is the pathway for me and I want to abuse myself in this way before I can become good at something and provide this level of niche service? [Karl]Yeah, I mean, just to pick up on something you said there. Every level of dentistry has complications. Okay. And what you’ve got to be able to do as a dentist, is be able to deal with the complications of the things you’re doing. So the fact that okay, implant, yes, I place dental implants, yes, I do sinus lift, and are all of this stuff that comes with that I, before you are ready to undertake that treatment, you’ve got to be confident that you’ve got a pretty good grasp of how to deal with the complications of doing that treatment. That’s one of the biggest hurdles to overcome when you’re pushing yourself to develop, do it, put in an implant in screwing an implant in dead easy. No problem at all. It’s chimps work. It’s the old jokes about theological the surgeons in the hospital, they just screw bones back together or whatever. You know, the chimps, you don’t need any kind of special skills really to screw in it, and put a screw in a jaw but it’s dealing with the complications, interpreting the situation, doing all the planning and all of that stuff that comes with it. And no matter what level of dentistry you are at, if we can categorize it into levels, even for the general dentist, you’re going to have complications. You’re going to have complications without MOD restoration that you’ve just done is going to break at some point, and you’re going to have to deal with that. Or you’re going to go to do an MOD restoration and you’re going to have to find that you’re going to find that those costs are really, really narrow, really thin, and they’re going to rake off if you leave them. You know, when you have to out. You have to make that decision direct and indirect. And so dealing with complications is something that you have to do at every point in your journey in dentistry. Coming back to your point about how did my journey lead me to where I am now? I never got to a point where I said, oh, actually, you know, being a general dentist doing the routine dental checks and all of this isn’t enough for me. What happened was I went to university and like most people, most students, most 18 year olds go into university to get dentistry. The biggest exposure to dentistry they’ve had is orthodontics. So I went to university. Oh great, I’ll be an orthodontist. Then I got into university, right? Let’s go and explore orthodontics, go and invest myself as much as I can in orthodontics. And I got there. I was going through it, I think. This is really boring. Don’t like this. It’s my opinion. That’s just my perception of it. [Jaz]If you don’t like dentistry, be an orthotist. We all know that. [Karl]Yeah. No, no, no. Well, I wouldn’t have looked at orthodontics and I didn’t enjoy the orthodontics, so I was like, okay, well what else is there? And I was going and I was going to be, actually, I’m not bad at taking teeth out, you know, obviously now 21, 22 year old thinks he knows everything because he’s been on to take out an upper six. But you know, I said, right, okay. Surgery’s possibly where it’s at. And then these things called dental implants, 2009, 2010, were really starting to take off. Think, right. Well, okay, how can I find out more about dental implants? And I was looking around at where I was going to go for my foundation year in dentistry. And there was this practice on the will called Glen Keir, and I was like, actually, they place implants there. They do a lot of implants. So the guys now my mentor, my foundation trainer was David Speechley, a guy called David Speechley And there were two foundation trainers in the practice who was Simon Wright. Both of these two are now professors and it’s just, you know, so I saw this practice like, oh, you know what they do implants. I had some colleagues in all the years that I knew from dental school had been there and said, oh yeah, it’s a good practice to be out, get good exposures to all this stuff. It’s like, you know what, that’s where I want to be. So I did everything I could to get myself into that practice. And when I was there, I did everything I could to shadow Simon and David placing dental implants. I thought, you know what, I quite like this idea of dental implants fill in these spaces, not having these fluffy dentures all over the place. So I immersed myself in the subject as much as I could. And then come the end of my foundation year, I was thinking, yeah, I still really like this idea of dental implants. I’d love to be able to do this. So I got myself on a course and I went and did Professor Buser’s course in dental implants in Manchester, and I did the year course and got myself some patience and Simon and David mentored me and as it went along, I was just really enjoyed doing the implants and I was still doing everything else alongside it. Still enjoyed doing the other bits, but the implants, I was like, you know what? I really, really like this. And so, I immersed myself in it a bit deeper. I went round and shadowed some more people. I went on more courses than I did a Master’s in it, and it just built quite organically. It wasn’t ever the case of, oh, I hate that. General dentistry stuff. So, I’m getting out of that. I want to do everything I can to the implants. I still do dental health checks. I still look after a list of implant patients. And I love that. I love seeing the same faces come back every six months. The relationship I’ve got with them, checking in with the kids as the kids are now getting older and all of the beautiful things of general dentist, all of those long-term patients that you see over and over again. I still love doing that, but I also really love the implants as well. And just so happens at the moment that more people need implants than, or more people need me to do implants and rehabs and things like this for them, than general dentistry. And so the balance is tilting that way. So it wasn’t ever a point of going, oh no, I’ve got to get out of that situation. It was just, I really love this situation. Let’s find out more about it. Let’s do as much to do with that as I can. And over time it’s just built and built and built. [Jaz]But you also did this thing whereby you thought it was orthodontics, so you are proactive. You did, you expose yourself to orthodontics and you didn’t get the same love back. You made a decision. Actually, this might not be for me. So it’s not to say that, you know, if you are a young dentist and you’re thinking, oh, let me try implants, and then you go to shadow someone and you might not like, enjoy it at all, and that’s okay. Now shadow someone else who maybe does oral surgery or someone who does endo and you can visualize yourself being in that position. So it’s about getting that exposure, getting that mentorship, getting some courses under your belt that are low level, and then eventually you build it up to something like a masters that you’ve done. That’s a good way to progress. And I guess it’s not about moving away from general dentistry, it’s more about finding a niche and an enjoyment of a slightly more specialized area where you can excel in. I guess that’s a good way to describe it. [Karl]And that’s the biggest thing for anybody coming out of university now if they’re wanting to, I listen to your podcast the other day with Pav about finding your niche in dentistry. I know it’s like an old one now, but it seems it was a while ago, but it’s that finding what you love and what you really enjoy and what you’re good at. And if it is, say you wanted to be a general dentists, go and shadow some people being general dentists. Go and find some dentists who are working in nice practices who you maybe look up to and you go and see how they work, see how they operate in whatever it is. You know, go and find out more about it. Read about it, read papers, read books. Go and shadow people. Ask people about it. You know, speak to people about it. Immerse yourself in that subject. And if the passion sticks, if you do it for a while and it’s still going strong, great. Do it some more. [Jaz]That is so true, and I think it’s a point well made that we always think about shadowing people with an enhanced skill or shadowing someone who’s an oral surgeon or an orthodontist or let me go shadow this person doing a sinus lift. But actually, I remember vividly my experience of shadowing Rajiv Ruwala as a GDP when I was in my DF one. And I’m thinking, I was thinking, wow, man, this is a GDP who just did some beautiful crowns on the anterior. Now I’ve just seen someone for cobalt chrome. Now I’ve just seen child. Everyone’s left smiling the variety’s great. So that was actually a big part of my journey. So I think I just want to emphasize that if you know, give GDP a shot as well, give general dentistry a good shot. Don’t just think that, okay, you want to be different. You want to be in that 7% of special services. 93% of density is general density. So embrace it. And you could still find your niche within general dentistry like you have Karl. But it’s still beauty of being a general dentist now. Dentistry is part of our lives. And, I like the bit in your book about taking control of your life and taking control of your destiny. So I want to ask you, I mean, I have some thoughts on this about, in terms of how I’ve done it, but can you give us examples of you, Karl, in terms of how have you thoughtfully and proactively planned your life and force your destiny in a way that has gone? [Karl]So, I really don’t like goals. Okay. I hate goals. Goals are for sport, goals are for these finite games. Football, basketball, whatever you want to play. It’s where you’ve got a tangible goal. You’ve got to score a goal. You’ve got to get a certain number of wickets and cricket, whatever it is. You have a set goal, there’s a set finish line. And that goal gets you over the finish line to get your achievement. And life dentistry is not like that. There is no finish line in this. Okay. Yeah. You might say when you die or you retire, is your finish line, but you’re not going to, there’s no end point. You don’t, nobody writes their net worth on their gravestone, you know, for instance, so you, oh, I want to earn this much money. I want to do this, or I want to have this sort of practice, you know, having a set goal. I just don’t get it. I’ve tried setting goals and I just don’t get it. And it’s, yeah, great business and all these corporate people who want you to do goes fine. Great. Okay, go for that. But, you know, when I was starting out an implant then, right? This goal, I’m going to set myself a goal at placing 50 implants a year. Great. Let’s do 50 implants here. Well, what does that mean? It is absolutely nothing because I could go around and place 50 implants into a piece of wood. Does that count? If I could, if I go to the Dominican Republic and place 50 implants into these jaws that are the size of tree trunks, does that count? If I’m in the UK and I’m placing implants, am I doing things just so I can get my 50 implants? Am I sort of maybe providing treatment unethically just so I can get my implant count up to place 50 implants? What happens if I’m doing really well one year and everybody wants implants and I’ve placed 50 implants? Wait. Yeah. And so I can slack off for the rest of the year now because I’ve done my 50. Great. Well, I’ll chill out and then in January I’ll start. Okay. And this whole sort of defined goal thing doesn’t make any sense to me. That is not to say you can go through like without direction. If you have to have some sort of vision, some sort of direction that you want, take it. Otherwise, you are just standing still. You know, the one certainty in life is change. Change is constant. Which means if you are not improving yourself at all time, if you are standing still, you’re not standing still, you are getting worse because everything else is getting better around you. So you have to constantly refresh yourself. You have to constantly improve your knowledge just to stay afloat in some senses. But, so you have to keep an eye on your direction and where you’re going and for me, let’s go back to the implant example. That was about not necessarily placing 50 implants a year, but to go, okay, well, I’m going to place an implant, I’m going to plan it meticulous. Write down to what incision I’m going to make. You know what local anesthetic, which sites I’m putting my local anesthetic in where and every tiny little detail. I’m going to take photos throughout that whole case and I’m going to reflect on that case as well. And every reflect on every little detail. And when that case doesn’t turn out 100% perfect because, hey, listen, in 11 years of dentistry, I’ve never done anything perfectly. There’s always something I could have done a little bit better in every case. When it doesn’t turn out perfect, I’m going to look back through those pictures. I’m going to look back through my notes. So I’m going to say, right, how could I have done that better? And if I’m just driven for going, oh, well, 50 implants, and once I’m placing 50 implants a year, I’ll be a success, then you’re not going to learn anything at all in that process. It’s the process of how you get there and reflecting on that process and improving that process that will ultimately lead to you becoming a better dentist. You know, the goal doesn’t matter. The outcome doesn’t matter. You know, goals, when covid hit, you know, everybody’s goals went out the window because goals don’t account for global pandemics. But if you focus on the process and your development and improving yourself day upon day, then the outcome, the goals that you would’ve set anywhere, you’ll smash them out the park because day upon day you are building yourself stronger. [Jaz]It’s the journey rather than destination. [Karl]Yeah. I mean it’s, there’s 1,000,001 cliches that we can throw around of that sort of nature. But it is, it’s about taking the steps day in, day out to build yourself stronger rather than just focusing on that destination, that endpoint, because the destinations will sort itself out. If you’ve started taking the steps in the right direction, you know, lean your ladder against the right wall before you start climbing it. Whatever you want. However you want to phrase it. It’s about giving yourself the direction and implementing the process. So for me, that’s not how many implants do I want to place next year, but it’s if I continue to do what I’m doing now, well, what’s my life going to look like in five years? What’s my life going to look like in 10 years? Not in five years. I want to own my own practice and in five years I want to be placed in a hundred implants, or I want a do of doing 50 full large cases. No, no, no. It’s if I keep doing what I do in now, what’s my life going to look like? And if I don’t like what I see, and we go, okay, well what can I do to make that life in five years look a little bit better? What can I do today that’s going to sow the seeds in the future? And the thing to get your head around here is there’s no immediate payoff. You don’t get this immediate gratification. We love within this world of instant gratification. You know, you put a post on social media and you go, oh great, I’ve got 10 likes, 20 likes, 30 likes. It’s only been an hour. Oh, I’ve put a blog post out. Yeah. Like 200 people have led this blog. That’s amazing. I’ve got this podcast. And you know, we celebrate the fact that, oh, he got thousands of people. Listen, great. But it’s, what do you do each and every time to make it that little bit better, to add that little bit more value to the people who are reading, to the people who are listening to you, to your patients that you are caring for, and you build those foundations and the rest takes care of itself. [Jaz]I love everything you said, and I just want to highlight the four questions that you’ve written your book, a line to exactly this theme. And obviously you’ve covered two those already. So, what Karl talks about in the book is how we can take control of our destiny. And four questions to ask yourself is, if I keep doing what I’m doing, what will my life look like in 5, 10, 20 years? Number two is how do I want my life to look in a year’s time? Number three is what do I currently do that I hate? That’s a really strong one. And lastly, what do I love doing and want to do more of? So, I mean to an example of how I have used those questions. Not recently, because I’ve very recently read the book, but going back, maybe 15, 18 months ago in my life, I’m just thinking. I’m in a scenario now where I decided that question number three, what do I currently do that I hate? I got to a situation Karl, where I just didn’t enjoy my commutes anymore. Yes, I was listening to audiobooks and podcast stuff, but the commute was long and I didn’t enjoy the lack of time with my son because I’d leave super early to go to Oxford and then come back and by then my son might be asleep. So I was really struggling with an internal battle about not having a time with my son. So now I have a three minute drive, but now I started walking, so it’s like a 15 minute walk. And I’ve adopted a shift pattern work, so I found somewhere that does shift pattern. So I work from eight till two or two till eight. The net result of that is I get so much more time with my son, I get to do the podcasting, and I get to still work environment that allows me to grow. So that was one example of me deciding, okay, this is where I’m at, but I want to take, I want to steer my ship in a certain direction. So I would encourage everyone to get Karl’s book, read that bit and really just answer it yourself, reflect on that bit, and come up with how you are going to take charge of your own destiny rather than allowing life just happening to you. [Karl]Yeah. I mean, what you’ve also done there, which is that another, in the essence are a lot of what the book’s about is coming back to why are you doing what you do? Why are you driving 45 minutes an hour to work every day and then doing the same coming home? And what would you rather be doing? You want to be with your son, you want to be with your family. Of course you do that. I mean, I’m a family guy. That’s, you know, you don’t have to need to start singing that. Thank you, but I I’ve always known, even before I had kids, that family was the most important thing to me. And I want to do everything I can so I can be the best dad, the best husband, the best family member that I can be. And that involves making sure I spend enough time with my family. That means making sure that I do enough work to provide a stable lifestyle for my family as well. And you know, it’s about figuring out why you are doing each thing that you’re doing. And you go, okay, well why do I travel so far to work if I don’t need to do that. What would I rather be doing? I’d rather be with my son. Right? What steps can I take to get myself in a position where I don’t have to travel? I could move closer to work or they could be work closer to me and you’ve built yourself this career, your skills, your persona. You know, you are well known in dentistry. Everybody knows Jaz now. But you built yourself, you’ve built your own personal brand opp to such an extent there. You know, right now you could probably walk into a job near enough anywhere in the country if you wanted it. [Jaz]I doubt that very much, but I see what you mean. I appreciate that. [Karl]But, building your own skillset up and developing yourself personally and professionally gives you that freedom to go, you know what, actually I don’t want to travel so far to work anymore. Maybe a job closer to home. And I’ve laid the foundations to actually give myself the freedom to choose where I want to go. And that does make all the difference. [Jaz]I’m going to ask two more main questions before we take any direction we want. And Karl, the next question is, I love that you mentioned the book atomic Habits. It’s also I think you probably told me about it some months ago. Really great book. I’ve been actually thinking about and we should probably do this, Karl, about how we can apply atomic habits in dentistry, and that is with how we motivate our patients to, how we motivate our staff members to how we can grow as clinicians every day. I think we should do it, Karl. Let’s arrange- [Karl]Yeah, there’s definitely something there. [Jaz]Atomic habits in dentistry. I think we can do such a great job of that. But I want to just ask you as a little flavor for what’s come, can you gimme an example of how you’ve implemented the power of atomic habits, either in your personal life or at work, because I know you’ve discussed it in the book. [Karl]Yeah. I mean, atomic habits is one of the best books, the personal development books I’ve read. I mean, I’ve made about it before. The whole ethos, the whole thing around Atomic Habits is, making small incremental changes day on day. And those changes, if you can improve by 1% every day, that 1% compounds. And over the course of the year, you get a 3700% increase in your effectiveness, whatever that might be. And the point of atomic habits is building those foundations. So one of the example that I use in the book is I was, I’d moved over to private practice and I’d been there for a year or two, and I thought, you know what, what I really need to do to take my dentistry to the next level is start using rubber dam for pretty much everything, everything possible. And so one day I just decided, right, you know what? I’m going to implement this today, I’m going to start using rubber dam for every composite restoration. I was already doing it for root canal treatment. I was doing every inlay preparation if an inlay fit, you know, whatever was, I was going to use rubber dam for pretty much everything. I could possibly have an excuse for using rubber dam for and you know, dental health check. Yeah. Should we use rubber dam for this ? But it was a case of, so mate, I could, that’s it. Flip switch. Okay, that’s what I’m going to do. You know, and yeah, it took me a while to get that rubber dam on at first because I wasn’t used to doing it as often. And it took a while because the nurse had to get it all up. But when you engage your team, you say to your nurse, look, I think we’re going to do a better job for our patients if we use rubber dam because it’s going to stop all that amalgam stain all over their mouth. It’s going to stop all their saliva washing around this filling while we’re trying to seal it up. If we can do this, I think we’re going to do a much, much better job for the patient. [Jaz]And that’s also how you sell it to your patient as well. [Karl]Yeah, exactly. It is. And you engage your team with why you’re doing it. And you say this is what’s happening for now. We’re going to do this. And so my nurse know now every single time, every single patient, she’s got the rubber dam on ready for me because she knows if that rubber dam’s not on the side, I’m going to ask for it. And she’s then going to have to go and get it. Okay. Because she’s already got the rubber dam out. It’s dead easy for me to then go, oh great. I’ve got the rubber dam that I’m going to use it. Everybody knows we’re on board. Okay, we’re going to implement this habit, we’re going to use rubber dam for everything. And in fact, it’s more than just easy for me to use the rubber dam. I feel bad if I don’t use the rubber dam because my nurse has got to the trouble of getting the thing out. So I know if I don’t use that rubber dam now I’m going to get the look. And I’m going to get daggers because I’ve made her get it out for every patient and I’ve not used it, so it’s easier for me to use it and implement that habit. [Jaz]It’s a way of doing it accountability. And I’m the same. I use rubber dam for pretty much everything that I can. And the other example I can give to those listening and watching, in terms of an anatomic habit that you can create is those who are on the journey into dental photography and you’ve bought the stuff, but you’re just not in the habit of taking photos. Well, don’t be that dentist who, when you’re ready to take a photo, you need to be like, okay, let’s get the mirror. Let’s heat the mirror now. Can you get the retractors out? You know, just has to walk out. Now you need to get your lens and attach it to your body, and then put the flash on. And then you’re thinking, oh crap, I forgot the settings. Don’t be that dentist. Have the settings ready on, in laminated or set on the camera ready. Have everything attached already. Have the mirror on the heater, already. Have the retractors there, and have this pre-chat with your nurse first saying, Hey, you know what? I’m really serious about taking photos, and I want to do this as much as possible. And then let’s start by doing an incremental change by every new patient will get photos and then build up from there. And then every composite will get photos. And then you’ll build and build and build. So that’s another implementation of atomic habit. So I’m so glad you mentioned that in the book. And then now I want to move on to, because I want to do a whole episode with you about incremental changes we can make atomic habits apply to dentistry. I’m so excited for that. [Karl]We’ll come back to that one. [Jaz]I took, yeah, we’ll come back to that one. And I want to talk about a really, I’ve saved the best for us because something that, I’m really, really keen for you to explore further is the support of charity from this book and in particular, a very, very, I mean, they’re all charities are important, but this is such a key charity. I met Jeremy Cooper at the BACD and I said to him, look, I want to do what I can, what Protrusive, to raise a bar and let everyone know that ConfiDental exists. So please tell us about why you chose ConfiDental and then, tell us about, you and your wife and how, you know, you are taking a direction in terms of helping people with helping dentists with their mental health. [Karl]Yeah, my mental health generally, okay, so I’ve never been formally diagnosed with anything, okay. But I have these periods of highs and lows, so almost like a very mild form of like manic depression. It sounds really dramatic, which Oh God, manic depression. Oh. But that’s sort of how it goes. And it ebbs and flows. And sometimes I can take a long time for a while and then I’ll have like a manic phase and then a low phase. A GP friend of mine sort of said it sounds a bit like what we call cyclothymia, which is like a mild manic depression. And I started reading up about it. I was like, eh, it kind of does sound a bit like me, really. It’s almost like it’s cyclical up and down. Call it my mom, period. Sometimes it’s, you know, sort of hits me like a hormonal imbalance every couple of months. And I just dip and I probably just offended 50% of your listeners. But, yeah, so mental health has always been something that I’ve had on my radar and my Yorkshire last. My wife, she’s a psychotherapist and so she’s a counselor, so she’s dealing with- [Jaz]I had this burning raise to know this right now, because I have a patient who’s a psychotherapist and I have a patient who’s a psychiatrist. I know psychiatry needs medicine first. And basically they just give you drugs. What is a psychotherapist like? How does that differ? [Karl]Alright. There’s lots of different types of psychotherapists, but yeah. Psychiatry is a doctor, a medical doctor, you know, one of the proper doctors, not as fake doctors. A proper doctor who has then gone and done psychology, additional psychological training to become a psychiatrist. Okay. A psychotherapist or a counselor is, so in my wife’s case, she did a degree in psychology and then she did a postgraduate master’s level diploma in counseling and psychotherapy. Now there’s a whole scale of different qualifications you can get as a psychotherapist from doing a weekend course or going right the way to doing a master’s degree and beyond. Yeah. So that was my wife’s path. She did psychology and then she went on and did counseling, psychotherapy. And again, as there are different schools of thought with occlusion, there are different schools of thought within psychotherapy. So you have, Freudian Type psychotherapy. You have, legend Carl Rogers, which is person-centered psychotherapy, which is sort of what my life’s original training was in the fundamental principle being, you know, nobody’s born evil, everybody’s born equal. You don’t blame the person, the perpetrator of whatever it is. Or you don’t blame the person for having said feelings or phone things that, you know, it’s a consequence of the things that have happened to them and all of this which is one school of thought appropriate for helping some people. There’s things like transactional analysis and all these different areas of psychotherapy. But yeah, Melissa’s training sort of originated in person-centered psychotherapy. But this sort of combination of me having these ups and downs and actually being quite open and free to talk about it because it’s something my wife and I talk about all the time we deal with all the time because of her line of work and in the middle of last year when Covid had hit and everybody was going, oh, it’s okay to not be okay. And all of this was bouncing around the social sphere and everybody said, oh, it’s okay to not be okay. And then you go, well, everybody’s saying this, but no one’s actually saying they’re not okay. I was getting a bit, I was getting a bity. It was like, you know, everybody’s saying it’s okay to not be okay. And maybe somebody reading that hashtag somewhere goes, okay, well actually I’m going to talk to my friend about this now. And that’s great. You know, you don’t have to do what I did, which is when you enter a particularly low dip, you write about it, you take a stupid photograph of yourself, and then you post a blog about it on Facebook, which is what I did. And showing everything, look, this is what it looks like when I’m feeling down. Okay. And you cry and you’re upset, and you’re down and you’re hurt, and a lot of the time, for me it’s often a feeling of complete apathy, a complete sort of devoid of any emotions. And, you know, I’m going to put this out there because what people often in that situation do, is go, Hey, I’m great guys. Come on, let’s go. And you beat yourself up and you get yourself back out there and you put this brave face on, and then you go home and cry yourself to sleep. And you go, right, well, this isn’t good. This isn’t right. This isn’t healthy. And what I realized was actually this cycle that I was in, I’m able to do something about it. And I’m not saying everybody can, you know, there’s a whole myriad of mental health conditions that, you know, we’ve got to be aware of. But I realized there was this pattern to it. And, it almost for me was a case of a tick along. Okay. And I’d get quite busy and then I’d go, go, go, go, go. And I’d basically burn myself out and have a mini burnout. Everything had shut down. I’d find it really hard to get outta bed. I’d find it really hard to get myself motivated to do anything. And then after a few days, my body would go right. We’ve hit reset. Now go again, but don’t do that again, Karl. That was very naughty, and I realized, I sort of through my reflection, my personal reflection log, my journaling and things like this, I did, I sort of started to see this pattern and this, these conversations with my wife that I was having, I was thinking, you know what? I can do something about this. So now when I’m getting to those points of seeing myself enter this little mania phase, right, stop, slow yourself down. And most of the time I can stop myself getting into that. [Jaz]Well done. [Karl]Now, well, yeah. But- [Jaz]I mean, I just want to just pause and say like, thank you for sharing this and putting yourself in a very vulnerable position. And I’m sure everyone who’s listening on their commutes have just taken a moment and maybe just gone, whoa. Like to what you said, and I really respect that you’re sharing this with everyone because I think it needs to be heard. And thank you for telling us about your very real experiences and then from there stems this desire to help other dentists, as you’re going to say in terms of through ConfiDental. I mean, is that a service that you used before or is that? [Karl]So yeah, so let’s get back to the point, Karl. The point is, yeah. You know, not if I don’t say this, who’s going to? If somebody what I’d consider a relatively mild form of all of this going on, who talks about mental health things all the time at home with his wife and is married to a psychotherapist, somebody who can help people like this and who regularly helps people like this. If I can’t talk about it, who’s going to, and maybe if I can talk about, then somebody else will have the strength and the confidence to come out and say, you know what, actually I’ve been struggling a bit and you know, you’re not going to shout this from Facebook or whatever the you want to do, you might go and talk to your wife, you might go and talk to your mom, your dad, your cousin, your friend, whoever it might be. That talking helps. And for some people who don’t feel that they can talk to anyone or they’ve tried talking to people, because you know, I’m so, so lucky that I’m married to Marisa because Marisa knows exactly how to respond when somebody’s struggling. And when I say to Lisa, oh look, I’m really struggling ’em, she goes, okay, tell me more. No judgment, no advice, no nothing. She just listens. And I mean, that’s invaluable. And what ConfiDental have set up this charity, they’ve set up this helpline. So you just phone it and you can just talk to someone and they listen and they’re there for- [Jaz]They don’t take any names, any GC numbers, or this is just there at the end the phone to speak to someone. They don’t even know your want to know your name or unless you want to relieve it, reel it or whatever. They’re just there to help you in a difficult situation. [Karl]I mean, exactly it. And they’re just there to support and they’re dentists who are volunteered and they’re just there to support you through whatever it is. And you know, I was speaking with John Lewis, one of the founders of ConfiDental and you saying, you know, a lot of the time people are calling up about issues with patients, about concerns over the GDC about and those are our people calling about just the overwhelming sensation of an inability to cope with life. And that gets people as well. Some people suffer with depression. Some people suffer with anxiety. Some people it’s imposter syndrome. There are all of these things. Some people it’s PTSD, you know? Traumatic experiences. And that can be a car crash, that can be witnessing a cardiac arrest in practice. You know, it can have a profound effect on you. It could be somebody suing you and going through legal proceedings, that’s traumatic. And so ConfiDental has been set up to help dentists and dental professionals who need somebody to reach out to, to talk to. They don’t know where to turn. As I say, I’ve been so lucky. I’ve never had to bring ConfiDental myself, but I’m married to a psychotherapist. I know I can say anything to Marisa and she will listen and not judge me. And you know what? That’s what you need. Sometimes you just need someone to go, oh, okay. Yeah. Jaz, that sounds like you’re having a really hard time. Tell me more about it. And that’s what ConfiDental do. And, you know, in terms of signposting them ConfDental, you know, you’re going to put the website in the show notes. I know you’re going to put phone number in the show notes, but of course the phone number, phone number for anybody you, who is thinking, you know what, I need someone to talk to right now. It’s 0 3 3 9 8 7 5 1 5. There it is. [Jaz]That number again is? [Karl]0 3 3 9 8 7 5 1 5 8. But yeah, it’s there. It’s there. And the book that I’ve written is there to inspire some love for dentistry, inspire some passion for dentistry, but I don’t want it to be one of these toxic positivity things that come in. I said, hey, look how fantastic this career is. You know, we should all love it all the time, because that’s not real. So there’s a whole chapter in there dedicated to mental health. And that chapter’s got a lot of stuff about my story in there, about how I experience it. That’s not how anybody else experiences, it’s just how I experience it. And it’s got a lot of stuff in about other mental health conditions, you know, some stuff. You know, small steps we can take, you know, there’s no single cure, we’re not completely powerless to this where there are things we can do to help ourselves. And there’s a lot of stuff in that chapter from my wife, from Marisa as well, you know, because I’m just a guy who gets down sometimes. She deals with this stuff all the time. Yeah. And she’ll kill me for saying this, but she’s the expert on this. She really knows what she’s talking about. And there’s a lot of stuff in the book from her that I think will be immensely useful. Both to anybody who’s struggling with mental health issues or concerns. They have, you know, you might not want em to lay yourself, have a mental health issue. You might just have concerns over your mental health. But it’ll, it’s immensely useful to anybody like that or anybody who’s in contact with anybody who’s struggling, anybody who, maybe your nurse is having a really hard time for one reason or another, and she comes to say, listen, Jaz, I’m really sorry. I just, and then the eyes fill up and I just don’t, I’m really struggling. I don’t know what to do. And on having some level of understanding about what that’s all about and about how you can help somebody, I think’s really powerful. And so there’s a lot of that in the book as well. And as you said, all the proceeds from the book, all the profits and everything is going to go to support ConfiDental. So it’s sort of all going to feed background to yourself. I hope you read the book and you’re less likely to need ConfiDental, but for those people who need it, any or every sale of the book, all the profits are going to go to confidential as well. And that’s- [Jaz]I would love you all listening, watching to show Karl support because he covers things such a beautiful way. And Ivan it is actually a really good writer. I know you don’t like to admit it. And you mentioned a few bits about your GCSE experience and whatnot, but you actually I do enjoy reading your blogs and you actually have got away with words. So it’s great. And you made me laugh a few times as well. Actually, I’ll will put that in there for you. So, thank you. And thank you for making yourself vulnerable, Karl, on this podcast. I really appreciate that from the bottom of my heart. Thank you. And I think it’s going to help a lot of people. I remember recording the episode with Emma Courtney. Hi Emma. Hope you’re well in New Zealand. She’s a fellow Protruserati and, we talked about burnout and her experiences and like some of the messages Karl, I got after that episode, like this, this lady messaged me saying I had to just stop my car, park my car somewhere. And I just had a cry because everything that Emma was saying was just describing her own experiences. And at that point, she realized, hang on a minute, I’m burning out. So if you are someone who’s really been emotionally affected by this episode, and I hope that can only be in a good way in terms of okay, we can identify who can help you, then please do make use of a ConfiDental, and I hope that this episode will be a stepping stone in the right direction for you. And if you could consider buying Carl’s book to read more and reignite your passion, and to anyone who wants to support ConfiDental in a way through buying this book, even if it’s for a young dentist that you know, and you want to inspire them, please do so. Karl, thank you so much for giving your enthusiasm, your stories and your motivational words, and for making yourself vulnerable. I really appreciate it. Thank you. [Karl]No, I mean, it’s okay to talk, but then people need to actually talk to make it okay to talk. And so, hey, there we go. I talked. I talked. So, yeah. I’m hoping the book is going to be out, at the start of 2022. [Jaz]And did you ever name, we keep calling it the book, but we don’t have a name yet. [Karl]Yeah. So the book, I’m pretty sure, I’m pretty sure the book is going to be called In the Loupe. Loupe as in- [Jaz]In the Loupe. Ah, I like it. So I like it. [Karl]Yeah. So I have a sucker for a player of words like you, with the Bit Between your Teeth. But, you know, in staying in the loupe, the secrets to build in yourself are a fulfilling career as a dentist, finding a passion for dentistry. [Jaz]I love it. [Karl]So anybody who wants to find out more, obviously sign up for updates about the book can go onto my Instagram, my Facebook, or on my website, my website, walkerfinch.com, or one word walkerfinch.com. And you can sign up on there, to get updates about the book. [Jaz]And read the blog post as well. They will keep you entertained and you get an idea of the reading style and what’s to come from the book. [Karl]Yeah. So I put a blog out once a week. Sometimes they’re short, sometimes they’re slightly less short, but yeah, no, it’s good to just get out there and hopefully, hopefully inspire a few more people just to think a bit more and reflect on what they’re doing and how they can build their own, you know, passion and each day and build it all a little bit stronger. [Jaz]Atomic Habits, my friend, atomic Habits, we have to do that episode. So I will be in touch. Yes, let’s get a date in the diary to do Atomic Habits as applied to clinical dentistry. We’ll maybe cover some big themes, some small themes. That’s going to be a really fun episode as well. Karl, thank you so much once again. [Karl]Thank you. Jaz’s Outro:Well, there we have it, guys, thank you so much for listening all the way to the end. Look, if you like the themes here and if you want to get a book or you want to get the book to gift it to a dentist that you know, who just needs to hear everything that we discuss and wants to have a paperback book that they can sort of follow along with and do some bedside reading that’s really going to work on their mindset, then check out In the Loupe. I’ll put it in the show notes below. And of course, as always, don’t forget to rate the podcast on Spotify or Apple or wherever you listen to. Thanks again, Karl. We appreciate you coming on. And for everyone else, I’ll catch you same time, same place next week.