Protrusive Dental Podcast

I will reveal a little ‘trick’ that might ‘recapture the bite’ on a patient who develops an anterior open bite (AOB) after wearing a nightguard/splint/occlusal appliance. There is a degree of risk and uncertainty when we prescribe occusal appliances as it hinges on patient compliance and factors that are out of our control. There are certain risks that come with treatment that we should consent for, and this includes bite changes. Occlusal appliances are not an exact science – the evidence base is not high quality. That does not mean they do not work, it just means that we need more data! We don’t even know the mechanism of HOW occlusal splints work as that is yet to be proven. Hello Protruserati! Welcome back to the third episode of #AskJaz where I answered three main questions from our Protrusive Dental Community – 1) developing anterior open bite after an occlusal appliance, 2) how to scan/bite register at a desired OVD, and 3) what should the occlusion look like on composite veneers or edge bonding? https://youtu.be/Li2W-ysYRIE 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 Dr. Mahmoud Ibrahim and I are currently working on a huge project called OBAB, Occlusion Basics, and Beyond – it will be the best occlusion resource in the Milky Way…and that’s our mission! We want to finally demystify Occlusion and make it Tangible AF! Join the waiting list HERE! Highlights of this episode: 1:51 Risk of having AOB after an Occlusal Appliance 15:48 Trick to recover an AOB that has developed 26:49 Bite Records for Stabilisation Splints 30:25 Checking the Occlusion after Composite Veneers 37:02 Occlusion Basics and Beyond Do join our Protrusive Dental Community Facebook Group. It has so many great gems and pearls shared in our little community – ONLY FOR LICENSED DENTAL PROFESSIONALS. If you enjoyed this episode, check out this episode with Dr. Barry Glassman – Do AMPSAs cause AOBs? Click below for full episode transcript: Jaz's Introduction: Occlusal appliances can be scary things. When we are given to our patients, we're at the mercy of their compliance. We don't really know if they're going to get along with it or not. [Jaz]We don’t really know if it’ll help their pain. If pain is the reason that we are prescribing in occlusal appliance, and a lot of times we are taking on a bit of risk because there are certain bite changes that can happen after occlusal appliances. And despite what you think, you know, you might think, oh yes, anterior only appliances, they’re the big culprits here. They’re the ones, those shifty devices, they’re the ones causing all the bite changes. But actually, you can get a bite changer. A patient can get a bite change from any type of occlusal appliance. So, I see this quite frequently on the Facebook groups from dentists and also lots of dentists message me and share some of the cases where they’ve had some bite change. They’re trying to get their head around what exactly happened. So, in this Ask Jaz episode, I’m going to cover three main themes. The main, the big one. The first one is, a patient who develops an anterior open bite after an occlusal appliance, and I’m going to teach you a trick that you can use if this happened to your patient to recover their bite. Okay? So that’s number one. Number two and three, a shorter one. The second one is how to scan or record using silicon bite registration paste, the patient’s centric relation record at the desired vertical dimension for something like a Michigan splint, for example, and the third one. What should the occlusion look like on composite veneers? These are three questions, or the last two are questions that were sent in by you guys. The first one’s something I promised Professor Paul Tipton, that I would do, which is reveal this trick. If you’re new to the podcast, welcome. This Ask Jaz series are kind of in their infancy, but I’ve got hundreds of questions that have been sent in by the Protruserati and just find time sometimes to just go through some of these things. And if you are a regular listener, thanks so much for always coming back. Let’s hit the main episode. So my friends theme number one, your patient gets an anterior open bite after a partial coverage appliance. Or actually, you know what, any appliance. You may have had a patient or nova dentist who had a patient who was given a soft bite guard or stabilization spin, or an NTI, SCi or something, and the patient came with some sort of a bite change classically, an anterior open bite, and this can be a little bit scary for dentists. And what happens that the dentist passes on this fear to the patient. And really, you know, I talk about it in other episodes, but this isn’t a huge deal, but it’s certainly an inconvenience if you didn’t warn the patient that this was going to happen. So that kind of makes sense. So, when this dentist colleague on one of the Facebook groups posted about this, about how she gave an SCi appliance and the bite changed and she was really upset, I wanted to help. So what I did was I said, listen, you can PM me. And I’ll talk you through a little trick that you can try to recapture the bite, which has worked well for a few colleagues. And so, professor Paul Tipton, THE Paul Tipton messages saying that he would love to know my little trick to solve an anterior open bite that doesn’t position the condyles in any other position than centric relations. So Prof, this one’s for you. I got you. And some of the other comments from our esteemed colleagues were along the lines of, unfortunately, whilst the incidence remains low, so that’s an incidence of a bite change or an AOB. After a splint is very difficult, if not impossible to resolve. So guys, I’m about to share with you the impossible. Allan, this is for you. Akhil, this is for you and for all the others that messaged me. Let’s do this. Let me show you the trick. But before I do, let’s just talk about what this dentist shared with us. So just want to thank this dentist for raising this to the group. And she said that a patient developed an AOB after a few months of wearing an SCi. So, for those of you who are unfamiliar, SCi stands for Sleep Clench Inhibitor, and it is the same thing as an NTI, which is the American version. So the British version is SCi, American version, NTI, right? So it’s those little appliances that cover like lateral incisor. You can get variations. But essentially a small appliance on the front is classically what we think of. When we think of an SCi or an NTI. You see, I was told at the school, never, ever, ever to prescribe a partial coverage appliance due to the over eruption that’s inevitably be going to happen, et cetera, et cetera. Fast forward many years and hundred appliances later, guess what? Over eruption hasn’t happened. It doesn’t happen. It can happen if the patient wears it for a prolonged time and all those things. But the AOB risk, the anterior open bite risk is a real one, but NOT FROM OVER ERUPTION. And that’s kind of the theme of the first part of this Ask Jaz. Now, this dentist on the group went on to say something very interesting. She said, ‘How unlucky, because the studies show a 1.6% occurrence of an anterior open bite.’ So she’s referring to the study. By Dr. Blumenfeld, right? So Dr. Blumenfeld’s survey, was a 512 dentist, right? And these 512 dentists gave 78,711 NTI splints. So those little ones, and of those 1.6% developed an anterior open bite. Now, what you need to know is that Dr. Blumenfeld isn’t a dentist. He’s actually a neurologist and he works in a headache center. And so he was fascinated when this appliance was being talked about by dentists as being able to help with headaches. It was natural for a neurologist who’s really into headaches to be interested in this field, and I really commend Dr. Blumenfeld for really integrating medicine and dentistry together. Because what they found is that when he incorporated the NTI protocols using a dentist, so James Boyd, they found that 50% of their migraine sufferers were now significantly better so that they didn’t need to rely on medication anymore. Let me say that again. Half of the people with migraines responded positively to the extent that they did not need medicines anymore. So I actually read a lot about this and Dr. Blumenfeld said that, now in his protocols in his neurology practice or for his headache center, is that patients will have an NTI and only those that don’t respond will then go on to have these heavy duty medicines. I think that’s absolutely fascinating. So there’s a lot of benefit for headache sufferers with this kind of appliance. But when we give someone an appliance like this, are we really facing this unlucky dip scenario that like spontaneous combustion, any one of these appliance like Russian roulette, you’ll get an AOB. Is this really how this works? Well, when I didn’t know much and I was like fresh off the course and stuff, and I didn’t really know and I hadn’t been experienced and I hadn’t really put much thought into it. I said this to my patients, I said, look, the studies say that there’s about 1.6% chance that you are going to get an AOB. And patients accepted it and I made peace with it. But just like, when we say about wisdom teeth, right? When there’s a surgical wisdom tooth and the tooth is impacted, then we say, okay, there’s an X percentage chance that you are going to get a numb lip. But for some patients, that’s a 0% chance. When their roots are like way away from their inferior alveola nerve canal, you know that this patient is not going to suffer from that fate, therefore they’re ultra, ultra low risk or no risk. Whereas other people, the nerve is intertwined with their roots and therefore they are pretty much, definitely going to get some sort of numbness or paraesthesia after having their wisdom tooth surgically removed. So we can’t use a blanket percentage figure to all patients. But you see, when I went on the course and stuff, they said that yes, your patients may get AOB and understood the mechanism i.e deprogramming, which I’m going to touch on shortly, but it never taught me the features to look out for in patients, which I’m going to go through again with you that will help you to recognize who is high risk and who is low risk for developing a bite change. And so if you want to learn more about this, well over a hundred episodes ago I was talking about this episode 41 of the podcasts was on anterior midpoint appliances. And I did another one, I think it was 58, where I did the continuation of that. And so within those two episodes, I go really deep into anterior midpoint stop appliances. And the cool thing now is that with my patients who are high risk, who I deem as high risk, I’ll actually put my leaf gauge in and I’ll take a portrait photo of them with potential anterior open bite that they could have from wearing an occlusal appliance. I.E I’ll take a portrait photo of them with the leaf gauge, their back teeth separated to roughly their central relation contact point. And I’ll show them this photo and I’ll say, listen, if you get a bite change, this is what it might look like. You might find that fine chewing at the front, like having a sandwich. You might miss the lettuce or you might miss the ham, for example. So you gotta talk about, in real terms for patients, you might not be able to bite your nails anymore. You might not be able to bite sellotape anymore. These are the ways that the patient will be affected. Thankfully, only psychopath smile with their teeth together. So really, aesthetics and stuff isn’t affected. It’s just those little things like that. But like I said, now with my protocols, I’m able to really consent my patients properly to the highest level. So hat tip to Dr. Michael Melkers, who taught me all this. And just as a way of revision, if you already listened to those two episodes before, or if you haven’t before, and this is all very new for you, the three main risk factors of someone getting a bite change or an anterior open bite spontaneously after an anterior appliance or any appliance. Any single appliance, okay? If the patient has these three features, we should warn them that their bite could change or they could have an anterior open bite. So they are in order, a minimal overbite to begin with. I.E, they kind of already have an anterior open bite. They have an anterior open bite tendency. They just maybe got half a millimeter of over bite or that’s it. And so all it takes is a little bit of a shift to reveal an anterior open bite. And so if you really do your homework and you go through all the Facebook groups and you find the previous ones, and you try and find some pre-op photos and models, you’ll find that a lot of these patients had minimal over bites to begin with. And it kind of makes sense, right? Because orthodontists are treating deep bites and you ask them, how easy is it to treat a deep bite? It’s not easy. It takes time, right? Especially if it’s a severe skeletal deep bite. You’re not going to give someone an appliance and turn someone with a true deep bite into an open bite, right? So, a deep bite is like ultra low risk for an AOB, but there could be a risk for a bite change. But let’s not get into that. So we’re specifically talking about anterior open bites, someone with a deep bite is not going to go from a deep bite to an anterior open bite from wearing any type of splint, right? Whereas the patient who’s already kind of got an AOB is more likely to develop one. Now, the second feature that informs high risk is having a large slide from the centric relation contact position to the maximum inter cuspal position. So basically your retruded contact position or rcp. So your first point of contact within centric relation. If these are all new terms to you, then maybe listen to episode 90, Basics of Occlusion. But essentially when your condyle is seated anterior superior in it’s snug position, the first tooth or teeth that touched together in that position, right? So that place and how different that place is to the patient’s comfort bite where all the teeth meet together and you bite together day-to-day bases your comfort bite, your bite of best fit. Now, if there’s a big difference between those, then it puts you at higher risk. How large is large? Well, people say that a 1.5 millimeters in an anterior posterior direction is considered large and half a millimeter transverse i.e. Left and right is considered like a large slide. So if your patient has got a minimal overbite, And they’ve got a large slide, they’re at higher risk. Now, why is it that someone with a large slide is at higher risk? Well, think about it. This large slide exists because there’s a difference between where the condyle wants to seat in this stable musculoskeletal position and where the teeth want to meet together and the way they meet together. So if any point the muscles want to relax or the teeth get worn, they kind of want to go back to that position. If that position is really far back, then that will change the bite. The patient will notice a change in their bite. And the last feature is a lack of posterior stability. Now this is explained really well by, imagine you’ve got two study models and upper and a lower, and naturally we want to put them together. And for most patients, we can put our models together and they fit together really nicely, right? We don’t need a bite registration because they just click together really well. But have you ever been this scenario where you’ve got these two study models and you just have no idea how they fit together? It’s like five different positions. This patient bite together in one position. They have an AOB, another position. They have a crossbite, and they’ve got like three other positions, which are class one. And it’s just, you can’t figure out, you need that bite registration. You see when you have someone who’s got very cuspy teeth and the teeth just sit together like a key and a lock, like a jigsaw puzzle, right? That’s good posterior stability. Whereas when you got really flat teeth, warm teeth and there’s not really good meshing of the teeth together, that’s poor posterior stability. So if the patient’s brain is kind of struggling to remember this bite, any hint of getting deprogramming, so relaxing the muscles, can you see the potential in the patient just going to any other new bite? Any other position because that previous position was the brain’s best guess. And it wasn’t even that good. It wasn’t even that comfortable. And so now when the bite changes, the patients kind of forgot the old bite because it wasn’t stable to begin with. So if you have someone with a minimal overbite to begin with, a large slide and quite flat teeth or lack of posterior stability, you can’t really tell instinctively how they should be biting together. Then that is a high risk patient. That is an ultra high risk patient. I think if you have two of these, you are high risk, but if you have all three, then you’re pretty much going to say to the patient that this will change your bite. And at that stage, you’re probably wanting that bite change so that you can restore them to that position. Now that dentist on the group again. Okay, now, and I’m coming to the trick. Don’t worry, I’m coming to the trick. Okay? I promise you, with a few minutes, you’ll know my little trick. Okay? So this dentist felt horrible. She felt like a little shock to her system because she felt as though it was her fault that the bite had changed. And she wishes that she just went for the Michigan splint, which apparently he didn’t get used to wearing. So is it really her fault? I don’t think so. Okay. I don’t think it’s your fault. I really, really don’t. And I was thinking of some analogies, like, how can I explain this right? Now, this analogy isn’t very good, but let’s run with it. Okay. There’s a film called Room and it’s pretty good film. It’s got like 93% on Rotten Tomatoes, and there’s a spoiler alert coming, so just run with it here. Okay. Room is about a mother and a son and they’re trapped in a room. And so the person who’s like captivated them or kidnapped them, just locked him up in a room and you know, they live his food and medicine. That’s about it, right? And so this kid was born in this room and raised in his room, and I don’t know, he’s like five or six years old and he’s never left this room before, right? So you can imagine he’s got very pale skin. He’s probably deficient in vitamin D and he’s not a socially normal child because he’s never ever seen another child before. So then, and here is a spoiler by the way. He makes a break for it with assisted by his mom. And so they make an escape, and they succeed. And so now this kid who sounds like the first five or six years of his life, in this room is finally now let out to the real world. And the real world has different conditions, different environments, better environments. Right now, he gets some sunshine. He’s going to get a tan. At the very least, he’s going to develop these social skills to see other children, see other people. And you see what happens to this child is that, as a response to this new environment, he changes. And I really think that in a similar way when it comes to our scenario that we’re talking about, the patient’s bite in a way was pathological in a way. And so when the muscles were able to relax, when they had an opportunity to relax, when you improved the environment, that’s when the bite changed. Because something had to change. Now the patient’s occlusion was out of this room and it got to experience a much more favorable environment. So that’s how I like to think about it anyway. So as a consequence of changing the environment, the bite changed because the bite i.e. The way the teeth come together is controlled by the muscles and the condyles. I guess the only issue is that we should be able to warn our patients that, yeah, okay, this is going to happen. And so the issue is not that the bite has changed, is that you didn’t anticipate that the bite has changed. So hopefully now you’ve got a few features to look for, to know when someone’s bite might change. But I’m going to teach you guys a trick. Right, the trick. Okay, prof, you’re listening. This one’s for you and everyone else on Facebook group who want to know my little trick. Okay? So you can use this trick anytime a patient has developed a irrecoverable anterior open bite. Now what I mean by this term, IRRECOVERABLE. Now, for those of us who wear anterior only appliances or even Michigan splints, for example, when we take it out in the morning, do our teeth go together straight into MIP? Maybe, but you know, sometimes you might hit your centric relation contact point or the bite might feel a bit funny and eventually, oh yep, I’ve got my bite. And then your teeth mesh together normally. And so that is someone who has a recoverable anterior oven bite. Someone with an irrecoverable anterior oven bite is kind of like the situation we’re talking about now. i.e. the reason the dentist posted that case on that group to get some advice. The patient removed the appliance. But they weren’t able to remember their old bite. Their existing MIP is now out of the equation and they’re biting in a new position, which is an anterior open bite. Now, by the way, I forgot to mention, I reached out to the dentist and I was helping her. I was coaching her about how to do this trick, and then she showed me the photos kindly of the pre-op situation. I can tell you now, it definitely wasn’t posterior over eruption the mandible had just shifted to the left, and by shifting to the left, it was now hitting an incline of a molar, and that resulted in anterior open bite and someone who had all those features, including a minimal overbite to begin with. So what’s the trick that I advised her? Well, those of you who are watching right now, you’ll see this, but I’ll describe it to those who are on their commutes listening on Spotify or on the Protrusive app, right? So let me make it really tangible and show you another case where we actually applied this trick to recover an open bite. One of my colleagues who’s a delegate of the splint course, she gave her patient a Michigan splint. This is before she became a delegate, and the reason she gave a Michigan splint is to deprogram the patient. I e relax the muscles, relax the lateral pterygoids, and test drive the vertical dimension. And then on the day of the fit of the Michigan splint, all the teeth are hitting. We’ve got the dots and the lines. The front teeth are hitting, the back teeth are hitting and excursions. We’ve got anterior guidance. Now, four weeks later, the patient comes back and what do you think has happened? Well, it’s worked. Okay. We’ve got some de programmation. So what that would look like is that the mandible slides back a bit. Distalizes, and now we’ve got a few dots to the back and no dot to the front. So i.e., we went from a complete of a bite on the splint to an incomplete overbite on the splint, and now we have a bit of overjet. So what do you do here? Well, you adjust it all again, you remove all the high spots, and then you achieve the even dots to the back and lines at the front, which is classic for a stabilization splint. So what this dentist does, rightfully so, is eight months of monitoring for whatever reason, I don’t know why it was eight months, okay? But there were no changes seen on the splint, and the patient was happy to proceed to a full mouth rehabilitation. So had lots of crowns and a treatment for his worn dentition. But this is where the interesting thing happened. This is where the anterior over bite might happen. So it’s very interesting. I’ll just read it out loud. So I’ve done a full mouth rehab for a tooth wear patient two years ago. In the diagnostic phase of his treatment, I made a Michigan splint for him. He wore it for deprogramming for eight months when his bite on the Michigan splint did not change anymore. So kind of recapping what I said already. Now, after his treatment was finished, I provided another Michigan splint for protection in his bite. At this point, his MIP was equal to centric relation, so i.e. He’s in his seated condylar position in the musculoskeletal stable condylar position, all the teeth were touching together. Occlusion is just so confusing. Does occlusion even matter? Wait, don’t you just grind away all the blue marks, right? You mean like plant it low, let it grow or leave it high and let them cry? Listen, what are these interferences even interfering with? Is it safe to lengthen teeth? How much can I raise my patient’s bite? How can you stop your composite restorations from chipping? Can you raise the OVD on a patient with clicking TMJs? Is canine guidance always better than group function? Why can’t I just use the DAHL technique on all my wear cases? Can I stop my patients from grinding? What the bloody hell is crossover? What should the occlusion look like after orthodontics? How and why do you check for fremitus? What on earth is a custom societal guide table? How do you use a leaf gauge? Do you always need to use a facebow? Does everyone really need a perfect occlusion? What is the difference between edge wear and pathway wear? Is it naughty to adjust the opposing tooth? What the is centric relation? Occlusion is coming. One does not simply just open the bite. May the force mitigation be with you. To make sure you don’t miss the crucial update about the launch of our occlusion course, OBAB head over to occlusion.wtf. That’s right. It’s actually occlusion.wtf. It’s almost released and you’re going to love it. Now, she saw him six months later to find that his mandible had distalised and only had contacts to the back with three millimeters of overjet. And so those of you are watching, I’ve got the photo right here. So we have an incomplete over bite and I would actually probably disagree, I don’t think this is three millimeters of overjet. This is five millimeters overjet. Remember, the overjet is measured from facial of the lower incisor to the facial of the upper incisor. So the patient actually probably went from a two millimeters overjet to a five millimeters overjet and a loss of anterior guidance. So how did this happen? Well, you know, sometimes patients deprogram more and for whatever reason, the patient wasn’t fully deprogrammed. That’s the most common thing. The other cause for something like this is a change at the condyle level. Think of the disc going out of place, or think of some resorption, which is rarer. And so anything at the condyle level, any changes, any pathology could change the bite and we can confirm it was muscular because our little trick worked. So what was the trick? Well, if you want to see it in action, you can actually go on the Protrusive Dental Community Facebook group. It’s kind of the same trick that we do when a patient is high risk. So you’ve identified a high risk patient. I would make one of these devices, which I’m going to share with you now to prevent an open bite so you’ve got a high risk patient and you make them this device alongside their splint to prevent their bite changing. It’s the same thing that we can give to someone who’s developed an open bite to recover that bit old bite. Now, at this point, you’re probably a little bit confused, but don’t worry, I’ll make it crystal clear, right. Now, this concept of positioning the mandible in a different way is actually borrowed from those who are treating the airway, because what you find with mandibular advancement splints for, let’s say sleep apnea for example, or sleep disorder breathing, is that because you’re holding the mandible forward, you get contracture of the lateral pterygoid muscles, and the risk is a patient will develop a posterior open bite because their jaw has come forward. They’re now protruding forward, their front teeth are meeting, they become more class three and the back teeth aren’t meeting anymore. So what they started to do is every morning when the patients wake up from wearing their mandibular advancement splint, is that they wear something like on the screen now, where I’ll describe it is an MIP bite, basically, is that it guides their jaw back into their MIP in the morning, so hopefully it prevents this shortening of the muscle, basically. And so this is AM aligner and it’s got indentations in it to really guide the patient into their MIP. So it’s kind of like an MIP bite registration, but I wouldn’t want to send a patient home with a normal PVS silicone bite because it’s very fragile, right? It’s going to break. So let me explain the trick now, right? So you have a patient and their teeth meet together fairly well, and then after the occlusal appliance, the teeth don’t meet together well anymore, and you have an anterior open bite. Now, if we accept the fact that it’s not, because of posterior over eruption and it’s just that it’s a change in the muscles. Then what we can do is this, okay, we get the models and we have to do this on models because if you try and get the patient to bite into their normal bite or their MIP, they can’t do it because they’ve kind of forgotten. That’s the whole thing about deprogramming. They’ve been deprogrammed, right? How can we reprogram them? Well, the way you do it is get the study models. You now squirt some Memosil or Exaclear. Clear silicone materials, right? They’ve got their resilience, they’ve got their bend ability in them, right? Bit of flex in them. That’s the word I was looking for. You then squirt it all around as if you’re doing a bite registration, a full arch bite registration. You then seat the models together by hand and you are basically creating the patient’s old MIP i.e. I used to bite like this, that bite, okay? You actually do it by hand and ideally you want to rely on some photos or some scans to help you. Because remember, the whole reason that this mess happened is that the patient probably had poor posterior stability. So you really want to pay attention, look at the photos, and as the material setting, you bring the bite together in the desired bite. The bite you want to go back to, right? And you let the material set. So now you have a bite registration of the old MIP using the study models, you now transfer that to the patient’s mouth, okay? And you get them to guide their mandible into this bite registration. So let me tell you how this dentist did it after I advised her, okay, so this is what she said. When the patient came, I got his previous models out. I showed him his previous bite and explained that it was changed because his muscles had relaxed. Before his arrival, I made an AM aligner with Memosil. So just like I described guys after the explanation, I fitted the AM aligner and asked him, and here’s the magic thing, because you know this is something that we make up because there’s no evidence that I’ve seen about how to recover someone’s bite. So we’re kind of making up. So, this dentist was smart. She advised him to bite into it for 20 minutes. Okay? So, the patient has an AOB but is now got this Memosil bite of his previous MIP and he’s biting into it for 20 minutes. So after 20 minutes, he then removes it and when he closed together, he was able to bite again into his old MIP straight away, and he recognized the difference. Okay. Without any pain, without any discomfort. Okay. The fascinating thing, which I absolutely find crazy is that the patient was unable to protrude his mandible before, but after this exercise of biting into his bite registration, he could. Isn’t that fascinating? This is the complete opposite of deprogramming. This is reprogramming, and it just makes sense because if the muscles have forgotten, why don’t we give the muscles some help and remind them? So those of you who are watching, here’s the photo of him biting onto this Memosil, which was made on the study model and moved to his mouth. Why it wasn’t this bite record using Memosil taken in his mouth? Because he couldn’t bite there. He couldn’t physically get into his old MIP again, he just had this distalize bite with a larger overjet. But this is now guiding him into his old MIP. This dentist went on to change his appliance from Michigan to something else, which isn’t so relevant. But he preferred this B-splint or this Dual Arch Anterior Scribe Appliance to his Michigan splint. And those who are watching is a para functional pattern that you see. So a big fan. Coloring these splints with a sharpie marker. And the patient gets to see their pattern. It’s like a gothic arch tracing that you get on these splints. So the patients see that they are still bruxing every night. Because some patients they think that they stop bruxing just because you gave ’em a splint. Whereas I tell our patients, listen, you’re still going to para function, but now you are para functioning on this piece of plastic then on your teeth. And so there it is again. The trick is reveal. So those of you are listening, it is essentially an MIP bite using the study models in the old MIP, and this can really, really save you. Now, I can’t offer any more guidelines because this hasn’t been studied and we’re kind of making it up, but it helped my colleague and it can help you too, if it ever stuck. This is worth giving a go because what else have you got to lose? This is a simple and a cheap way to attempt to recover the bite because what’s the alternative, right? Either the patient lives with this AOB, which is totally cool, I think, or B, they consider orthodontics or restorative to try and get their old bite back or something similar to their old bite. So I think it’s a really handy little trick to have up your sleeve. I hope that made sense. And if it didn’t make sense, and if you’re listening, then maybe you want to just go to the app or YouTube and watch this bit. But in a nutshell, it’s reprogramming the bite using the patient’s own MIP bite record using the study model. So it’s not deprogramming, it’s reprogramming, it’s trying to make that irrecoverable AOB into a recovered AOB. And if any of you use this, do comment, let us know. Let us know how you get on. And maybe we can do a study one day in terms of recapturing these old bites. So Prof Paul Tipton, I hope you found that useful. And anyone else who thought it’s impossible, maybe this is a way forward. Okay, so that was a long one. I’m actually exhausted, but we’ve got time for just two more questions. And these are much shorter, right? There’s question number two before we talk about occlusion on composite veneers. The question is, when recording at your desired vertical dimension in centric relation, how do you record it? Do you gun in some bite reg around the side when they are in their retruded position? Okay, so let’s talk about this and let’s really clarify and make tangible what this dentist means. Let’s say you are making a Michigan splint or a Tanner splint or any type of stabilization appliance. Classically, you would make this splint at centric relation. So the condyle is in a musculoskeletal snug position, superior anterior against the posterior slope of the articular eminence. Because like I said, it’s a snug position. It is a good position to be in. It’s not essential position to be in, but if the muscles relax, that’s kind of like where the condyles can easily find. Now classically, when I was trained, I was taught to take a centric relation bite record, so just beyond the first point of contact. And then a face bow and then what the technician would do is a technician would mount everything on a semi adjustable articulator. And then because the bite registration was pretty much at the point of contact, we now need to open because we need a minimum thickness of splint material of 1.5 to two millimeters. So the technician then opens the bite on the articulator, but remember the articulator, although a very useful tool, does not a hundred percent accurately mimic the patient’s condyles. So by opening the bite, there is a degree of error introduced, so we can be a bit more clever because if at the point of doing the bite record instead of recording it at that very first point of contact, or just beyond it, why don’t we record the bite at the required vertical dimension. i.e. Record it in a position whereby we’ve already respected that 1.5 to two millimeters of minimum thickness. So what this looks like for me is I’ll have a leaf gauge in, because I like to use a leaf gauge. It’s very, very convenient. It’s not suitable for all patients, but it’s a very, very handy tool. And so as I have the leaf gauge in, and I’ve set it now so that there’s no back teeth touching, I’ve got the patient in centric elation, grind forward, grind back, squeeze together the muscle seat the condyle so I don’t have to do anything. It’s a hands off approach, the muscles seat the condyle, and because I have that space now, I’m going to scan the left bite and scan the right bite at the centric relation position with my desired thickness. Already there, or you can actually gun in the bite registration material as this dentist suggested. The beautiful thing about this is that now the technician uses the bite registration at the increased vertical dimension, but still at centric relation. And the scenario they have now is that once they’ve mounted the models, they’ve got the space ready, they can just start waxing up for the splint. They don’t need to open the bite or close the bite anymore. They pretty much fill in the space with wax. And this is where the magic happens. Now, whether I’m doing, DAHL composites, full mouth rehab, or a Tanner splint, or a Michigan splint using this trick has been really brilliant because when the patient bites together after I put my temporaries, or put my resin or put my splint in, I found much less adjustments to do. So, I think this is a wonderful thing to do. Anytime you’re aiming for a centric relation record, give the bite not at centric relation, but your desired vertical dimension, which may be at centric relation contact point, but if like for a splint, you want to give them some space, don’t let the technician open up the articulator. You give them the perfect space, and now their error of opening and closing the articulator, which is not the patient’s mouth is removed. So thanks for sending that question. I would name you, but I didn’t ask your permission to name you, so I don’t want to offend anyone. So, that’s that. Now question three and the final one, I think we’ve gone on for far longer than I anticipated, but checking the occlusion after composite veneers. So the question from this dentist on Instagram is, ‘Hi Jaz. Would love some advice on an occlusal question. After placing composite veneers on upper anterior teeth, should the incisal edges of upper incisors will be in contact during lateral guidance? What about in protrusive movements? What markings am I looking for on the articulating paper? So all from the articulating paper, right? Thanks in advance.’ Right? Great question. Okay. I love it. Let’s just boil it into his fundamentals. Okay. So first part of the question is, after placing these veneers. Okay. Should the incisal edges be in contact during lateral guidance? I think it totally depends on what the starting situation is, because if you start with our friend, the anterior open bite again, and you put some veneers. On someone with an anterior open bite, then the edges will never touch, right? Because they have an AOB. And if you’ve maintained that AOB, maybe you’ve lengthened the teeth, but and reduce that AOB, but they still have an AOB. So no matter how much lateral excursion they do, there’s going to be no articulating paper mark on those edges. Now, on the opposite side, if you’ve got a severe class two patient, right, they might not even go all the way to the edges because the amount of movement they have to do to go on the edge is significant. They might go there, right? But they might not. So for that kind of patient, again, they might not go to their edges of their central in incisors, in lateral excursion. So really that eliminates a few groups of patients. Would your patients who’ve got a normal amount of overbite, you know, 10% or more, then there is potential for those teeth to touch. So should there be contacts or it depends on the overbite. If there’s enough overbite for anterior guidance, then eventually the lower incisors may and get onto the centrals. So there isn’t hard and fast rules out there, should they? But it’s rather will they? And if they will, why don’t we optimize that environment? Now, in an ideal world, it should be canine guidance to start with and then swiftly and smoothly, right? And I don’t mean smooth, like shiny, smooth. I mean like the mandible finds it really easy to move left and right. What we don’t want in a scenario is that the patient’s bruxing, for example, right, and they’re going left and right and they’re bashing against this composite. And this composite, it’s so steep. It’s not letting the mandible move. And by not letting the mandible move, it’s putting a lot of stress and strain on those restorations. But instead, if you shallowed out the guidance, the mandible can just move freely and not put all that pressure into your restoration. So let’s recap. You go canine guidance, for example, in the classic scenario, because I can’t cover every single scenario because the question you’ve asked really is case by case by case. So canine guidance, for example, transitioning onto the edges of the centrals, okay? And if they go into crossover, crossover is when they go all the way to one extreme. And I’ll show you an example of this in a moment. For those of you who are watching, the patient who goes into crossover may well come onto their central edges quite regularly. So in a nutshell, should the patient contact on their edges? Not necessarily. It depends on the existing occlusion, but when and if they do, make sure the transition to them is nice and smooth. So whether that is from the protrusive or left and right, you don’t want ’em to be canine initiated and then suddenly have a jerky movement towards a distal incisal of a central, that’s not going to be good. Right? You want everything in harmony. And sometimes that means having nice, straight lower teeth, or at least not these sharp jaggedy edges of lower incisors, which are doing no one any favors. So always have a look at the opposing and see sometimes you might optimize the environment. I tell the patients I’m doing a manicure for your lower incisors and they love it. It feels much better and it reduces the harmful forces and pressure on your upper anterior composite veneers. So before we talk about, the next case, which is protrusive, for those of you watching the video, I’m showing you a patient who’s a severe bruxist. He destroyed one of my small splints in a matter of six weeks. So I’m showing after his dialed composite restorations what his excursions look like. So they’re nice and smooth as they come onto the edges. They’re really smooth, nice contacts on the edges and as we go to the other excursion. Now we’re going nice and smoothly, transitioning to the centrals and now into crossover. And there’s no jerky, there’s nothing hitting prematurely. The mandible can move freely left and right, and this is what we’re aiming for in Protrusive. It should be the same thing. It should be no jerky movements as the lower incisors bite onto the upper and it come protrusive. I want to see nice, broad, even Marks ending on those edges or even beyond. But I want them to be nice and even I don’t want one incisor to be taking more load than the other. And I don’t want like a thin marks. I want nice, thick, broad marks. Okay. Why do we want nice, broad marks onto nice broad edges because it reduces the pressure. Okay? Because ultimately pressure is force over an area. So if you’ve got a thin little chicken scratch of a line, then there’s going to be a lot of pressure, right? That broad line has more area, so that force is spread over more area. So it’s a bit like, if someone’s going to walk all over you, , do you want them to walk all over you in high heeled stilettos or wearing flats? Right? So I think we all know the answer to that one, and that kind of is a crude way to explain the kind of marks we’re looking for. So to summarize that, we want nice, even strokes that go from the MIP contact all the way to the edge, and I want nice even contacts on the edges. So the lower incisors, upper incisors come together, the edges are unchipable. And that’s really important because I’ll show you now for those of you’re watching, but those, you’re listening, there are these group of patients, okay, who just love coming edge to edge then. Even though they’re class two and they’ve got like, you know, five millimeters over jet and you think, how on earth do they go there? But as soon as they bite together, things fit together perfectly because they like to bring their edges of their teeth together. Couple of reasons I think one could be airway, right? They could be bringing their jaw forward during stressful scenarios to bring more oxygen in to improve their airway. And the other theory, which actually is supported by some weak evidence is that by tapping on your front teeth, you reduce your corsol levels and you reduce your stress. And so regardless of the reason, it’s important to identify who spends a long time on their edges and who doesn’t, and those who spend a long time on their edges, please, please, please double triple check these excursions and make sure the edges are well accounted for. You don’t want any sort of uneven edges or sharp bits or fragile bits, okay? You want nice, thick, broad composites. If you’re doing composite veneers on someone who likes to be. Edge to edge. So hope you enjoyed that. It was very much an occlusion theme today sparked by that Facebook group, and we’ve talked about taking bite records at the desired vertical dimension and a little bit about occlusion on composite veneers, if you like this kind of thing, then me and Mahmoud have put together around about 30 hours, can you believe it, of content that’s ready to come out in March, pre-launch deal coming. So the way you can get involved with that is www.occlusion.wtf. Well, there we have it. Guys, thank you so much for listening to this Ask Jaz. I hope you found that stimulating and interesting about how we can recover someone’s bite. And for those of you who want to learn more, maybe listen to those episodes that I referenced about those anterior only occlusal appliances, part one and part two that I did way back around about a hundred episodes ago. Can you believe it? If you are looking for an occlusion course, then me and Mahmoud Ibrahim have got some very exciting coming up. So on 7th of March we’ve got a pre-launch deal coming. So if you want to be in the know when it comes to this pre-launch deal, you want to head to occlusion.wtf. That’s right. occlusion.wtf is an actual website, I promise you. Enter your email address and first name and I’ll email you when we have that deal ready for you. It’s something that we’re super proud of. Worked really hard over the year. In fact, have a listen to one of our beta testers had to say. Hi, my name’s Marwa. I’m a general dental practitioner. Occlusion Basics and Beyond does exactly what it says it’s going to do. It takes you from the very beginning, the very basic principles of occlusion, and as you go through the modules, your knowledge just gets built upon and built upon. So much so that by the time I reach the end of the course, 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 contents delivered. Mahmoud and Jazz, walk you through things in such a clear way that things finally make sense. So I’d really recommend this course to anyone that’s looking to lift that cloud around the dreaded topic of occlusion. So, once again, that’s occlusion.wtf. If you want to stay in the loop and talking of in the loop, that is exactly what the next episode is about. It’s about Karl Walker-Finch’s book, it’s called In The Loop. I’m very excited to speak with him, to wet your appetite for this fantastic book, which is dedicated to a very important dental charity. So I’ll see you next week for that episode.

This episode gives it all away – every micro-step on how to successfully treat white patches with Teeth Whitening and ICON Resin Infiltration. If you are an experienced clinician or new to White Spot management with ICON, you will gain something from this blockbuster. After the success of the ‘Teeth Whitening Under-18s’ episode, Dr. Linda Greenwall is back to make resin infiltration tangible. Dr. Greenwall shares everything from assessment to troubleshooting! https://youtu.be/CYLXUGTXPRI Check out this full episode here 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: Download the Protrusive Treatment Guide for White Patch management Icon Resin Infiltration inspired by this episode – the Infographic that summarizes this episode with the exact micro-steps and the little nuances with helpful diagrams and tips all in one flowchart. Please show your support by signing up as a Protrusive Premium member – once you’re in you can download our mighty flowchart and infographic from the Protrusive Vault section (as well as the many benefits of membership!) Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 1:42 ICON Treatment Flowchart 7:39 The science behind Icon Resin Infiltration 16:35 Using Resin Infiltration Posteriorly for Caries 19:33 White Patches Anterior Resin Infiltration Protocol 22:08 Resin Infiltration Treatment – Air bubble Analogy 32:50 Patient Communication – Treatment Planning and Fees 34:50 Resin Infiltration Technique – after the etching process 40:36 Predictors of success and failure 45:02 Expected longevity of Resin Infiltration 47:02 Etiology of white spots 47:57 Dr. Linda’s advice when starting a white spot cases Learn more about Molar Incisor Hypomineralization with THE D3 GROUP FOR DEVELOPMENTAL DENTAL DEFECTS Check out the Tooth Whitening Techniques Book, a compilation of before and after photos of patients produced by Dr. Linda Greenwall If you enjoyed this episode you will also like Teeth Whitening Secrets for Success Click below for full episode transcript: Jaz's Introduction: Did you know that resin infiltration was initially developed for the management of early carious lesions? But it's actually taken off hugely for the management of white spot lesions anteriorly. I've been using icon resin infiltration for a few years now, and I've had some pretty good results. Jaz’s Introduction:And so this stuff, this resin that infiltrates into these white patches, like our guest Linda Greenwell, the way she beautifully describes it with her soothing voice is that the white patch is like an air bubble, and she explains that analogy wonderfully throughout this episode. And it seems to be a really great, minimally invasive way to manage white patches, either after orthotics or MIH or of any origin. Hello, Protruserati. I’m Jaz Gulati and welcome back to another episode of the Protrusive Dental Podcast. That’s right. We got Linda Greenwell back again after that amazing episode about the rules around whitening for under 18. If you haven’t seen that, do check it out because it does tie in well with this episode because one of the things that Linda will teach us is the importance of tooth whitening before doing resin infiltration. In fact, Linda leaves no stone unturned. Every single micro step and the nuances and considerations, and even the troubleshooting. What if things don’t go to plan? It’s covered so comprehensively, so beautifully that I think DMG, the company that makes the stuff will probably host this podcast episode on their own website. We also answer burning real world questions such as, do you have to use rubber dam for this technique? And can you use any composite, like sometimes you actually have to have composite at the end of it. Do you have to use a bond before you use the composite or is the adhesive with the icon enough? And what is the best type of composite to use at the end if required? So if you listen all the way to the end, you’ll find the answer to that one as well. Protrusive Dental Pearl:The Protrusive Dental Pearl for you is the best infographic or treatment guide you’ve ever seen. As you know, some of the Protrusive guides before have become pretty famous for the amount of detail and concise amount of knowledge on them. And so what we’ve done from this episode, because there is quite a lot to remember, a lot of little nuances. I imagine if you made a flow diagram of this episode, you’ll see later what I mean. It gets a little bit complicated, but don’t worry, we’ve done all the hard work for you. We’ve mapped out the exact microsteps and the little nuances with helpful diagrams and tips all in one flow chart. That treatment guide is essentially everything you ever want to know about icon resin infiltration with our protrusive masala. Sprinkle all over it. If you want to access this treatment guide on icon resin infiltration, then check out the Protrusive app. It’s an IOS and Android. You can also access from your browser. If you just head to protrusive.app, that will take you to the app website itself. It’s under a section called Protrusive Vault, and you’ll find so many of the previous infographics and files, which is only accessible to the premium members. It’s thanks to the premium members that this podcast can stay alive and viable, so I thank you so much for your support. Before we joined the main episode with Dr. Linda Greenwall, I wanted to announce something really special with EVO 4. EVO 4 is the latest generation of Enlighten Whitening. The changes with EVO 4 really make it superior, so now there’s no more in surgery stages, three weeks, all at home. They’ve also done something very clever with the tray design. So the whitening tray, sometimes posteriorly, they sort of flap off. There’s a lack of retention sometimes. Quite often molars have small clinical crowns, you see, and that allows saliva to come in. So kind of like with the aligners, they’ve actually built in an attachment, single attachment on each side, which is optional to use, but I’ve used it and super easy. So if it gets you better results, why not? And they’ve incorporated that as part of the EVO 4 system. The final change, which is pretty important, is that now the gel will ship to you with the tray so you don’t have the gel lying around the practice. It comes with you as a bespoke order with the patient’s whitening trays. Now, the benefit of that is that the gel doesn’t stay lying around the practice, and the more it lies around the practice over time, the more it breaks down, the more it breaks down, the more acidic it becomes. The more acidic whitening gel becomes, the more sensitivity you have. Can you see where we’re going with this? It’s less sensitivity. It’s fresher gel for better results to celebrate the launch of EVO 4, my buddy Payman Langroudi and Enlighten Smiles are giving away 20 free kits to the Protruserati. It’s super easy to get a kit. All you have to do is go on the Facebook group, Protrusive Dental Community. On there, I’ve started a thread, and on that thread I’ve asked, who wants a free whitening kit? Of all the people who comment, we will randomly select using one of those random apps that you see online. 20 winners. So you can start using either on your patients or your staff or your family with the new EVO 4 system. So the Facebook group again is Protrusive Dental Community. Just search it on Facebook. You’ll find it. Thank you again. Enlighten and Evo 4 for supporting Protrusive Dental Podcast. Now just check out this really geeky, fantastic episode with Dr. Linda Greenwall. Main Episode:Linda Greenwall, welcome back to the Protrusive Dental Podcast. How are you? [Linda]Thank you. I’m good. [Jaz]It’s great to have you back. You blew us away when we talked about whitening for under 18. It’s a very controversial topic and it got a slightly controversial response on social media and email, which is fine. We kind of expected that, but in a good way that a lot of dentists were like, wow, someone’s actually standing up i.e you for the profession. So that’s wonderful. And I was actually at dinner, the weekend. At my friend’s house. And he’s a dentist, and he asked me a question, Linda. He said, which,’ Guest have you had on the podcast whose story really inspires you?’ And it is just, like the almost like the most inspirational guest you’ve had.’ And I said, okay. It has to be Linda. Because of your background, your story, your mission, and the clarity in which you communicate your mission statement is just so you know, you are oozing passion about this in all your educational ventures and what you’re trying to . Achieve. Through whitening and much further for the restorative dentistry. So I think it was an easy choice for me. So thank you for all that you do for our profession. [Linda]So just one more follow up. There’s two more things. Number one, we are really making this year to campaign for the under 18 children because MIH, which is the disease, and a lot of the kids have these white spots that we’re going to talk about. MIH is a disease and it’s one in six children have this disease. And so whilst they need the mild cases, need icon resin infiltration, they start with whitening. So we are going to focus on the disease aspect, and I’m going to do quite a few series of lectures on the disease aspect of MIH because it’s pretty severe and there’s a whole lot of new information. That’s the first thing. The second thing is we’ve ramped up our care for the child refugees this year through the Dental Wellness Trust charity that we are working on. And a call to anybody who wants to open their practice on a Sunday, on a weekend to help the child refugees. These children are asylum seeking families, but we only work with the children. They are not eligible for any NHS treatment or anywhere else. So, we do this treatment for them. We are happy to do it and provide it. This next week we are going to a hotel in Paddington to screen 40 children who need to be desperate for dental care, who can’t get it. So anybody who wants to volunteer, please message me afterwards. Any of that, we’d really love some help. We need to be ready to roll up your sleeve, so thanks so much. Thanks. [Jaz]If you weren’t already in love with Linda, there we are guys, you know, what a beautiful, noble thing to do. And just so to make it easy that I’ll put a link in the show notes so they can directly contact you for that. And you’ll just let me know which is the best contact afterwards so I can take them directly to be able to them to get involved in helping. So that’s amazing. So completely right with today we’re talking about icon resin infiltration, and you already touched on. You know, whitening may be a part of this, but before we get to that, I just wanted to help dentists understand, because dentists, we weren’t taught this at dental school. Like many things. And when we come across this, you know, “New Technologies”, obviously it’s been around for a little while now. I’m sure you’ll tell us. We get a little bit skeptical about actually using it in the practice. So first thing to cover is what is the science behind icon resin infiltration? How does it actually work? [Linda]So the way that it works is literally as it sounds, it’s infiltrates a porous area with resin. It was originally discovered, I think it’s more than 15 years ago now. By a group of researchers in Germany. One of them was called Paris. One was called Lueckel, and one was called Pharck, P-H-A-R-C-K. And he did a lot of research on this, and I saw this information presented in Chicago when I was lecturing and when I saw the technology, I was like, this can be applied for patients with whitening and for white spots. And this has been nearly 10 years ago. And since then, we’ve been applying the technique. So when a patient has got white marks or white spots on their teeth, you have to think of them as an air bubble within the tooth porosity. The reason that it occurs, I don’t know, we discussed this Jaz, but we need to talk about it. One in six kids have this. Anytime a tooth is starved of oxygen, so the little embryo is starved of oxygen. It’s creates an air bubble, there’s a defect, and it becomes porous, and that is prenatally, postnatally or perinatally, anything that occurs around the birth. So when that happens, there’s a defect in the truth. What we know now with the new research is albumin for some reason gets incorporated into the developing tooth structure. An albumin stops the tooth structure from hardening and calcifying, so it’s soft and it peels off. It just where you get post erupted breakdown and the tooth just starts breaking down and you know, it’s a very severe, there’s about seven different categories. About 20 years ago, a pediatric dentist noticed this disease. Up until about 20 years ago, we weren’t really seeing it much, and all of a sudden we started seeing this. The history shows that it was around 200 years ago, but it’s much more prevalent now. So it’s now one in six, it’s now globally, all countries have it. Denmark, for example, they’ve eradicated tooth decay completely and they just deal with the severe MIH cases. So MIH means Molar Incisor Hypomineralisation. There’s a really good website if you put it on the case notes as well, on the podcast notes. It’s called www.thed3group.org. And that is for children, clinicians, parents. Everybody wants to know about MIH and white spots and white mark. So I’ve prepared a whole series of literature. I can give you some of the literature in your case notes. What is MIH? What are the treatment options? What is resin infiltration? In fact, I’ve produced a book of before and after photos for patients. [Jaz]Oh, wow. [Linda]To see what it does with a little bit, it’s all picture books rather than technical words. So again, that is available, which would soon be available on Amazon. But explaining what it is. So the kids that come to see me, they are been traumatized, they have been bullied because a lot of it is brown, white, and marks. The parents are traumatized. The parents have so much guilt. So one of our options that we want to do, we actually want to do a research study surveying the parents because the parents have lived with this guilt that this cause something that happened during the birth caused the child’s teeth to be this way and the parents feel very strongly. There’s no access to dental care on the NHS for this treatment. And under 18 whitening as we discussed, but, our next little project is to interview. Often I’ve been videoing the mothers after the treatment for the kid, the mom starts crying, not because of the fees, but because of the impact for that child, and everything is about the impact of the child and the mental wellbeing. So in my book, which was published in 2007, second Edition, tooth Whitening, I wrote an index of treatment need for children with white spots and white marks. If it’s impacting the child, then treatment. If it’s not impacting in a child, wait till later. So we would start, very rarely we would do eight or nine years old. We wait until all the teeth are wrapping, so about 12 years old. And normally when they leave year, then year five, year six, and they’re go into high school before that time, that’s when they really want to get the treatment sorted out. [Jaz]Now, I just want to say Linda, it is really good you mentioned that because from the previous episode, we did, teeth whitening under their 18s. I don’t think this was the impression that was created at all, by the way, but I don’t want dentists to interpret that as when they see a 14 year old with white spot, they will say, ‘Hey, let’s treat it.’ It should be a case of need. Ie It’s actually bothering the child. If it’s not bothering them, then that’s the conversation you could potentially ask, oh, is it bothering you? And, later time in their life, basically. But if it’s definitely bothering them and the parent, then that is a worthy conversation to have at that point. [Linda]That’s right. But if it’s not, then you just move on and leave it over. But there are a lot of patients and unfortunately because of the, you know, they can’t get treatment anywhere else, they do travel a lot. And that’s fine because if this is all that it needs to help their mental wellbeing, this is fine. So, you know, as dentists, we are not psychologists or psychiatrists, so we cannot diagnose depression and all those things, and that’s not our remit. But at the same time, we can see when a child is impacted. And if a child is telling you, they don’t often initially tell you that they’re being bullied at school, but when it is, the mother will say, and often, the recent case that I saw with a kid. The child was so, he’d biten the inside of his lip and his cheek. He was so upset about the bullying, not only so there’s an internal thing where they hold it all together, but the external thing that the teeth are brown and yellow and defects on the teeth. So the beauty about resin infiltration, is that it’s non-invasive. Generally it’s non-invasive, but there are things that can happen, which you need to be aware of, but it’s a simple non-invasive treatment. And as you know from our previous discussion, whitening is first always whitening because you want to see what whitening can do. Because what happens is that these cases need to be widen for a prolonged period of time. So not 4 weeks, not two weeks. Most dentists think, oh, it’s all over in two weeks. It’s actually longer. It’s about six to eight weeks, or eight to 10 weeks, because you want to see what can whitening do for this patient first before you do the resin infiltration because- [Jaz]Absolutely. [Linda]The whitening can shrink the lesion not entirely gone away, although we have seen it go entirely away with patients who’ve got tiny little white spots. So we’ll talk about predictions later, but if it’s small, it’s easier to get rid of. If it’s pale white rather than very opaque, then it’s much harder. So those are kind of some of the things. So the science behind, basically this technique was done as a method for treating early D1, D2 carious lesions, and that’s when it was just penetrating in the enamel and on the radiographs. And we have many patients, and I know you do as well, when you see they take their bite wing radiographs, you see these little triangles in their enamel and you go, okay, what’s my treatment decision here? Do I leave it and tell the patient to floss more and use interproximal little brushes, or do I intervene if it’s only in the enamel? If they change the habits, we can keep this lesion just as it is for seven years. Maybe nothing will get worse, but if it’s just like sort of tiny, but in the dentin, what we do with our digital x-rays is you can sharpen the image and when you sharpen it up, there’s a little thing on software of excellence. Some of the software, you sharpen it, you can actually see there’s a little bit more decay than on the first digital image. But anyway, when we see that those are your decisions you need to make, do I treat it? Do I intervene, do I prevent it? Do I go through the fluoride and flossing, et cetera. My opinion on those cases especially when they’re multiple lesions, is we all know that the patients don’t really change their brushing habits all. They don’t really. As much as dentists, we work so hard at trying to get them to change a behavior. We are not always as successful as we want. And so for those patients, I do the resin filtration posterior. [Jaz]Which was actually going to be one of the questions I want to ask later on whereby from my understanding, the technique was initially for molars and using it for E2, D1 caries. And so it’s great to hear you are using it, but why do you, I mean, it sounds like such a great, minimally invasive way to treat these early lesions. Why do you think the uptake amongst, cause I don’t know. I know loads of clinicians and very few that I know are actually using this for molars. I particularly, I myself have the kit, but I use it for interiors and I haven’t had the training to use at molars and I’m a little bit apprehensive and I feel like maybe I should be doing it for molars. Because it’s such a great thing to offer your patients. Why do you think uptake has been slow? [Linda]So just a couple of things. By the way, Jaz, with your group of listeners, we can do hands on with you and your team, whoever wants to do it as part of the podcast because we can do it online. And so then- [Jaz]Amazing. [Linda]You don’t have to go somewhere so we can do it. So there’s two different kits. So you can do, and there’s an anterior kit, which is a round sponge, and there’s a posterior kit which has a different applicator. It’s got like a matrix, it’s a green handle with a matrix which you swap around and I can send you photos of it. And it’s got little pores on the green side. It’s got little pores. So let’s say your lesion is on the lower right six mesially. You twist the applicator and you put it just mesially. You pre wedge or you put an orthodontic wedge, an orthodontic separator through. You wedge it, you place your matrix and you do the etch, and you would etch it again for two minutes. And then you would go straight on to the resin and the resin is on for three minutes and then a further minute. So there’s a set protocol which we can go through, but that is for posterior. My point is on these patients, nothing is going to change. And then we are eventually going to have to drill them, those lesions. So why don’t we just try this? Only problem is that the resin is not radiopaque. So you need a good preoperative radiograph to say, this is how it is. Now you can undertake the technique. And I explain to patient, it’s like a clear fissure seal. [Jaz]Got it. [Linda]Because we do a lot of fissure sealing in the practice, so it’s like a clear fissure seal. This is prevention. We rather intervene and prevent rather than wait for the lesion to get larger. And most parents are quite acceptable on that. And so it’s a simple technique to do, but you can’t see it working. You can do the technique, you can’t see it with an anterior, it’s all in front of your face, so you can see it working and you can see what’s going on, but it’s a good thing to know about. And as you know, Jaz, I mean the reason for the success of your podcast. And just by the way, after we did the other one, I was stopped all over when I went to lectures and they’re all like, ‘Hey, I’ve just listened to it. I loved it.’ But so you’ve got a very impactful, very wide range of people. This is wonderful and congratulations. [Jaz]Well, thank you so much. Let’s make it happen because it’s a technique I want to learn. And this podcast was made for greedy reasons, in sense that I wanted to share a very specific bit about how to move to Singapore as a dentist so that I can help those people. So I’d free up more of my time and eventually it led to me talking about things I love. And this is such a great thing, minimally invasive dentistry. And there’s loads of people who actually. Use icon resin infiltration anteriorly for those white spots. But we just lack that direction. And I think what you can give us is that direction. So I will put a little ad in here for like, ‘Hey guys, if you want to come and join us for the HandsOn Online kind of thing.’ Is it like a HandsOn, like virtual hands online? [Linda]Hands on. We send you the hamper. And then we all do it together. [Jaz]I love how you call it a hamper. That’s so good. So great. So we can do that. So essentially the resin infiltration works by, well first whitening. Then the resin- [Linda]Then you wait two weeks. [Jaz]Infiltrates into the tooth. [Linda]But you must wait two weeks because you want the resin, the enamel bond strength to reestablish after whitening, it’s 20% reduction. So you complete your whitening treatment and get the patient to come back two weeks later. So you’re ready for resin infiltration. Cause you want the bond to be working really, really well. [Jaz]Great. And then on the day it’s rubber dam isolation. [Linda]Rubber dam isolation. If you can’t, we use Optragate. Some kids don’t like the intrusiveness of rubber dam. We tend not to use local, so it can be uncomfortable for children. So if we can, and we also do it for everybody with white spots between adults and kids. It doesn’t have to be just kids, and it works just as well on adults as well. So you would isolate because you are using hydrochloric acid. So you would isolate either with a full rubber dam or you can do the Optragate with a barrier. And the Optragate works very well and you just bury it up. Some people just barrier where the white mark is on the tip of the tooth. So there’s different types of isolation that you can do, but you must do it because the hydrochloric acid causes staining on the gingiva, does cause burning. You get chemical burns. There’s no legislation about hydrochloric acid. You can use whatever you want, whichever concentration on whichever age. No legislation on this. Of course, as dentists, we need to do everything that’s safe and there’s product safety legislation and the beauty about icon is so much research on this and there’s ongoing research. I traveled last month to Paris to work with Professor Jean-Pierre Attal, and they have, which is very in innovative. They’ve got a discoloration clinic at the University in Paris. [Jaz]Wow. [Linda]And I go there to consult with them, to help them. I’m what you call like the special, I don’t know, like a, the godmother. The godmother for them. The fairy godmother, the godmother for the clinic to help them. And we look at cases together. But Jean-Pierre Attal has published so much, and if you want to look up more, look up his work. And he has PhD students all the time working on resin infiltration. And so I always go to learn with the best that I can learn. And so I spent a wonderful day in the clinic working with him and in his research lab looking at resin infiltration under the microscope and all those things. And so we working with them and producing more papers on this as the new information is coming along. [Jaz]So, what does it look like? Cause you likened the porosity or the white spots like an air bubble. I love that sort of likening into an air bubble. It’s a great visual image. And essentially once you infiltrate it, can you go over that analogy? What happens to that air bubble? [Linda]So then what happens, there’s a few more things about that. It depends. Little about the white mark. It depends where the white mark is located. If the anatomy of the white mark is also really important, so if the white mark is like a thin crescent on the cervical area, because it’s been poor oral hygiene, those are really super easy to do the resin infiltration. Really easy cause they’re tiny demoralization areas where the white markers on the incisal tip or in the body of the tooth and there is a depth and there is, it’s very, very opaque. And on the severe cases, there’s actually enamel missing on their labial enamel because their enamel’s so weak. There’s a divot, like a, from a, I don’t know if you play golf, but there’s a piece missing out of the enamel. And so you need to do whitening resin infiltration. Plus you need to do a composite bond and you need to be ready to do a composite bond as part of the treatment plan. And often some people find it difficult to work out. Is it a amelogenesis imperfecta or was it MIH. Or is it, you know, there’s many different type of things that it could be, or fluorosis, for example. But, so you need to look at the location, where is it? And then if it’s severe, it needs to have a composite bond. So when we go with the analogy of the air bubble, the first step is you would clean the tooth. I use pumice and Hibiscrub with a little tiny micro brush, not a normal prophy brush, but the pumice and Hibiscrub. Then I would use my aqua care and I use it on the sylc mode, so the sylc is like, it’s got Novamin inside with vanilla flavor, we tell the kids it’s going to be like a vanilla ice cream on your tooth and we jetted and clean it. So you’ve got that, which starts the abrasive. Very mild. Abrasive, but it’s jetting in, so the conditioner, because the problem with MIH children is they are super sensitive. So just rewinding a little bit. And many, many cases need sensitivity management treatment. That’s really important. And but this is the whitening. But that’s part of how we diagnose that it’s this. There’s not only MIH, it’s for all white marks and white spots and white specks and flex and all kinds of things that you would do the resin infiltration. So you’ve got a nice clean tooth. Now you decide. Is this a basic lesion? Is this an intermediate lesion or is this an advanced lesion? A basic lesion is orthodontic demoralization, poor oral hygiene with those white lesions. One isolated little flick, tiny little, tiny little thing. That’s step one. The intermediate lesion would be, again, one lesion, quite diffused, a jagged edge, quite diffused within the middle. So it’s like a spider shape lesion. It’s not clearly demarcated. OBAB:Occlusion is just so confusing. Does occlusion even matter? Wait, don’t you just grind away all the blue marks, right? You mean like plant it low, let it grow or leave it high and let them cry. Listen, what are these interferences even interfering with? Is it safe to lengthened teeth? How much can I raise my patient’s bite? How can you stop your composite restorations from chipping? Can you raise the OVD on a patient with clicking TMJs? Is canine guidance always better than. Why can’t I just use the DAHL technique on all my wear cases? Can I stop my patience from grinding? What the bloody hell is crossover? What should the occlusion look like after orthodontics? How and why do you check for fremitus? What on earth is a custom suicidal guide table? How do you use a leaf gauge? Do you always need to use a facebow? Does everyone really need a perfect occlusion? What is the difference between edge wear and pathway wear? Is it naughty to adjust the opposing tooth? What the is centric? Occlusion is coming. One does not simply just open the bite. May the force mitigation be with you. [Jaz]To make sure you don’t miss the crucial update about the launch of our occlusion course, OBAB head over to occlusion.wtf. That’s right. It’s actually occlusion.wtf. It’s almost released and you’re going to love it. [Linda]An advanced lesion is multiple lesions on many, many teeth upper 4 to 4. Large deep lesions plus a central incisor with a whole piece of enamel missing, or it’s brown or yellow because there’s a defect. So those are your lesions. So you would start with the basic- [Jaz]One little trick. I learned Linda, and I just want some validation from you. Is that, is this a good thing to do? Is this something that you practice as well? Is that to shine a light cure behind that central incisor with the big white patch and see, can you still see the outline of that white patch. And that gives me a clue as to, okay, what are we up against here? Because if you can’t, if you see the outline the white patch, that tells me that, okay, it’s potentially going to be quite deep and more of an intermediate to advance. Is that something that you practice as well? [Linda]Yes. So that’s called transillumination and the way that we do it, we take a photo with it as well. We use, instead of the curing light, you can use a curing light, but SDI make a really good diagnostic light. So instead of the white, instead of the blue light, it’s a white light. So we take a photo with no flash with the light behind. And then you’ve got the photo of the transillumination before this. There’s a researcher whose name is Omar Marouane. Not marijuana, but Marouane. From the University of Tunisia and David Manton. They’ve published on this. And he’s done a whole, a series of transillumination as before he starts. And then as the treatment is completed and with the transillumination, you can see how the lesion shrinks and you can see how the lesion is penetrated with the resin. So going back again, then we need to assess, what am I dealing with, with the transillumination? Then you will etch the tooth. So the etching, it’s called Icon Etch, and that’s for two minutes. Now, we are not used to etching for two minutes. We are used to our 15 second quick flash, flash. So this, you need a timer, you need to time it out. Exactly. And the way that you do it is you place the etch all the way into the lesion. But what happens, because it’s an air bubble, it’s very porous, so it just sucks in all the etch like that. And so you need to, during those two minutes, you need to keep replenishing. So you twist, it’s a special syringe, which is a twist sponge, so that you twisting and you keep replenishing as you go along and you massaging in gently not tickling the tooth, but more like massaging the etch into the tooth and you keep going and going and going for two minutes. If you’re doing a lesion with sixth teeth, what you would do is you place the etch after isolation all the other techniques. We said go with the etch on all sixth teeth, and you start, you set your timer for two minutes, and you start massaging all the way for two minutes on all those teeth. [Jaz]On that point, the surface area that you’re etching, Linda, would you just do the, imagine you got quite, well demarcated white patches, 3 to 3, let’s say canines, canines. Would you want to do just the white patch only or do you want to extend it a border beyond the white patch? And if so, what is that border that you’re aiming for? [Linda]You don’t want to extend it too far. You don’t want to extend it too far, so you can just go over the little white area. So there’s a margin, but coming back to the air bubble analogy, what you’re doing is you’re opening up the top, the lid of the air bubble with your etching. So you would then use the alcohol not for drinking. We taught in Croatia when you and the guy just, he lost it at the alcohol and so we couldn’t carry on with, he couldn’t get it out. It’s not for drinking. The alcohol is a test. It’s the test because alcohol replicates the refractory index of enamel. [Jaz]Of the result that, you know, if you were to resin infiltrate at that point, it was like a preview, right? [Linda]It’s a preview, it’s a test. So you put the alcohol on and you drip feed it for 30 seconds. Very, very, you drip and you watch, so you just drip it and check. If when you drip it on the tooth, the white spot’s completely gone. You know that you can go on just on your basic step etch alcohol resin infiltration. That’s a basic case. But if when you drip it on the tooth, you think, I’m not really sure on this, it’s not looking fab, because you can still see the whole extent of the white lesion. You go back again, then you start again. So you do more micro abrasion so you can then you’ve got a few more abrasion options. You can sandblast with a MicroEtcher from Danville, you can sandblast it. [Jaz]How many microns? Because that’s the next question my Protruserati are thinking right now. [Linda]Honestly, you guys 30 or 50. I don’t think it really, maybe we’ll go on and on about. [Jaz]That’s what I think too, but that’s the next question that they’re going to be thinking. [Linda] Our dentists just keep, you know, I know we anal, but this is like, it is what it is. Whatever it is. 30 or 50. It doesn’t matter guys. Don’t lose sleep over it. You know, whatever you’ve got, you will then. So you sandblast. So you go sandblast etch alcohol, and you do that up to seven times. If you have availability, micro abrasion paste, that is- [Jaz]Opaustre? [Linda]Opalustre™, and you’ve got 6% hydrochloric acid. Then I will micro abrade, so often I know it’s going to be a complex case, it’s a deep lesion. I go straight onto the micro abrasion before I do anything else because again, that roughens up the surface. So you, if you go onto the advanced lesion, you can do only etch alcohol sandblast, sandblast etch alcohol, sandblast etch alcohol. Now, there is a new step, which I saw at the University of Paris. Professor Jean-Pierre Attal has taught his students to take a scalpel and where it’s really, really chalk. After you’ve etched it, you opening the lid again of the air bubble and you gently shave off the very opaque, like chalk you gently, gently so that you’re not using a handpiece unless you need to. You gently shaving off some of that chalk dust and then you go back and you go etch alcohol, etch alcohol, and then you test it as you go along, but that way- [Jaz]Up to seven times. [Linda]Yes, up to seven times. But that way, you committed. If you start with your handpiece or your scalpel, you committed to a composite bond so often. Actually, I would say like 80% of time, I would always add the composite bond onto the treatment plan anyway. If you don’t need to do it, you don’t, but you don’t want to do it as an excuse afterwards because, you know, so you just added on. [Jaz]You’ve answered one of my queries, and actually a question that I discussed with a dentist before is that when they’re communicating and they’re treatment planning for patients, the way I, and I’d love to know, I’m sure you got much better automated version than what I do, but essentially, I charge the patient or the parent or whatever for I will manage this white spot, how, I will manage it. There’s a range of things that I might do. I will manage it. It may go up to removing some enamel and doing some composite at the end. It may stop short of that, but I will. So, because one lady dentist, she messages me saying is that, I don’t know how to charge this case. I don’t know how to communicate it because, I want to tell them, okay, it might be, it’ll be whitening. And then it might be icon, but then if it’s a composite, I’m going to charge you this much more. And if it’s this much more I’m not, I’ll be like, don’t do that. Just charge it as a package and just do what you need to do. What are your thoughts on that? [Linda]I think that’s good, but often, so as we discussed, sometimes whitening does the trick honestly, in a 5% of the cases. That’s it. So then you don’t have to have anything else, which, so that’s why I think you need to charge properly for the whitening and then the management of the white spot. And then you can go into the package, the resin infiltration or removing enamel and then with a composite bond. But if you know it’s going to be, then you were, if you know that there’s already a defect, you’re going to do it anyway. So I like your idea. I think that’s great. That’s a very important to choose which composite you’re going to place over that. But coming back to the actual technique, you need to warn the patients that you may need to remove a little bit of the enamel. So that, yes, it’s minimal invasive. And the other thing, one of my students messaged me afterwards said, the tooth goes very flat. It does go flat if you’re massaging and etching and all that, and sandblasting. And then again, you need to pre-warn the patient. The tooth number one may become more translucent because you’re taking off a tiny layer. So you see the little mamelons, you know, you see that little blue translucent area. More often it goes more flat and it’s got a horrible taste during it. So even though it can feel rough at the back, and again with kids, you need to just warn them. So just coming back to the technique, so we’ve done the etching process. Then once you see, okay, the alcohol is really removed, I can see it’s working. Then you go in with your infiltration. And the infiltration is done twice. So there’s two schools of thought. This is the classic thought is that you go in for three minutes. Again, if you’ve got six lesions, you place it on, it’s still the air bubble, it’s still porous. So to get, it just keeps being absorbed. So you keep replenishing as you massaging in for those three minutes, replenish, replenish, keep replenishing. So you’re twisting and holding and massaging and checking. All that. Remember, really, really important, to floss through because the resin, it’s a clear resin. It’s called TEGDMA resin. It will adhere between the two teeth, and its difficult after it ends approximately. So you must floss through before you go. Then you will do your light. Your light, it’s 40 seconds, not a quick flash of 20 seconds. So the way I do it, if I’m doing six lesions, is I will flash it across all of them just to get started for 20 seconds. Then I go back individually. And do 40 seconds each lesion as we are going along each lesion like that. Just checking. Again, some research says, but we don’t recommend it at the moment cause we need more research. Why don’t you do it for longer? Why don’t you just etch for 11 minutes and place the resin for that amount of time? But there’s not enough research. Again, we go with Professor Jean-Pierre Attal, who’s done the research with these PhD students on it and published a lot. So you will do all your infiltration for three minutes. It’s a long three minutes, and you keep going and going and going. Massaging, massaging, massage it, then floss through. Then you go back again. At that stage you can transilluminate and look and see what the resin has done the first line of resin. And then you go again with one minute. Et cetera, floss through. Then you need to look and see how it’s looking and make sure there’s not too much excess. You know how resin is. The TEGDMA resin is quite flowy anyway, so just have a look and if you need to remove any excess, you take your soflex disc, not the black one, but like a medium blue, not the navy, the medium one, smooth over and use a rubber wheel. And also those lovely composite polishing burs, the EVEs and the Astropols and all that purple and cream, you just polish. You just polish it up nicely. Remind your patients not to go and have anything with food staining. Immediately afterwards, one of my students sent me a photo where her patient made to have ramen 10 days later and the teeth became orange. I think it’s because, number one, that maybe there’s a couple of things. Maybe the risen wasn’t cured enough, so you need to really do those 40 seconds of cure and then make sure it’s smooth enough so that it’s a nice labial contour is nice and smooth, not a big blob of resin. [Jaz]Hence why you use the polishers in a sequence to make sure it’s resin. So you are polishing the resin as you would do for a composite. [Linda]Like a composite. Yes. And then afterwards, in terms of maintenance, It’s a really good technique. What we also learned from working with it is that the resin keeps going. It keeps infiltrating. So just on the first occasion, you think, I’m not really sure if it’s fab, you go back again. You know, that’s the end of the appointment. It’s been your hour. You’ve done this. You’ve gotten, you know, because between the photos and the consent and the explanation and the technique, it’s a good hour. A good hour means another 10 minutes as well. Anyway, and so after that you bring the patient back and you would review the patient about three weeks or a month later because one of the very first times I did this technique, I didn’t do any whitening for a patient who was about 64 years old. I wasn’t even sure if could work. At the end, when I finished, I was like, this is not bad. When she came back, it was even more stunning, but it’ll completely eradicated. So it keeps working, which is why you say to the patient expectations, manage the expectations. The other thing is when you’ve got a rubber dam on, you’re going to get more white spots visible than within the first place. So often on those kinds of cases, I will actually draw with a pencil the white spot, the extent of that white spot. It’s there. Because I don’t have to do that one, that one and that one because- [Jaz]That’s genius. I didn’t consider that before. That’s so clever. [Linda]Just, but you just write, you just kind of draw that and you work on that part of the tooth first. Then you rehab the patient, rebates come back and you review the situation. Now the next common question is, what happens if you’ve done the resin infiltration? Will the whitening work? And the answer is yes. So because the way whitening works, it works in multi directions the same way. This is a new hot topic. We can discuss it another time. Whitening and Invisalign, hot topic number three. Very, very hot. [Jaz]Mm-hmm. [Linda]And the same way when you’ve got the buttons on the teeth for the Invisalign, they think, well, don’t do the whitening now. Wait till the end. Absolutely not. After a few weeks, you get on and do it. And the whitening goes underneath, through the enamel, through that way from the pulp dentin into the enamel, it goes that direction. So it’s absolutely fine to do the whitening at a later stage if you want to rewrite it. [Jaz]That’s a real gem. And I didn’t even think of that question to ask you, but you’re, I’m so glad you covered it, that a lot of people are concerned that once they do the icon resin infiltration, that’s it. They’re done, they can’t whiten. But you just answered that really well. And there’s a few other questions I have, but you know what? I’m going to save those for our hands-on session, so there’ll be lots of goodness there. So I think you’ve described the protocol beautifully, and you’ve also talked about about transillumination stuff. What are the predictors of success and failure? Are there any cases that you see that you think, oh, this might not work so well. Or equally an opposite to that. Cases that come in and say, yes, this, I’m going to nail this. Because a lot of dentists, when they’re first starting out with this technique, they’re always like, oh, let me ask a mentor. Cause I’m really not sure. [Linda]Let’s just say there’s just one more thing. I just wanted to mention this. [Jaz]Sure. [Linda]In terms of the predictors, if you don’t infiltrate completely and when you finish the infiltration, at the end of the point or the end, the first resin, the first time you kind of do it, you go, ‘Hey, but there’s a white halo around this lesion.’ That means you haven’t completely infiltrated with resin properly. Okay? So at that stage, if there’s a halo effect, it means it’s not infiltrated deeply enough or correctly. So you need to then go back a step or two. You would take your black soflex disc, remove the resin, go back and sandblast and go back again so that you can go deeper with it. Otherwise, it’s incomplete infiltration. Even- [Jaz]So this is like a repeat icon resin infiltration. Like a few weeks after to fix a halo that because you know, you missed it, whatever. We’re human whatever. Yeah. [Linda]So, that can happen as well, just so that you know that you can go back and remove it. But it’s always, that’s why you can go up to seven times, you’ve got all this time to make sure that you completely infiltrated and the use of the scalpel to take the chalk dust off also helps you to go deeper. So. [Jaz]Amazing. [Linda]That’s good. And in terms of predictors of success, we spoke about the size of the lesion, the color of the lesion, and the opacity of the lesion. Super duper opaque will probably need. Mega abrasion, which you might want to take a handpiece a little bit and take the lid off more of the air bubble so that you can go deeper with the resin. If you see that it’s not great, you go deeper again and you’re going to score art with a little round bur a little bit there. So then it comes back to a really important thing, which composite do you use? Over the icon over the, because there’s a whole lot. And the recommendation from Professor Jean-Pierre Attal is not to use an enamel composite. Cause enamel composite is translucent and you’ve got a white lesion, opaque lesion. You would use a body composite. So look for a, like a dentin composite that’s ultra white. So that’s why we do the whitening to blend in to the opaque, to blend the white to the surface around. So you want to do that and then you choose your composite. We would use a bleach to shade composite, but not a translucent. Always. There’s a Tokuyama, A1 body, which Jean-Pierre Attal uses. There’s a brilliant composite from DMG where they’ve got a bleach shade composite, which is fabulous. There’s another one from SDI, which is called Bleach Shade. Bleach dentin, which blends over. So you need to, again, like you’re doing, you know if you’re going to do the technique. Now, what we didn’t discuss was that, you don’t, after you’ve done your resin infiltration and you’re going straight onto your next step composite, you don’t have to re-etch and you don’t have to rebond because you’ve used the TEGDMA bond. The TEGDMA is an unfold resin. You go straight on and you put the composite straight over and you scotch it. [Jaz]But you can cure though, right? You can cure it to see where you are or don’t even cure it. You put the concept over the uncured, TEGDMA. [Linda]No, no. So, you cure it and you do your three minutes of resin curing. But then you go straight with your composite. So before you even start the case, before you’ve even isolated, before the rubber dam, I’ll just put some cotton wools in and work on your composite shade. Just check your shade if you’re going to go on with a bond. Check your shade before you even start where that white lesion as is. Look at enamel shades, look at body shades, look at dentin shades, and just choose which composite is going to be the one. Because there is a defect, you have to do it and then you go back. Cause otherwise it’s going to mess you up in terms of the color afterwards. [Jaz]Brilliant. I think that’s so many real world tips here, including the actual, that was a question I was going to say for the hands on. I was like, okay, which composite? And also how do I put the composite on? Do I use Universal Bond afterwards? But you’ve answered that brilliantly. We don’t need to do anything, we just add the composite on. [Linda] But you need to sculpt it nicely. [Jaz]Sure. I like to use like some of the brushes from cosmedent and whatever, just to get a nice blend. And then obviously the full polishing protocol, amazing. What is this common question again? What’s the expected longevity of this? So some dentists say, I’m a little bit concerned, do we have enough data or how it’s going to look like in five years and 10 years? What is the evidence suggest or clinical experience? [Linda]The research has shown that it’s predictable with the following discussions that we’ve had with all the different basic case, intermediate case, advanced case. Longevity, it doesn’t come back unless incomplete infiltration. In terms of stain, you know, some patient with poor oral hygiene, if you’ve done a beautiful composite bun, you get a black line or a brown line where the joint is, you don’t get that, but you may, which I’ve been doing it for the last nine years. Now you make it like a tea stain, a very light tea stain over where the resin is, and all you do is just polish it with your rubber wheels and that’s that you don’t need to redo it. Don’t need to redo it. So that’s- [Jaz]Do we have, I imagine success rates are a difficult one to gather because every lesion is unique in terms of depth. So do we have enough sort of success rate data based on the how variable it is? [Linda]When I first learned the technique and saw teaching the technique, one of my students came up and said, no, it doesn’t work. But now we know there’s modifications. Every lesion is different. And they said, because MIH has got different chemicals, it doesn’t really work on MIH. So we’ve modified the technique, and by modifying the technique, you get a much more predictability, and you’ve also got the predictability of doing a composite bond. So with all that, the success rate is high on it. [Jaz]Amazing. I mean, you’ve answered all my questions and now I’m really excited for this, this hands-on session, to do molars and anteriors for those who haven’t done it before. Are there any other messages that you want to pass on to dentists who are maybe learning about icon resin infiltration for the first time? I feel like we’ve covered the assessment of the lesion, the actual clinical technique itself, and you’ve gone way well and above and beyond in terms of the nitty gritty details. Any other messages you want to pass on to dentist while you have the microphone? [Linda]I think that also from our point of view, the etiology, which is unusual that you’ve gotta ask patients or their parents their birth history. So you want to know, for example, were you born early? Were you on time? Were you late? Because early preterm babies, they’re premature more likely to get white spots. Another interesting thing is celiac disease, for example, celiac disease also results in white spots, again, because there’s calcium absorption deficiencies, right? From an early age. So medical history is important, is relevant, and you want to show that you’re a caring practitioner and that’s really important. But basically the technique is, you know, whitening resin infiltration, composite bond. But you still want to get a more understanding of the medical history because from our point of view, we also scientists as well as clinicians, and we also need an empathy factor that’s really a very important, the care factor. A patient is a human being and so we need to modify, communicate really well. Expectations, pre-op assessments, paperwork, really key Jaz. You must have your paperwork, you must have explanations, and then you can build up your photo library. That’s why I created these books. Again, it’s available if you want me to send for you to see. It’s nice as a clinician, when you starting, start on basic cases, start on an orthodontic demineralization case. You know, one tiny flick. Just get used to the technique. Also younger kids, the younger patients can be a little bit easier, just depends. And then you build up a library of cases, in your experience so that you’ve got a whole library. And that’s why I show my patients this case looks like this little boy and we, for this little boy, we did X, Y, and Z. Yours looks like this. It’s not so severe. Then you can show them. Some of the severe, you know, because some patients are so distraught that they’ve just got a one tiny little white flick on the tooth that when they see other cases that is really much more severe than, it’s not so bad, but communication, paperwork, financial planning in terms of the costing, the signed consent form. In terms of consent, patients always have to have a 24 hour cooling off period. All the risks and benefit all the options. And the whole beauty about resin infiltration is that the option is veneer or a crown, I mean it’s very severe. It’s like so minimal invasive. That’s why for me it’s like why wouldn’t you? If this is, if it would you do it for your daughter. Absolutely. So, you know those kind of things, but you must explain the ramifications. Some dentists charge per arch for the whole lot or some dentist charge per tooth, whatever works for you. But sign the consent form, sign the financial arrangement. Make sure at your treatment planning discussion, a financial arrangement has been made with a parent and they understand the five different options in your practice of how you take care of fees, et cetera, so that it’s all run smoothly and that’s taken care of it. The admin’s taken care, and then you just go onto the cilinc. [Jaz]Amazing. Linda, thanks so much for, I know you’re such a busy woman, and I really appreciate your time and giving so much information. I’ll be in touch with yourself and Rachel to get find a date. We’ll do this. It’s going to be great to do a Zoom session. I’m actually excited. I’ve done fair few anterior cases with great success with Icon Resin Infiltration, but I’ve never done a posterior and I’m actually really excited to learn that and be able to offer that to my patient, so we’ll be in touch guys. Stay tuned for that. Linda, thank you so much. [Linda]Thanks so much. Thanks, Jaz. Jaz’s Outro:Wow, there we had it. Was that absolutely mind blowing? This woman is just so full of knowledge and the little nuances that she covers is why she’s number one at what she does. Guys, I’m a huge fan of Linda Greenwall and so if you want to do some hands-on training, DM us on @protrusivedental on Instagram and let us know. And so if there’s enough interest, I will get in touch with Linda and we will make it happen. Just like we made the Portugal trip happen, we can easily make this happen. Do you remember if you’re a Protrusive premium member, not only can you claim CPD for this full episode, which was full of educational gems, but you can also head to the Protrusive Vault to download the treatment guide with all our Protrusive masala. Just like I said before, It is phenomenal. I hope you love it. I hope you use it. I hope you’ll be extremely practical. You should print it, laminate it, keep it the surgery so that you can successfully assess and treat any type of white patch. Thanks to that document. Listen, if you found this episode useful, do send it to a colleague and I look forward to catching you in the next episode. Thank you again.

‘Doing’ Social Media is HARD work!’ Do you find it difficult to make time for this? Do you worry about professionalism and ethics on social media? How about the blurred boundaries between professional and personal life? Dentistry is no exception to the trend of using social media in today’s culture. Dentists are using social media to connect with their patients and create new opportunities for patient education. However, dentists face ethical challenges such as how to best communicate with patients online, and what is the best level of consent to get from patients when we post their photos and videos? In this episode, Dr. Alessandro Devigus also suggests how to use social media as a business tool and how to keep your personal life and professional life separate. https://youtu.be/TEBmlDlybLE Check out this full episode here 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 “React and interact with your audience how they WANT you to see” – Dr. Alessandro Devigus Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 1:19 Dr. Alessandro Devigus’ Introduction 4:20 How Dr. Alessandro started on Social Media 6:30 Drawing the line between personal and professional account 9:41 Importance of having a social media for Dental practices 14:38 Dentists posting full protocol cases on social media – good or bad? 20:14 Spotting fake dentistry 24:57 Making time for social media 31:59 Consent from Patients for sharing their photos – how to do it? If you enjoyed this episode, you may also enjoy Personal Branding for Dentists, Logos, and Websites with Shaz Memon Click below for full episode transcript: Jaz's Introduction: You don't need me to tell you that SOCIAL MEDIA is absolutely huge in all of our lives. If you're listening to this, I'm sure you're involved in social media in some way or another. Jaz’s Introduction:It’s NO EXCEPTION for dentistry, but this creates new problems and dilemmas, new ethical dilemmas for us dentists. How do we best communicate with patients online, and what is the best level of consent to get to patients when we are posting their photos and videos? And where exactly do you DRAW THE LINE between PERSONAL and PROFESSIONAL? These are the burning questions we cover with Dr. Alessandro Devigus, who not only has a huge following on social media, but he’s such a level-headed guy as an extremely experienced, successful clinician. One of the topics we discussed, which you may resonate with Protruserati is HOW to MAKE TIME for SOCIAL MEDIA. Many of you are struggling to find the opportunity throughout your busy lives to actually have a presence online. And so when I ask this to Alessandro, he had a really good answer, and it involves doing a bit of work, a bit of an audit of your time. So that’s something we cover towards the middle and end of the episode. Hello, Protruserati. I’m Jaz Gulati. Welcome back to an Interference Cast. This is like a nonclinical interruption. If you’re new to the show, then thanks for joining. Do check out all the other episodes. Mostly a lot of ’em are clinical and they’re very geeky, and I get very excited about teeth and dentistry, and hopefully that gets passed onto you. But we talk about some varied themes. So hope you enjoy this episode with Dr. Alessandro Devigus and I’ll catch you in the outro. Main Episode:Alessandro. So I know this podcast we’re recording today is about social media, but we must know what is your secret to looking so youthful? [Alessandro]It’s my wife. I’m married for 33 years, so happy wife, happy life. [Jaz]Happy wife, happy life, and somehow good skin. [Alessandro]Yeah and it’s my Sardinian roots. So, Sardinia is known for people getting very old. So my father is now almost 90. There are a lot of people there. And I think the number one secret of getting old and looking good is reduce stress. [Jaz]Mm-hmm. [Alessandro]Stress is the one or the number one thing making you older quicker, let’s say, mentally, physically with all aspects this is from my point of view. It’s not that I’m a super healthy food eater doing sports every day. I don’t smoke. I drink alcohol, but I don’t smoke. I think smoking is one of the number one. Things all smokers always tell me, yeah, but you drink red wine and whiskey. Say, okay, but I don’t drink bottles a day. So I think I have under control not to drink too much, and yeah, and again, having a good family, a good social network that helps you if whenever there’s an issue. I think these are the key elements creating this, and in this atmosphere or in this context. I think you show, or you look younger to the other people. Although you are not young, you know what I mean? So, it’s- [Jaz]Mm-hmm. [Alessandro]Maybe you have seen this also with patients. Some patients they come, and they are 40 and they’re saying, oh, life is awful and blah, blah, and then they look and feel and express being much older- [Jaz]And tired. [Alessandro]Yes. And then you see 85 year old guys, not walking straight, but smiling and are being happy. And then you feel the spirit. You feel the youth coming out and they say, okay, maybe tomorrow it’s over, but I will enjoy my life. Life is too short not to enjoy it. So this is a very important point, I think. [Jaz]For those guys listening. Alessandro sounds great for those watching. He looks great as well. You have to take my word for it. And if you don’t already watch the episodes, you can catch him on YouTube and Instagram, whatnot. Just remind everyone, you came on the photography episode, and you talk a little bit about your roots, your interest in photography. Today we’re talking about social media. And I mean this in the most kindest way possible, Alessandro, right? I just told you, you look great for 60. Okay. Most of the six-year-old dentists I know they steer well away from social media, yet you are blossoming on social media. What you do on social media, I don’t see many of this doing. You are wonderful at social media. So, tell me about how you got into. Just the habits that you have on social media, your presence on social media and I mean, again, I mean this in a nice way despite your colleagues who maybe your age have probably don’t even have an Instagram account. So, tell me about that. [Alessandro]So basically, I restarted my social media career three years ago. So I was on social media when everything started because I’m a computer geek. So I was one of the first Twitter user. I was in immediately on Facebook, on all these channels, but then realized that I made a big mistake. And this is something, let’s say the first important message goes out to everyone, young, old, whatever, women voice man. Don’t mix your social media and your private life. So be aware you can have a private account whereas a young girl, who show bikini photos of yourself, or as a young man pumping in the gym, that’s fine. I’m not against this, but don’t mix these accounts with something that you want to be professional. So if you have an account for your dental office, don’t show yourself too much in your private life driving your Porsche or whatever because this creates a wrong image. Even if you have achieved something in your life, making it possible to buy a Rolex or all these gimmicks that people think, wow, if I have a Rolex, if I have a Porsche, I’m a bigger, I’m more important. But if you feel doing this or wear expensive clothes, don’t show that to your clients. It’s like my brother, he has like four Ferraris. He would never take a Ferrari driving to a client, never. You know, then you take your normal car, you dress yourself like you have to in a business suit or in your office. So react and interact with your audience how they also want you to see and this is the number one message of how to start or how to think about starting your social media career. [Jaz]Alessandro, I wholeheartedly agree with you on that. What about, I’m gonna play devil’s advocate. What about the situation whereby like I, myself, I do this whereby, I post a dental stuff on my, not Protrusive Dental, but on Jazzy Gulati, I post a Teethy stuff. But now, and again, I have family because for me, family is one of the highest values. And what I think that does is it humanizes me. So when prospective patients come say, oh, he’s a father, he’s a husband, I want to go to a family man. Do you think that’s okay? Showing your children, showing yourself not necessarily in bikini and whatnot, not necessarily luxurious, but in a family environment or, I like football, Mans Tonight, cricket. What about those things teach us about. [Alessandro]Yes, I think this is important to show yourself then it’s your decision in what extent you want to integrate your family. I always tell people, look, have you asked your children if they want to be on social media? Do you have the written consent of your three-year-old boy or girl jumping around, making a fool on your Instagram account? So these are the points. I think it’s important to show people that you are a father, that you have a family. You can share these facts in short things, but don’t overdo it. Don’t overdo it. What I do is this is something important. From time to time, I do a new story. Talking about who I am. So I tell people, look for all those, for the new followers, for all people not knowing me. My name is Alessandro Devigus. I’m a Swiss dentist with passion for digital technologies and I want to share this and this and this and that, and that and that with you. And so it’s like a refreshment on people not knowing who I am. You cannot expect that over, because social media is very short life information, so from time to time you have to repeat, and I agree with you that you can integrate your family, but your family has to agree on that. So this is an important point. Just don’t, just take your smartphone, shoot the videos and post them. And then after that, your wife might say, ‘Hey, come on. What the hell are you doing?’ You know. So I think this is important that it’s in agreement. And again, be also aware that your children might in some years say, ‘Hey, Dad what the heck did you catch me when I was falling down the clip? And now it’s there and my colleagues are sharing this video, showing me this video of me failing.’ So be careful. Be aware of all these facts. But again, I agree. Show your audience. Show your clients. Show your patients that you are married, that you have children. [Jaz]That you’re human. [Alessandro]Yes. That you’re a human. Yeah, absolutely. But don’t overdo it. Do it on a regular base, but not every day. So let’s say 5%. 5% or max 10% should be personal stuff and the rest should be professional stuff. [Jaz]And that’s different to your other personal account, which you may have, which could be private, for example. And that’s where you could just do expression of yourself as an individual rather than you, the dentist who’s now speaking to patients all along which is great advice, I think. And that’s really good. Let’s switch gears a little bit to the main first question I wanted to ask on this episode, which, and we kind of touched on it already, is that we are at a stage now where I would say 99% of general practices have got some sort of a website. Not all of them are good. Yeah, I know some practices who don’t even have a website at the moment, still to this day. Okay. And then fine, but most of them do. But a lesser percentage has social media. Now, one thing I truly believe in over the last year or so is like with Protrusive Dental, social media. I don’t do much on Twitter. Okay. And actually, I’m thinking that I’m not gonna do much on Twitter because it is just, I don’t resonate with it as much. And I truly believe now that if you’re gonna have a social media, then do it properly. There’s no point in having a social media and doing one post a year on that account, because someone else might come on and check the Twitter and be like, oh, this isn’t very active, this isn’t very good. And then be like, oh, this is not representation of that brand. So one mantra I follow is that if you’re gonna commit to having a Twitter, do it properly. If you’re gonna commit to having Instagram, do it properly rather than just having it for the sake of having it. So where do you see social media for practices who have websites and then maybe for them to get to a social media presence now is too much of a big step. What would you say to that dentist listening now who hasn’t embraced social media yet? [Alessandro]Basically there, there’s some research and dentists are also visual. Let’s say visual people. So what we are doing, what we are communicating is our patients want to look better. So they want to change something. They have problems we solve. So it’s a visual thing. So Twitter for sure is not the right channel to interact with your patients. Then we have like in Instagram, TikTok, and Facebook, there are others like Snapchat and WhatsApp. WhatsApp is almost an underrated social media tool that you can integrate also in your marketing campaign interacting with patient. But be careful with communicating with your patient on all these channels. Watch out for the legal issues. So I tell dentist, don’t share too much information via smartphone with your patients. There you should use safe channel. Safer channels. So a patient might send you an image of a broken tooth, that’s okay, because he sent it, it’s his information. If I took a pic, if I take a picture of myself and share it, it’s my problem. But you as a dentist, you cannot just take pictures or receive images and share them with others without asking the permission of the patient doing so. So this is the side effect coming back, I would say today, you should focus on Instagram. If you are a younger generation dentist who wants to fool yourself a little bit and you have a young team that also wants to dance, TikTok might be an alternative. I’m not so much into TikTok. I tried doing so, and I found that what works on Instagram doesn’t really work on TikTok, so my main focus is on Instagram because what I found out, Facebook still is the largest community. But not really engaging. So you easily , I call it and we discussed it already for me. Facebook is the happy birthday platform. If somebody says, oh, it’s my birthday today, then you get wow, hundreds of comments. If you post some valuable content, nobody interacts. So this is the situation. Facebook is great if you want to promote your office with advertisment because you have 2.5 billion people. It’s easy. And it’s interesting if we have done some research, there are more dentists having a Facebook page than having an Instagram account or other social media. So in the dental community, if you ask them, number one is I have a Facebook account because at the end it’s also mandatory to have one if you want to have an Instagram account. But still the dental community or the medical community is still number one on Facebook not being really active. This reflects also the average age. The dental community is getting older and Instagram is like, oh, I have an Instagram account, but I don’t know where to start. So the thing that I felt browsing over the last two, three years, many dental accounts is. I would say 90% have no plan. [Jaz]I agree Alessandro and one observation I’ve made, and something I spoke about in a little mini webinar that the BDA did recently to young dentists about social media is, and please tell me if you agree or disagree with me, is that I want dentists to decide who their account is for. Is it for dentists or is it for patients? Because a lot of the time dentists are posting up shots that only a dentist would appreciate and labeling perikymata, et cetera. Whereas a patient would be like, what the hell’s going on? Whereas patients wanna see full faces and other types of videos, which the dental community may not engage with as much. Basically, they still would. So would you agree that, you know, as a dentist or dentist office, you need to first cite, okay, are you actually making content purpose-built for patients and the public or other dentists and you wanna show them your line angles, et cetera. Would you agree with that? [Alessandro]Absolutely. And this is one big mistake a lot are doing. They want to do both on one account and this doesn’t work. [Jaz]And some do, but there’s they’re few and far between. And you alienate the one or the other sometimes. [Alessandro]But if you look at the successful accounts, they’re not really showing. Nobody shows blood images because patients don’t want to see any blood, any that a dentist might even like, but the patients don’t. But what, I also must say this before and after, before and after, before and after thing gets a little bit tiring. Some patients might jump on this, but you see also on this more successful account that they’re mixing more and more personal stuff with this. So they do less before and after. And show more behind the scenes what services they are offering, showing up themselves. So this is the thing, because I had an interesting discussion in life with Miguel Ortiz, dentist from Boston about all the fake dentistry we are seeing on social media. And nobody cares. Nobody cares. Not even the dental community. They give likes to photoshopped images and it’s amazing. It’s amazing how uncritical the audience is towards the information posted on social media. But again, I agree and this is an important information and message to the dentist out there. You have to decide, is my account for my patients and potential new clients, or do I want to share how cool I am or not even how cool I am. I think I have to share my knowledge with the community but then please share the knowledge before and after is not sharing any knowledge and what I have experienced over the last three years. I have posted thousands of comments asking, can you please share more details on this case? You don’t get any answers. What does this mean? They know that they’re a fake. [Jaz]Okay. I mean, I think it’s a platform issue as well. [Alessandro]Or is it an arrogance? I don’t know because it’s called social media for a reason, and I see that especially the dental community is missing out being social on social media. If you post, then you have to be ready to answer questions. Otherwise, turn off the comments. You can turn off comments in your post. So then if I look at the picture and I seek, there’s no way to post a comment. So the person who posted this image or this video doesn’t want any interaction. But if you post and anybody is able to post a comment, then please, please, and this is a message and I want to everybody to listen to this. If I ask you a question, I want an answer. I tell people, if you don’t ask questions, you will never get answers, but I have to modify this. If you ask questions on social media, it’s most likely that you don’t get an answer. And this is sad for me. This is really sad. If we don’t communicate, if we don’t talk to each other, we will not grow. I don’t learn from a cool before and after a while I say, wow, I will never be able doing this. I want to learn. And if I ask a question, you can answer, I don’t answer this question, but please give me an answer. And I always ask in a polite way, you know. [Jaz]I have seen that and I can vouch for that and I think I personally think Alessandro, while we’re talking about it, could be a difference, innate difference between Instagram and Facebook. So firstly, I agree with you that the reach is different when I share a video. I did share a video the other week about this cool suction tool about cleaning crowns. It got 1700 views on Instagram and 201 on Facebook. So I definitely agree with you in terms of how content and media is consumed and reached on the different platforms. But there may be a difference. So when, sometimes when I share full protocol cases, A) Instagram only limits me to 10 images and I can’t individually caption each image. Whereas on Facebook, I can post the entire series of 125 step by step, and under each image I can write a caption. So I do feel as though that these are fundamental differences and it becomes more difficult. However, I do agree that when someone asks a question, it’s good for engagement. It’s good to grow our community of practice by answering questions, and I do feel that Facebook sometimes does this better, and I think that’s something for us to learn and grow from. I think overall, taking a step back, I have learned so much from social media in terms of dentistry. It’s actually amazing, I think. Are you used to say more from Facebook than Instagram, but nowadays, I think from Instagram as well. I think there’s so much to learn, but you’re right, we should maybe be a little bit more critical of the stuff we see and too fair. I don’t even consider. When I see photos on Instagram, is it been Photoshop or not maybe it’s just me being rose tinted glasses or whatever. Any ideas on how to spot a fake? [Alessandro]I think if you are a decent dentist, you immediately see that papillas cannot grow, that something looks too perfect than nature. And I have to tell you. Maybe you can see some veneer cases that have done that really look like nature. But if you go close, then there are only a few things that are really perfect and the larger the things get, the more you see that it’s not nature. But the thing is that most people don’t want to see it. It’s like going to Cirque du Soleil, you know that you are in a Dream World and for two hours you go and watch the show and dream on, let your mind flow. And I think too much people are consuming social media that way. Again, they’re not critical. They’re giving likes for things. I sometimes also scroll the feed and then double tap, and then I go back and say, no, no, I don’t like this. I don’t like this. So then I remove my like, you know what I mean? And people- [Jaz]Because the algorithm responds, it’ll show you more of what you like in the future, which is- [Alessandro]Or people tagging you and then you feel like forced giving a comment. And now I’m really starting to sometimes also being critical, but again, always in a polite way to start interaction. And what I get sometimes that I get a direct message telling me, why are you so critical? Why are you posting negative comments? Say, no, this was not a negative comment. If I ask you a question, why have you selected this material? This is far off by being negative. [Jaz]It’s gonna help to, for everyone to grow and learn and share. [Alessandro]I want to start the discussion, and again, a lot of people are afraid of starting discussions on social media. [Jaz]Again, I do think Facebook lends itself better to discussion. That’s how I feel. [Alessandro]Yes. And that’s also why you see a lot of Instagram accounts of dental Instagram accounts are still private. [Jaz]Mm-hmm. [Alessandro]They are still hiding themselves because two reasons. They don’t have a strategy, so they look at other feeds and see, ‘Oh, my feed looks strange.’ Or don’t know what’s wrong. So they keep it private or they are afraid of entering the discussion. So these are the two points, and I always tell people, ‘Hey, come on, show yourself.’ I want to see what you’re posting. I cannot follow everybody who is private, just to see what’s behind the account. If it’s just a private account, showing family picture or is it, and this is coming back, the importance also of how you show, how you present your account on Instagram. The importance of the, of your profile page, of your bio that you write there, who you are, what you’re doing, what your goals are, and then try to be consistent in your feet. And so I’ve personally, for example, also started reposting pictures of others dental photography. So, reposting artistic photographers, especially from people from South America that they’re great in doing all this artwork. I don’t know where they find all the time to do so. And then I say, okay, if I just repost clinical images or let’s say artistic images or try doing artistic images myself, I’m one of a million. You know what I mean? [Jaz]Mm-hmm. [Alessandro]So it’s nothing special. So then I started, okay, why not share my knowledge with the audience? And this is then finding this is then the topic, finding your niche. So what you want to share, what you like sharing with others. And I think this is the way to go on your social media if you want to show yourself as a dentist, as a private person, so on. And again, coming back this is then one, one thing, and the other thing is showing your office, showing what you are doing, showing what you are, offering your services, et cetera. Two, be like the window, the showcase of your office attracting potential clients. [Jaz]Absolutely. It should be an extension of you. It should be a projection of you and your values. I totally agree that. I remember being in a lecture in 2014 of some dental marketing expert, but there’s a group of dentists in the audience. So this was like eight years ago. And I remember the biggest objection that my colleagues, which are, who are mostly my senior at that stage, of my career, were saying that, where do you find the time? I don’t have time, you know, amongst children, clinical dentistry, life, and everything that happens. Where do you find the time to post? So what would you say to that dentist who has this as their number one objection? How can they magically find the time? [Alessandro]Just check, start checking your agenda. And then it’s like, uh, if if somebody tells me I don’t have time, then I ask him, okay, for one week, write down what you’re doing when. So when are you getting up? What’s the first thing you’re doing? What’s the second thing? And just write down how your days are going, and then you might see, ah, in the morning, I’m just sitting 30 minutes on the toilet. Maybe if you take that much on the toilet, use this time to do something. You spend 30 minutes drinking coffee. Or whatever, or in my dental office, I have the routines. Most of the dentists then say, okay, from eight to five I’m totally blocked, and after that I have some time. But if you then after analyzing your schedule, still realize that you don’t have time, then it’s mandatory to look for professional support in the sense, look for a coach, for a social media manager that helps you. If you still want to present yourself or your dental office. And this makes totally sense because if you then calculate, you should cut off two hours a day from your dental schedule to become a social media manager yourself. This doesn’t make sense, and this is way, way too expensive. Your fee, or at least the loss of working hours over the whole year is worth thousands of pounds or dollars or Swiss Francs or whatever. And if you calculate this, I agree, and this is why, I don’t know why not more dentists are coming to me. I’m offering these services. I have some people behind me helping me with producing content or giving me ideas. There are some tools you can use. By the way, I’m now setting up like a mini course that will be free, how to start with all this, but it ends up- [Jaz]Amazing. [Alessandro]It ends up with a decision, okay, I have the time to do it myself or with some members of my team, or I don’t have the time, and then don’t wait too long. Then get in touch with me or other people who are offering services, coaching services. So I have some dental practices I’m coaching, and we have a coach, a call once a week to discuss what are the next steps, what can be improved. And then you find so many small things that are not working. And at the end it’s slowly the engine starts running and then you’ll get happy and don’t spend, don’t do anything that you don’t like to do. So if you feel forced being a content creator on social media, then stop doing this and look for professional help. [Jaz]I think that’s great advice and I’m glad you mentioned about how to get more help. Ie reach out to you. Is it @dentist.Camera that you wanted them to reach out or where is the best way? [Alessandro]Best way is my Instagram account and maybe I’m allowed to do a small advertisement at this stage. [Jaz]Please. No, please. I insist you’ve helped me so much. Please do. And reach out to Alessandro and learn more about this and his website’s wonderful. He’s all, everything he set up is just wonderful. I know he’s got a team behind him and actually I’ve got a team behind me as well. So a lot of people me messaging me saying ‘Jaz, how do you find the time?’ Leverage, you know, I needed a team. I want to be a father; I want to be a dentist. I can’t spend my whole life in front of a screen. So you have to then get other people involved in your team. [Alessandro]Absolutely. So, we are now launching on September, The Dental TV. So this is like an initial naming, but maybe we will rebrand it because it started as the idea of having a dental photography conference. Then we had to postpone that we had to cancel. Then we thought about going on an online conference that was saying, okay, we have so many online conferences. This would be just another one. So, I started inviting more people. So now we have over 30 speakers. And what I have decided, because I’m also now collaborating with Sony and Vimeo, that I will start my own Vimeo OTT channel. So basically, this is like Netflix for dentists. So, I will have an own video channel and we are now setting it up with an app for iPhone and Android so you can watch and consume and subscribe from all platforms. That’s pretty cool. And you will have then there all the content and we have four pillars, photography, video, communication, and social media. And I’m reaching out to experts in all these fields, giving you and let’s say the dental community a platform where they can learn all about these topics. And this is the goal to really create something, to build up a community there. And I’m pretty confident that this will be something successful. It’s basically a lot of YouTuber go over then to this Vimeo OTT or other platforms because you have better control. You can monetize better because then I will like create, like for Netflix, it will be subscription based. There will be some free stuff you can host online events. I will post there my webinars. There’s so many things and the industry are also interested in participating, for example, posting information about their latest software they have or whatever. So, this will be a good mix for the dental community for sure. So, thank you for giving me the time to explain. [Jaz]No, no, please. I think this will be great. I look forward to you to be part of it. I look forward to joining Dentist TV. I think it’s a great idea. We’re having something similar with the Protrusive App, but it’s in a different way. So, I think we need more of these channels to be creative. And you are prolific content creator, Alessandro, and you need to have a dedicated channel. So, I’m so glad you’re doing this. So well done. My last question for the day now, and I’m gonna sort of tease everyone the out intro for this question. This is another pain area. So we discussed about the time issue and you covered that beautifully ie to revision. Guys, if you’re having issue with time, you need to audit your day. And then once you’ve audited your day and you can’t find any time and you don’t wanna be a social media manager, then get some external help and reach out for coaching with Alessandro, @dentist.camera. Now my last question is consent. Dentists worry, and rightfully so about getting the right level of consent before posting a video or photo of their patient, or their smile, their teeth, or of their step-by-step photos. How do you gain consent in 2022 from your patients to post their mouth online? [Alessandro]That’s an important question then for us, it’s like a multi-step procedure. Step one, when a new patient comes in, they have to fill out their anamnesis [Jaz] Fine. Like a medical history form. [Alessandro]The questionnaire. Do you have any diseases and whatever you call that anyway- [Jaz]Medical history. Yep, absolutely. [Alessandro]So, and at the end of this, they have to sign it anyway, and there’s a point where they can cross, they can mark this. I agree that my information is shared with other dentist. Because I have to share it with other dentists if I’m doing consultations or I need support. I work closely with the University of Zurich. In more complex cases that we exchange information and that pictures taken can be used for publications, lectures, and on social media. [Jaz]Okay. [Alessandro]So this is number one. But then if somebody signed that- [Jaz]But is that like a tick box or is that there by default? Do they have to tick it? [Alessandro]They have to tick it so it’s something active, so they have to do it actively. Second thing, if I have a case that I think I want to post it or use it for a lecture, so it starts most that I use it for a lecture or a presentation or a publication. Then you go again to the patient and say, look, I recorded this case. And I would like to use it for educational reasons so other dentists or the community will see it. Do you agree? And then you put it in your medical history, say, okay. I ask the patient if she or he agrees that I can use the pictures and then they say, I had only one patient disagreeing. And then I say, okay- [Jaz]And just to clarify. The first one was written. It was a tick box. The second time from the same patient you ask verbally. [Alessandro]Yes. [Jaz]Okay. [Alessandro]But I write it down in my medical history. So you have like the thing open and you record everything that you’re doing with your patient, and then I take a note and say, okay. I ask the patient if it’s okay to use these images for an article and then write the patient agreed. So there’s no need to sign again or whatever, but it’s important that you ask the patient and you get this agreement or this okay from the patient. And again, I think if you ask politely, most of the patients agree. [Jaz]In my own experience, yes. I mean, if you just say, look, I would love to use the images to show other patients, or I would love to share this with other dentists because I think there’s a lot to learn here. A lot to share here. Yeah. Maybe had zero or maybe one I can think of that said no ever in the last, you know, nine years. So I agree with you. Patients are usually very happy for this. And then sometimes the odd one will say yes, but don’t show my face. And that’s totally cool. You need to respect that. But yeah, very rarely will they say it an outright no. [Alessandro]I have many patients asking. For their portrait pictures. So when I shoot my portraits, there’s a lot of patient asking if they can use them for their social media so- [Jaz]Yes, I had a male model actually. I took some portrait photos and then he actually now use it as part of his portfolio for his modeling. Why not? [Alessandro]Yeah. Yeah, why not? No, no. But again, important, ask your patients for the permission before doing so, not just post it. And then you get like the letter from the lawyer saying, okay, dear, your doctor, what have you done? So, the problem is if you have posted something, it’s almost impossible to delete it. [Jaz]Yep. And also, when you post it, it now becomes property of Instagram or property or Facebook. So, you need to respect that. The social media then owns it. So, it’s really important to get that level of consent, I think. [Alessandro]Yeah. This is also an interesting question. I have to ask someday the editors of books and journals. Because many authors publish them, they’re pictures of books out or articles on social media, and basically, they would not be allowed to do so because the property is on the editor of the book or the article. So, if you publish articles, the copyright goes in most cases to the editor and you agree with that in this small letter text that nobody reads. [Jaz]Yeah. It’s true. But the scary thing though is, and something, the reason why we take it seriously is that there’s nothing stopping anyone. Like you post up a video of your patient and then someone can just download that video, put it on TikTok, and make and perverse the meaning of that, you see? So this is a little bit of scary time, so we just have to proceed with caution. I think that’s important not to forget this. Alessandro, you’ve been absolutely brilliant today. We’ve talked about photography before. We talked about social media. Are there any closing remarks that you want to give to dentist before we send this out to the big, wide world? And hopefully lots of people join you on your Dentist TV. I look forward to that. Please give us your closing thoughts on the topic of social media and dentistry. [Alessandro]Basically it’s social media in general. So number one, be social on social media. So this is my number one thing I want to spread out. Second thing is think about if you really want and have the time to start a social media career or a social media journey, look for professional help if needed. So don’t say, ah, this guy is doing better than myself. Ask these people, what are they doing? Being consistent is one of the fact, let’s say in the dental office, I would highlight the words love and passion. So you have to be passionate about what you’re doing. You have to love what you do on social media, it’s a little bit passion, a little bit love, but the most important thing is consistency. You see a lot of burnouts on social media that you don’t see in the dental office in that extent. So social media is something that can be really demanding, taking a lot of energy from you. So there again, try to be consistent and if you feel like running out of ideas, not knowing what to do, not having any goal or plan again, look for professional help. So these are the key elements on being happy and social on social media. Jaz’s Outro:Guys, enjoy social media. Have a presence for your practice. Have a presence for yourself if you think that’s the right thing for you. I think what social media has become is, yes, there’s bad points about social media. We kind of touched on a little bit. It’s always important never to compare yourself to someone else. I think Alessandro just mentioned that. And don’t compare your uncut life to someone’s highlight reel. Right. That’s like number one pathway to depression stuff. So remember that everyone’s always projecting the best and sadly Photoshop stuff as well. But, have a presence. Enjoy, have fun with it, and if you’re not having fun with it, get some help. I think that’s that’s a message there. Well, there we have it guys. Hopefully you feel a little bit better about your interactions on social media, but also how to portray yourself on social media. It can be a dangerous place. It can be a minefield. So some of the guidelines that Alessandro presented to us, I think are really helpful. Although this episode wasn’t eligible for notes, this is eligible for CPD because ultimately social media is a form of communication. So if you’re on the Protrusive App, scroll down below, answer a few questions and get your CPD. You’ve come all this way after all, and as ever, I thank you so much for listening all the way to the end. If you wanted to join our community, there’s one on Facebook called Protrusive Dental Community, and it’s just got the loveliest people with a self-selecting bunch who listen to podcasts, and it’s absolute pleasure to read the discussions we have. Please do join us, but if you’ve been trying to join, I’m not accepting you. It’s because you haven’t convinced me enough that you’re a dentist, so you kind of have to message me on Instagram or something to convince me that you are a dentist. And sometimes you might ask for proof and whatnot, but it’s only because you wanna create a safe environment for our community. Thanks again, and I’ll catch you in the next episode.

There are a billion people globally who have sleep-disordered breathing and only 20% of them have been diagnosed and treated. In this episode we revisit sleep-disordered breathing and how it is connected to Dentistry. Dr. Aditi Desai, from British Society of Dental Sleep Medicine is just the most passionate Dentist ever about this crucial and often overlooked topic. You will hear the passion in her voice or see it in her eyes if you watch the video version of this podcast. https://youtu.be/0aG8iQdbkeY Check out this full episode here 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: Removing Aligner Attachments – A step-by-step protocol including the use a UV torch to see if there’s any resin left and which different burs and polishers I use. https://youtu.be/SP1irVhyzRw How I Remove Aligner Attachments Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 1:27 Protrusive Dental Pearl – Removing Attachments 4:31 Dr. Aditi Desai’s Introduction 7:25 What is Sleep-Disordered Breathing? 14:51 Mandibular Advancement Splints for Snorers 16:14 Signs and Symptoms of SDB for Dentists 20:24 Referral Template for General Dentists 24:55 Adverse Effects of Oral Appliances 28:15 Link Between Periodontal Disease and Obstructive Sleep Apnea 31:05 GDP Referring Directly to a Sleep Physician 33:48 Home Sleep Testing 36:18 Patient Compliance with CPAP 41:32 Learning Basics about Sleep-Disordered Breathing Check out Dr. Aditi Desai’s website, aditidesai.co.uk. And if you are in UK, you can check out British Society of Dental Sleep Medicine and support their upcoming event on March 4th. If you’re interested in getting into space now, you should check this out! If you enjoyed this episode, you may also like Airway – Dentistry’s Elephant in the Room with Prof Ama Johal Click below for full episode transcript: Jaz's Introduction: Sleep disordered breathing, sleep apnea and airway problems dentistry. These are some of the things that have become quite an area of interest in dentistry and for all the right reasons, because as dentists, we're in such a brilliant position to SCREEN for AIRWAY ISSUES beyond just snoring. Like we don't wanna just treat snoring. Jaz’s Introduction:We want to ADD YEARS to our patient’s lives. And if we can diagnose or we can’t diagnose, but we can screen for sleep apnea and airway issues and get the patients the help, and then we can be involved in potential therapy such as removal appliances to bring the mandible forward and that way we can have a huge impact in someone’s life. I was always taught that the two times you can save someone’s life dentistry is A) if you detect or diagnose a mouth cancer, or B) a barrett esophagus or someone’s got acid reflux and for them to get investigated and have a camera to explore that area. However, I think a third one that wasn’t mentioned to me in dental school, but definitely should be there is sleep disorder breathing or sleep apnea because on average that can take 10 years off of your life expectancy. And in case you think that sleep apnea is a disease of the fat old man, you are totally mistaken. So whether it’s in children or in adults, this episode with Dr. Aditi Desai, who’s just the most incredibly passionate woman ever on this topic, it’s gonna open your mind. So please lend me your ears. And for those of you on YouTube and on the app, your eyes to this Protrusive Dental Podcast episode. Hello Protruserati. I’m Jaz Gulati. Protrusive Dental Pearl:I’m your host and I’ve got your Protrusive Dental Pearl for you today, which you can access in the show notes. So essentially the Protrusive Dental Pearl I have is my sequence for removing Invisalign attachments. So it’s like a video. I’ll show you exactly what I do, how I use a UV torch to see if there’s any resin still left. The different burs I use and the polishes I use. I don’t think I have the best, I don’t know about different protocols and stuff. I just do what I’ve been doing for many years and it works really well now and then we get the Optragate in. We use a series of burs and polishes. We get a really nice result. A few of you did ask me for a video on removing attachments, so you got it. The Protrusive Dental Pearl will be in the show notes. Just scroll down wherever you are listening or watching, scroll down and you’ll see that video. And if you like that one, give it a thumbs up and let me know. Do you do anything different? Is there a hack that I’m missing that you want to share with the Protruserati? Let’s join the main episode with Dr. Aditi Desai, and I’ll catch you in the outro. Occlusion is just so confusing. Does occlusion even matter? Wait, don’t you just grind away all the blue marks, right? You mean like plant it low, let it grow or leave it high and let them cry. Listen, one of these interferences even interfering with, is it safe to lengthen teeth? How much can I raise my patient’s bite? How can you stop your composite restorations from chipping? Can you raise the OVD on a patient with clicking TMJs? Is canine guidance always better than group function? Why can’t I just use the DAHL technique on all my wear cases? Can I stop my patients from grinding? What the bloody hell is crossover? What should the occlusion look like after orthodontics? How and why do you check for fremitus? What on earth is a custom societal guide table? How do you use a leaf gauge? Do you always need to use a facebow? Does everyone really need a perfect occlusion? What is the difference between edge wear and pathway wear? Is it naughty to adjust the opposing tooth? What the is centric relation? Occlusion is covered. One does not simply just open the bite. May the force mitigation be with you To make sure you don’t miss the crucial update about the launch of our occlusion course, OBAB, head over to occlusion.wtf. That’s right. It’s actually occlusion.wtf. It’s almost released and you’re gonna love it. Main Episode:Dr. Aditi Desai. Welcome to the Protrusive Dental Podcast. How are you? [Aditi]Thank you very much for inviting me, Jaz. I’m pretty good. I think. [Jaz]You just told me you’d like to run your admin sessions and do your zoom meetings and stuff, so I’m very glad to catch you on a productive day because we want to fill the ears and the eyes of dentists, those who are watching with a very important topic, which is on the huge list of topics that are barely scratched at Dental School. And so many dentists I know, they will gladly admit that, you know what, when it comes to airway, I have zero idea. It’s something that we’re openly saying that, you know what? We don’t know at the moment. And I feel as though, I dunno how you feel, but as a nation, we are so far behind the States and Australia. Is that something that you feel? [Aditi]You know, I thought that we were much further behind the States and Australia, but actually we are not. I think we are a little bit more measured in how we actually conduct ourselves. You know, we are not sort of trick in our presentation, our presence. So I think dental sleep medicine in this country has been around for a very long time. But what we don’t have is we don’t have the regulation that we require. And for me, I think that is the most important aspect of it because we need to establish that credibility. And until we have that credibility, how are we going to actually close that gap between medicine and dentistry? Because I think that the subject matter is such that this is the one area in medicine and dentistry that’s gonna bring the two fraternities together, which I think is important. I mean, how can you possibly dissect the head from the rest of the body? [Jaz]Yes. It’s often the way that dentistry is like completely segregated. And I agree with you. Sleep is such a great connector of both the medicine world and the dental world. But before we dive into that and we talk about the guidelines and the changes and how dentists, no matter where you are in the world, I mean particularly UK cuz talk about UK based guidelines, but wherever you are in the world, how you can get involved, what are the things they need to look out for in general practice and how to better serve our patients. That’s the mission of this podcast episode. But I wanna learn a little bit about you. Tell us about your journey, how you ended up interested in this niche field of dental sleep medicine. [Aditi]You know, I’ve been a dentist graduated 45 years ago, and I’ve pretty been, I’ve been a very lucky person. I’ve had a wonderful career. I’ve done dentistry in every field that you can think of. But the one spot of dentistry that really rang my belts was airway and I actually came across this when, many years ago when asked the BBC dentist, a patient, came into my clinic from Australia, gave me some really stinky, smelly silicone monoblock and said to me, ‘Can you fix this? And I looked at it. I thought, what is this? And he said, it helps me sleep. And you know, he wasn’t a pleasant man. So I thought, well actually I don’t know what it is. So I think it’s better to say you know, to learn to say no is so powerful. So I said, I’m really sorry, but I can’t. But my mind took me back a little bit and I thought, you know, what was that? What do you mean silicon monoblock that helped you sleep? So I started looking a little bit into it that I came across a British Society of Dentist Sleep Medicine, and that is my journey. And I started to learn a little bit more, you know, attended a course, then they invited me to join the board and then, I think about seven years ago I was elected president and I remained president. I wish somebody would want to take over my job now. But we’ve been very lucky because it’s actually given me an idea of how dentistry goes beyond drilling, filling, restoring, whitening, and aligning. I think all of that is very important of course, but to be able to actually look at a patient and be able to help them with their quality of life is as important as whitening somebody’s teeth. And making them feel good about themselves. So that’s my- [Jaz]Agreed. This is something that can add years to our patients’ lives and improve their quality of life. How I am early on in my journey, but definitely something I’ve looked at thought, wow, I need to start screening my patients more. And the way it happened with me was a similar experience to you. I was at Guy’s Hospital, I was a DCT, and I was working on the consultant clinics and we had one clinic. About once a month, every two weeks where we would see patients who had a positive diagnosis from the sleep condition of mild to moderate sleep, to breathing or sleep apnea. And then we would be making the exact same. Can you believe it? This was 2015, the monoblock silicon appliances at the hospital. And then I was like, what on earth is happening here? And then as I delve further into the world of bruxism and TMD then I realized, whoa, this is connected so much to sleep. And we’ll touch on that. So, it is great to hear of your drive and your passion to spread the word. So I guess the first starting point for the dentist listening to this, who has no idea what’s going on, what is this sleep apnea? Can you just start by probably saying something that you probably say to a lot of introductory talks. What is it that we’re up against? What is the main issue? What is sleep disorder breathing, essentially? [Aditi]Right. So sleep disorder breathing is a syndrome. It’s a collection of disorders which create a syndrome where people are not able to sleep and breathe efficiently enough when they do try and do that together. So it’s really a disease of sleep. It’s also a disease of breathing together. So whether you sleep in the day or you sleep at night, whenever you sleep, you have a problem. It’s really all about the collapsible airway. It’s the unsupported part of your airway, which has no bony or ligamental support, which tends to collapse now when you have complete collapse, for 10 seconds or more, that’s called a sleep apnea. An obstructive sleep apnea. Now, that has got to be distinct from central sleep apnea, which is a neurological condition. So that’s got nothing to do with us, and we don’t get involved in treating patients with central sleep apnea. So for us, obstructive sleep apnea is at one end of the spectrum, and at the other end of the spectrum are people who snore. So you know, we all snor. Now and again, we have a good night out. We come back, lie on our backs up. You know, we’re snoring away. That’s okay. That’s benign snoring. But when somebody’s snoring every night through the night, that actually becomes pathological. So if somebody’s just snoring all night, they still can wake up in the morning feeling tired, because the brain is being aroused constantly through the snoring. And not only is it affecting them, it’s also affecting their bed partners and people who are in the house. So it’s almost like treating two or three for the price of one. When you treat somebody snoring. And when you try and think about, I think there are a billion people globally who have this disorder syndrome, and only about 20% of them have been diagnosed and treated. In this country, we are looking at over 2 million people who have this disorder and only 20% may have been treated and diagnosed. [Jaz]My son is actually in that category. He’s only three. He’s having his adenoids removed in two weeks. He had a positive diagnosis. He had a home sleep test. It was 21 seconds where he was not breathing, actually. They found that. So, again, from my own experiences, again, another reason I’ve taken an interest in myself. So, the dentist might be thinking, wait, what has this got anything to do with teeth? [Aditi]When I mentioned the number of 2.2 million, I was talking about adults. And children, men are managed differently, although their symptoms may be the same. You know, they don’t perform that well at school. They are sort of somewhat, they might even have bad, bad wetting. They might have behavioral issues. You know, all of these are part of a child’s sleep apnea problems and they always get put away as the naughty child or the difficult child because they may even have ADHD. But, you know, to treat a child patient who has deep apnea as a result of tonsils. It is actually, it’s amazing cuz I’ve seen some of my patients, one or two child patients who’ve had their tonsils removed and by the time the GA is gone and they’re awake again. They’re a different child. It’s as remarkable as that. [Jaz]I’ve heard that a lot myself, a load from dentist, parent dentist whose own children, have been through it. They’ve told me that they’d actually have to keep checking if my child is still breathing because what they realize actually their breathing is much quieter. [Aditi]Yeah. [Jaz]That’s the first thing that people / parents told me actually. [Aditi]So, but you see, this disease is no longer a fat and 50 man’s disease. I mean people used to, when I first got into this field, any man that walked into my clinic had a big punch of big fat neck and his posture was trying to open up his airway. I kept thinking, he’s sleep apnic, he’s sleep apnic. I could be on a bus, on a train. I said, he’s sleep apnic. But I’m very wrong. It was almost like a hammer and nail situation. It was absolutely not that at all. But now I, the majority of my patients are not fat and 50. They’re females. They’re males. They’re very young. My youngest patient is 17 years old. You know, adult. When I say adults, 17, almost 18 years old. They are slim. They’re incredibly thin. They have very long, thin, narrow face. They’re very slit noses. These are the things that we look at, the very sort of narrow arches. And these are the patients that I see a lot of. So it’s no longer a fatten 50 man’s disease. Of course there are fatten 50 who are sleep apnic, but you can’t stereotype them anymore. You can’t just look at a thin person and say, well, you’re tired, you’re snoring. It’s fine. You’ll be fine. They may not be fine. They may have serious sleep apnea. So that’s where, I’m very keen. Every dentist who looks at a patient, looks in the mouth and sees their telltale signs and has the telltale symptoms, they should just have their red flag up thinking, let me just assess them mentally. Once they’ve done the mental assessment, then they can ask a couple of pertinent questions and then get them screened officially and formally diagnosed by a Sleep physician and then treated. So if a patient comes in, for example, and says, ‘Mr. Gulati, I’m actually snoring and my wife will not sleep with me anymore. Can you please help me?’ And you say, of course. You know, let me make your mandibular advancement device or a mono block or whatever you decide to make them. You will be actually working against guidelines. Because our guidelines have changed. We have to assess these patients, have them formally diagnosed by a medical professional, that medical profession will then give us an outline of what they believe to be the right pathway. But that doesn’t mean that you don’t treat the patient while they’re being assessed. [Jaz]Mm-hmm. [Aditi]Because remember we look at the NHS pathways and the NHS pathway we’ve got a long, long waiting list. [Jaz]Absolutely. [Aditi]You get these patients to wait for two years before they’re seen. In fact, I spoke to one of my ENT consultants this morning. He said he has a five year waiting list in the ENT Hospitals. [Jaz]Wow. [Aditi]Five years. Now, whether that is for surgery or whether that’s for CPAP, I don’t believe that CPAP will be five years. Although we have had this latest CPAP debacle where the Phillips recalled all their CPAP machines, so there’s been a huge shortage. Now, these patients need treatment. If you’re a snorer, yes, let your wife sleep in the second bedroom for a couple of nights, you know, maybe a couple of months. That’s okay. That’s not gonna be too much of a slippery slope, however, these patients giving them treatment with a mandibular advancement device while they’re waiting for their CPAP Machines giving them some treatment rather than no treatment at all. [Jaz]Can I just stop you there cuz I think we’re touching on something really, really good and I like how you’ve gone right in and this is gonna be very, very good, but let’s make it even more tangible because many dentists actually have been on a course to treat snoring and then maybe fell into, oh, hang on, if I’m treating snoring, I also need to do this tickbox of exercise of screening for obstructing sleep apnea. And then they sort of back off and refer. if it’s high risk and then medium risk, they just go ahead and treat. So with the new guidelines, I think it’s August, 2021, right? [Aditi]Yes. [Jaz]So we’re referring to the same guidelines here, and I’ll share that in the show notes for those listenings so you can download those. So if you’re wanting to treat a snorer and you have done your screening and you feel as though that this patient is a simple snorer only and you feel as though that they don’t have the high risk signs of obstructive sleep apnea, can a dentist go ahead and make that mandibular advancement splint without referring to the gp? So that’s the first thing I wanna unpack. [Aditi]So what the British Society of Dental Sleep Medicine have come up with is it’s almost like an algorithm. It’s a guideline. You know, it’s giving you a pathway of risk, high risk, low risk, moderate risk, and you know what to do. See, if a patient is low risk, asymptomatic, the word is asymptomatic. That is the most important one. Okay. And as soon as they’re asymptomatic and they’re snorers, yes, go ahead and make the device, the mandibular advancement device. But documented record that says that you made this only for snoring and advise their GPs that you’ve actually made a splint for snoring only. The next important thing is these patients need to be followed up because this disease or syndrome is one that gets worse over time, age and weight. So somebody is just a benign snorer or a pathological snorer and asymptomatic may get worse as they get older and fatter. And we all get fat as we get older. Now I’m also, I’m a little bit floppy as we get older. You know, that’s a fact of life, unfortunately, much as I deny it. But there we go. [Jaz]With those in the medium and high risk, now before we follow the algorithm and you can share that, what are the symptoms that we are listening for and what are the signs that we are looking for as a general dentist so that we can start to have an involvement in this very important area of what is the interface of medicine dentistry? [Aditi]So a patient will not come to you saying, I’m going to the bathroom three times a night. Cause we are dentist, they’re not gonna come to you and say, you know, I may come to you with a headache but they’re not gonna come to you and say, you know, I wake up feeling terrible every morning cuz that’s not what we do. But they will come in and say, I snore. And they might so say, gosh, I just feel so tired. Or you are treating them and suddenly fall asleep. Or they might start snoring just that they’re go into that light sleep. They might just start snoring. These are telltale signs. The other symptoms are that they might be tooth grinding. They might be complaining to you of TMD or facial pain or headaches. These are the most important cardinal symptoms and signs that they would present to a dentist with. If on the other hand, a patient is coming in to see you and you think that they’re looking red-faced, they’re punchy, they’re fat, and they’re on a cocktail of hypertensive drugs. Or they’re diabetic or they’ve had a stroke, and you look in the airway and you can’t see the airway. These are things that you need to look at and say, well, okay, maybe let me just ask the question. By the way, how do you sleep? How do you feel when you wake up in the morning and he says, oh God, I feel terrible when I wake up in the morning, when I wake up with a headache. Or people are not aware. They don’t know what to say to a dentist when they come in. It’s all about education. It’s all about education, raising awareness, and then providing access to treatment. For me, that’s my mantra. Raise the awareness, provide the education, and then give them access to treatment. That treatment may be something that we are providing. Or provided by somebody else. Now going down the algorithm. So if they’re asymptomatic and snores, you provide them with a mandibular advancement device, but make sure that it’s documented that you’ve done that and advise the GP that this has been done so. [Jaz]Got it. [Aditi]That’s the most important thing that we have to look out for. If, on the other hand, they come in complaining of snoring, but they’re symptomatic and they’re very tired and they’re sleepy in the day, then they must go for a formal diagnosis. [Jaz]Formal diagnosis. Even before you’re make an appliance only for the snoring. [Aditi]Yeah. If you make that, well, not the diagnosis. If you think that this patient is symptomatic, they are at risk of OSA. The guideline says that you refer them on for a formal diagnosis, okay? [Jaz]Mm-hmm. [Aditi]But you can make them a mandibular advancement device just to combat their snoring while you send them off for a formal diagnosis and make sure that you advise whoever you’re referring to or the GP that you’ve actually made that the splint only for them to be able to sleep or sleep with a bed partner for snoring. That’s it. Not because you’re saying, oh, actually the treatment for this patient is a mandibular advancement device. Because doctors do not like us treading on their territory. The other message is to make sure everyone realize it, this is not a dental condition, it’s a medical condition. [Jaz]Mm-hmm. [Aditi]It’s a medical condition that needs dental intervention. And this is the first time that the NICE guideline actually acknowledges the role of dentistry. It’s taken me almost 10 years to get recognize that actually dentistry has a pivotal role in managing these patients. And not just dentists, but also the whole dental care professional. The hygienist, the therapists, cause who sees the therapist and the hygienist more than anyone else. The patients will see them more often than us. Right? [Jaz]Absolutely. I think you’ve covered a really wonderful thing there. How we should not be writing in our notes the diagnosis of obstruct sleep apnea. That’s for the medical, that’s for the physicians to do. We can write, screened for, and moderate high risk and then arranged the referral. So the first question is, in the, in the UK obviously it might vary in different country, but in the UK we need to be referring this to the GP. Now I use our little S4S, have a little docket that, that is a very nice little template to GP. Do you guys have something to give the dentist to help the referral? [Aditi]Absolutely. So the British Society of Dental Sleep Medicine, we’ve actually just about to launch us, our new website. And when people become members, you have access to not only the, the algorithm, the pathway. And we also, and that pathway by the way, is accepted by the ARTP, which is, you know, the British Sleep Society, ARTP, where they will actually they’ve actually said, yes, we recognize this as an acceptable pathway for dentists to follow. And that’s also very powerful. So it’s not just dentists telling dentists that we are okay. It’s the medical fraternity that’s telling us that yes, actually what you’re doing is correct. So we’ve got that pathway. They also have access to screening documents. Screening questionnaires, and they also have access to consent form that we have actually gone through over and over again to make it fairly robust to make sure that we don’t fall into the pitholes because, you know, now this is now on the actual radar of certain, maybe even some of the indemnity insurers we need to make sure that everyone who is protected, you know, we may think that a bit of tooth movement, a bit of jaw pain may be okay, but actually there’s no need for that to happen. We can do everything we can to mitigate those side effects with the use of the appropriate device. So the one thing I always stress to all my members and to anyone who comes to me for any advice or help is yes, go ahead and do your courses. Go ahead and get industry led courses if you want to, but if you really want to do the right thing, learn to use more than one device because one device does not fit all. There’s no such thing as one device. It’s almost like the CPAP masks, right? One CPAP mask does not fit every person, so each one has to be personalized. We have to do the same thing for oral appliance therapy, so we are about to create a consortium of Oral appliances that people will be able to pick and choose from. [Jaz]This is brilliant. And just wanna add I have the same philosophy with occlusal appliances. I manage a lot of bruxism stuff and part of the very first thing I do is an airway screening. So if anyone is as high risk, I would not make that occlusal appliance, cuz from what I believe and what I follow in the literature I’ve read and occlusal appliance for bruxism can make your obstructive sleep apnea worse by opening the OVD and distalize manual, making someone more class two. So, if anyone’s high risk, I’ll always refer them on before making the appliance or because the correct appliance made for them may be something that will also help the airway. So yes, it’s not just everyone gets a Michigan spin or everyone gets soft bite guard in that regard as well. So it’s very similar. [Aditi]You can make a splint upper or lower or whatever you wanna make for every patient, but if there is a risk of sleep disorder breathing for you, like you said, make it protrusive. If you’re making a protrusive splint, then the patient will be fine. But you know, we have so many patients that have been treated with Michigan’s and tanners and we’ve made them apnic. I’ve just seen a medical legal case that I’ve been treating recently, and this gentleman had a class three jaw alignment, went to Maxfax surgeon. And instead of looking at his maxilla, which was underdeveloped, they retruded it with surgery and orthodontics. They’ve made that patient severely apnic. Now, you know, we are gonna have to do corrective surgery, so I’ve just made him an occlusal appliance, you know, with all his pins and screws and everything, and it’s gonna be a really long, protected legal case. But I’m terrified because I, having to protrude that jaw, with all this you know, surgery that it’s had is quite challenging. But, you know, we have to be careful that patient assessment is so important. Making them if you don’t assess the TMD, for example, that’s your baby, right? So if you don’t assess the patient properly, for potential TMD issues, with the splint, then you are really going to, you know, get yourself into trouble. [Jaz]And I had one colleague recently who posted on one of our forums on Facebook that a patient came and he had snapped a post crown on the upper lateral incisor, and the patient felt as though it was from the pressureof the appliance and she wanted to know, is that, is that possible? So can you please explain about what kind of adverse effects could happen with these oral appliance therapies to bring the mandibular advancement splints because we need to appreciate, just like you said, for there’s main different designs and therefore we need to pick the correct design based on the occlusal features and the dental features that were presented with. [Aditi]Do you know? You’ve hit a very important point there. I have learned, all have learned through my mistakes. That’s the best way to learn cuz you don’t wanna make them again. I remember I was sent a patient by one appliance company through their marketing and they asked me to make a device for them. And that device was not suitable for this patient because this patient’s mouth was full of bridges and crowns that I had not provided. And because they were metal ceramic, we took the radiographs, they all looked fine. No problem at all. No root care is nothing. And then of course, in my wisdom, which was not a good element at the time, this many years ago, I provided him with a device that was holding onto the teeth in a different manner to what other devices do. So he was literally gripping within the triangles between the teeth. So the next day he came, I provide the device. He was really happy off he went. Two days later, he comes back into my clinic and he chucks the device at me with the bridge in the devices. And I looked at and I thought, oh, you know, and it was completely rotted. It was so badly rotted. And he said to me, you have done this. And I said, no, I haven’t actually. But what had happened is because I could not assess that treatment, and it wasn’t treatment I had provided, I couldn’t tell how good or bad that restorative work was. So we dug the bridge out and we repaired it and we you know, put a root post in, put it back in. But you know, it never really worked well because of that, I was always worried and the next time, that post came off again and I realized actually that I had made him the wrong device. I should have been a bit more knowledgeable about what kind of device that gentleman needed. He wanted something that was gonna be easily repaired, easily adjusted to a new bridge. Where there might have been a silicone lining, perhaps, maybe a SomnoMed® device, which would have a silicone lining that is adjunct, that is actually replaceable. Say for example, the S4S device, the SleepWell. That also has a silicone lining, but that lining is not replaceable. You can’t replace it. So, but this silicone lining in the SomnoMed® devices, you can replace it. So if a patient comes in, tooth breaks, you put a onlay, inlay, crown, whatever you do, all you do is re-scan or re-impression, send the device back to the lab, and they just put a new lining in. So that’s why I go back to the thing. You must have knowledge of more than one device. [Jaz]A hundred percent. [Aditi]And this thing about TMD for example, you know, it’s a myth that you can’t treat any patients with TMD. In fact, sometimes with the right assessment you actually make these TMD patients better. By opening up that jaw and protruding is slightly- [Jaz]Down and forward. [Aditi]We can get that disc recapture. So these are facts that we need, so the blanket statement do not touch patients with TMD. Do not make a device for people who are bruxing cause they’ll break it. It’s not true. It’s just not true. In the same way with periodontal disease, do not treat people with periodontal disease. That’s half the population. [Jaz]There’s just other appliances that we need to learn about that you can use the appliance without putting pressure through the periodontal ligament. [Aditi]Not only that, but did you know that there’s a bidirectional link between periodontal disease and obstructive sleep apnea? One makes the other work. Inflammatory Disease. Both of them create inflammation and periodontal disease gets worse when people have always say there’s absolute, there’s quite a lot of work that’s been done by Jill Levine from – [Jaz]Yes. [Aditi]And also by Maria Carra Clotilde a great friend of mine from Paris. Now, she gave a wonderful talk at the RSM last year on periodontal disease. Now, if you see a patient with periodontal disease, not people that you just blow or click it and the tooth drops out. Of course, these people need a bit more care, but you know, people who have got uncontrolled periodontal disease, you should be thinking, why can I not control this? Do they have the additional signs and symptoms of OSA? You treat OSA and that periodontal disease can be controlled, not in every case, but they can be controlled. [Jaz]It’s another factor to consider, isn’t it? [Aditi]Exactly. So I think that if you then have a device that you treat the OSA. Motivate these patients who are not, who are pretty gently feeling crap anyway, and they don’t want to, they’re not motivated to seek help, make them feel better, and then they can go and seek help. So, I wouldn’t discard every patient with periodontal disease. You have to guard the guideline actually does say that, you know, we guarded with TMD and periodontal disease, but I’ve just written a big document for the transformation services, of sleep services in this country with the NHS. It’s gonna be published soon. And in that I have actually documented provisors that do not discard patients with perio disease. Do not discard patients with TMD. Treat them with a little bit further assessment. [Jaz]Yeah, I think that’s needed rather than a blanket statement. Now, Aditi, just so following on the path, let’s say we have that moderate to high risk patient and we’ve been a very good GDP. We’ve done the screening, we look beyond caries, and perio. We are looking at a patient as a whole, but we make that referral. Using, let’s say the society sort of pathway and form. And it goes through a GP now, hopefully, and I, I want this episode to be listened to by GPS as well. Cuz some GPs, they speak to some patients and they say, nah, you’re under 50. Uh, what’s your BMI? Nah, you probably don’t have a obstructed sleep apnea. So this very much, I know you know this. Very much exists in the medicinal world as well. They need more training. I think they realize that as well, actually. So there’s a huge change and shift coming in terms of medicine and dentistry, in terms of learning more about this condition. Now, let’s say you get a GP who I find that with these referral letters, which are quite nice, they actually give the GP a lot of information to go by and that GP is then able to make the referral to a sleep physician. Am I right in saying that I as a GDP cannot refer directly to a sleep physician? I have to go via a GP? Is that correct? [Aditi]Not necessarily anymore. We are actually looking at direct referral into a sleep service, and that is something I’ve been driving for as well, because- [Jaz]Absolutely. [Aditi]I’m sorry, but not everyone has the, they’re not, everyone’s not the favorite view. They can afford private care. We need to make the pathway simple and less onerous for the patient. I mean, come on, this is about patient not about us. And the GPs are not interested in a lot of cases. Not everyone, but a lot of GPs are not trying to actually train GPs to make them more aware of what their role is has been a bit of a challenge for everyone. The RSM, the sleep section of which I sit on the council, the dental section, we’ve all been trying to get the GPs to be a bit more engaging, but they’re so busy and inundated. This is the last thing they want to do.That’s my opinion. Okay. That’s my own personal opinion. [Jaz]I hundred percent agree, from what I’ve seen, I know you’ve seen much more, but from my experiences with other colleagues and the fact that one of my patients the other week told me that he had to literally get a heart attack to be able to be see a GP face-to-face nowadays. So again, another barrier because the times that are actually getting to even see a GP is, can only be slowing down the workflow. [Aditi]Yeah. So that’s why we are trying to get these referrals straight into the sleep service. The NHS sleep services and make it less on risk. But again, the other drive is that’s assessment, screening, and diagnosis is actually going to be brought into primary care, and that is why the dental role has become even more important. So we are looking at dentists. pharmacist, GPs, all of them are gonna be more and more involved in the initial screening and assessment of the sleepy patient. And once that’s been established, then they can be sent into secondary care and then into tertiary care if necessary. Cause a lot of them are tertiary referrals. They do need tertiary care. I mean, at one end of the spectrum, you’ve gotta be nice snores. At the other end of the spectrum are people who cannot sleep and breathe at the same time. They just can’t do both together. So these are the people who need to be artificially ventilated. And these are the tertiary referrals. But I mean, we don’t get involved with those. Cause the moment you see someone who comes in and says, by the way, , I’m sleepy. For example, if they want to say, oh gosh, I’m always sleepy, or you think they’re looking a bit sleepy. Did you know that the bags, the bluish gray tinge around the eyes is also a very cardinal symptom of somebody who might have OSA? So, especially in a child, you know? So if you look in the mouth and you think, you know, airways blocked, tooth grinding, you know, neck is fat, he’s snoring. You know, gray eyes. I mean, isn’t that enough to say to you, let’s get this patient screened. Just to go one step further, Jaz, home sleep testing. In the states, they have been very adamant to not allow dentists to carry out home sleep testing. That’s the ambulatory sleep testing. You know, the way their patient is given the kit, they either bring it back or they throw it away and you get the result through the cloud , they have actually relented somewhat in some states, but in this country now we can give out home sleep tests as a dentist. However, that sleep test must be formally reported and assessed by a sleep physiologist or a sleep physician. You know, who has the expertise to- [Jaz]Could you recommend a service that you use in terms of a dentist who may a little bit more switched on and wanna start, you know, listening today? Then we like, oh, I didn’t know I could do this. [Aditi]Absolutely. So what I do is I use a kit called the WatchPAT One , which is an ambulatory one that you give to the patient, you lock it on the system that do the test at night and then throw it away. I get the results through the cloud, but I also elect for that on the system. I elect for that test to be reported formally by one of my medical colleagues for example, and they, I’ve got a dearth of them, so I get the report back saying, this patient has, is snoring in this body position is positional snoring or positional sleep apnea stops breathing. So many times the AHI score or the oxygen levels are desaturating to the point where we recommend that this patient should have a CPAP trial or they might just say if the patient is a bit sort of on the borderline, they’ll say, well, actually they could also try a mandibular advancement device. So that’s for me medical legally that keeps me in the clear. If by then, make them a medical oral appliance, that’s fine. The guidance does say that, you know, for anyone sleepy, whether there’s a snorer, mild, moderate, or severe sleep apnic, they should have a CPAP trial no matter what the level of disease. [Jaz]Yeah, I was gonna ask you about that because I felt, when I read that in the guidelines, I know it’s great that they’ve mentioned dentists for, in the guidelines, but from reading that it’s like every patient who gets that diagnosis, the gold standard is a CPAP. And then, so what we’re waiting for is really a leftovers. So, how do we work with the, how do you get busy because you wanna help these patients who can’t get on with their CPAP. How do we filter those patients? How do we get, how do we attract those patients? I guess that’s a big topic as well. [Aditi]So that in itself is quite, that’s a very moot point actually. So if a patient is, they’re go into sleep service and they are all given CPAP, we know that we have as much, as many as 50% of people who will either be intolerant or unaccepting of the CPAP. So this is plan B for us, which is why the next one. [Jaz]Aditi, can you just mention for those young dentist listening who’ve never heard of CPAP before, why it’s not so sexy, or why it might not be so sexy and what it does and how it works? [Aditi]So, CPAP is actually a mask that you wear over your face. All the nose and what it does, it’s like a pneumatic splint. It’s got a big sort of elephant trunk with a little machine that sits on the side of the bed and what it’s doing is actually pumping air into the airway and it’s actually opening up that airway. What it’s not doing is not pumping oxygen or air into your lungs. It’s only opening up that airway, which has collapsed in order to keep it open so the patient can continue breathing normally. So these are the patients where the claustrophobia of the mask or the nasal, where if they’ve got nasal congestion, they may not be able to tolerate the mask itself, the air going through the nostrils and some people, because it’s quite an unrest thing to wear. It’s not sexy, like you said. They don’t wanna wear it. And some of machines are quite sophisticated, but they may not be the ones that are available on the NHS, the ones that are available on the nhs. Some people might find them noisy. Bad partner might find them noisy. Pregnant women find them intolerant because you know they have to sleep on the side and the mask keeps on shifting away. So there are lots and lots of side effects. People talk about the side effects of all appliances. [Jaz]Yes. [Aditi]If I give you a list of side effects where if you ever come to any of my courses, I’ll give you a list of side effects that have been shown for CPAP, including skeletal changes, including dental changes. These are important points that one needs to remember. It’s not just your appliances that have side effects. Everything in sciences has a consequence. [Jaz]I guess the other thing worth mentioning is I know of some colleagues who spoke of some patients who might travel a lot and they can’t take their CPAP on their flight with ’em, and they’re afraid to fall asleep on their flight because they’re worried about the whole snoring and whatnot. And the fact that if they go camping and whatnot. So sometimes, these patients may be in a situation where they rely on their CPAP at home cuz they get along well with it, but for holidays of other times, they may well benefit from an oral appliance. How do you see that fitting into it? [Aditi]So that’s actually quite a good way of describing it because I think it’s all got to do with raising awareness. If you let the public know that there’s hope beyond CPAP, then they will come to you for help. People don’t always want to wait for the NHS. They’re long waiting lists. They’re fed up. They feel that the wife or the husband, and I don’t wanna be sexist here, if one of them gets into the second bedroom or sleeps on the couch, they see that as a slippery slope for their marriage. And I think for them, they need help. And they need help desperately. So when they come and see me, for example, they never say to me, oh my God, I just want you to treat my snoring. I’m fed up with it. They will never say that to me. They’ll say to me, look, I’m doing this for my bed partner, my wife, my husband, or girlfriend, or whatever, because she is not getting a good night’s sleep or she’s fed up or she’s in the other room, you know, so they’re doing it for others, not just for themselves, but they don’t care whether they’re snoring or not because they don’t wake up if they are waking up constantly and they’re waking up choking as a result of, because all snorers are not sleep apnics. But all sleep apnics are pretty much snorers. [Jaz]Yeah. [Aditi]That is a distinction you have to make. So if you’re treating a snorer, are you treating just the snorer or are you treating the sleep apnic? If you’re treating the sleep apnea, the byproduct of sleep, treating the sleep apnea is they’re gonna treat their storing as well. So that’s more important to remember. So you were asking me about how do we get these patients, well, you get these patients by raising awareness, providing the patient with knowledge of what is available out there. And if the patient then decides and elect not to try the CPAP, as long as it’s documented, then you can safely make them an oral appliance. But everything has to be documented. Remember, medical legally, if it’s not written, it did not happen. [Jaz]Yeah. [Aditi]I cannot tell you how important that is. [Jaz]Well, I really appreciate everything you covered and also for sharing that difficult experience you had with a patient with a bridge. I think that’s so real world for us as general dentist and restorative dentists it’s great to really be nice to hear over your experiences and your learning journey. The main thing we wanna wrap up with is getting this information to the dentist so that. I’m hoping was a real eyeopener and an ear opener for dentists who are just very new or haven’t heard of steep soil breathing and how we have a role in screening. And then for those patients who do not get along with their CPAP or as an adjunct too for when they go on holiday and stuff, may need a mandibular advanced splint. We need to learn more and we don’t need to just go on one industry led appliance and give that same appliance to everyone. We need to give a few different appliances. So please, how do we get involved in the UK as a dentist and around the world? How do we get involved to learn more from you guys? [Aditi]Call me, I think, no. I think the most important thing is get on the British Society of Dental Sleep Medicine website. There’s a death of information there. Yes. You know, we’ve got a new website coming. It’ll hopefully, I hope it’ll be launched by the end of the week or next week. If it doesn’t, it’s not my fault. But to attend a course that’s led by a credible society because we are now part of the British Sleep Society. So we are actually working with the medical people. Not just dentistry on its own. [Jaz]Perfect. [Aditi]It’s not a coffee club anymore. So I think for me that is important, having industry led courses, which are, you know, industry is so desperate to get into since the publication of NICE Guideline Industry is in here, running courses, you know, showing them how wonderful their devices are, of course they are. Please, let’s be measured about this. Learn about the basics of sleep disorder breathing. Learn about how to treat this patient effectively and safely, and then learn about the various devices afterwards because you know you will find your own favorites. You’ll find the ones which were favorites. I mean, for example, I was the face of Novel. You know, I’ve done videos with them, I’ve done photographs with them. I’m on the internet, but you know what? I don’t make any of their devices because I’ve had more problems with those than any others. But that doesn’t mean I’m stating it. It’s in my own hands what works for me. There are others who will have other devices, but that for me is if you go into the BSDSM website, you will be able to. courses, which are unbiased, totally unbiased, you know, and we have mentorship- [Jaz]And there’s one on the 16th or so. I just saw on your Facebook, you didn’t tell me, I just saw the 16th September in Manchester. So that’s an example of one of the courses that you guys run. would the course like that obviously covers a lot of theory in terms of screening, diagnosis, how to work with the GP, but to what extent does it cover oral appliance therapy? [Aditi]It covers all of that. The only thing that we are not doing face to face is because of Covid, but now we are going to get back into face-to-face where we’ll have a hands-on element. So on the 16th, although I’m not running that course, cuz I’m doing, I’m not running another course on the 16th, the people that are running the course, that my board members, they are very experienced. And they will show everyone how to take a George Gauge registration, for example. Cause if you get that wrong, scanning and taking impressions is pip squeak. We all know that. That’s not skill. The skill is getting that jaw registration correct. Cause if you have any aviation, then you’re running into trouble. And that’s what is the most important thing, especially when you’re working with precision devices that are so accurate. You’ve got to make sure that absolutely. [Jaz]Like the Somnowell, right. I’ll just name a brand. Is that classified as a precision device? [Aditi]I wouldn’t call the Somnowell, a precision device. I haven’t used Somnowell for the last 10 years, maybe. I work with ProSomnus very closely. They’re the American company. I work with Panthera, which is from Quebec. I do provide so devices as well. They’re very good. They’re market leaders too, but I think those three are probably the ones that I work with most closely. [Jaz]Mm-hmm. And I like that. And just like, and it very much backs up what you said, you know, and I’ll say it’s, look, I’m friends with S4S look, I’ve used our appliance for, but I just feel a lot of my colleagues are GDPs because they’re so good at marketing GDP, all they know is a Sleep Well appliance. And that’s it. and so, I think we owe it to the presion in our patients to, to think, you know, beyond the soft sprint for everyone, beyond the Michigan for everyone beyond the sleep well. So we need to do that. And I think BDSM is a great place to start. So I’ll put all the links in a show notes. When I email out my list, when I launch this episode, I’ll make sure there’s a direct link to go through website so you can learn more. So this could be the starting point, at the very least, if you can screen patients and start making those referrals and having those conversations, I think we’re gonna improve the health of the nation. [Aditi]Absolutely. And Jaz, one other thing before I go. So we also have an Academy of Dental Sleep Medicine, of which I’m also the president. And what we are doing is we are actually working with the Academy on behalf of the society to run courses, which are not just foundational courses, but you know, going that little bit more. Cuz what I don’t want to do is end up like the, when you ended up years ago, becoming an implant dentist, you went to a table, you had a pig jaw, you drilled a hole, you put the screw in, and you thought, I’m now an implantologist on Monday morning. We have gone beyond that now, and we want to teach, I want to teach the members what can go wrong and how to manage it and what not to do more than how to do the right thing. Because you know, like I said, scanning and impressions are not that important. So we have a website for the Academy of Dental Sleep Medicine as well, and they’re gonna have modular courses online. And then eventually, very soon, we are about to launch. Well, we, we’ve got the master class that we launched in 2019, but then Covid hit. So we are gonna relaunch it in October, September, and then the PG cert also goes out, hopefully. Jaz’s Outro:Brilliant. I’m gonna share that link with everyone. Check it out myself as well. So, amazing. You’ve been, you know what? I love your style, Aditi. You’re so direct. I hope you hear that. I hope people praise you for this, because I just love, like, boom, boom, boom, boom, boom. You’re so succinct. There’s no waffling. I love that type of educator. I definitely wanna learn more from you. Really appreciate you coming on and sharing so concisely, so beautifully with all the dentists listening, and you are more than welcome to come again. Well, there we have it guys. Thank you for listening all the way to the end, and if you did so then just answer a few cheeky questions and get some CPD. My team will email you certificate and we’ll keep doing so for as many episodes as you want. It’s just one of the many benefits of being Protrusive Premium Member. So if you download the app or go on the app on Chrome, if you just use type in on your URL browser protrusive.app, it’ll take you to the app homepage. Once you actually have an account, you can actually access the app through iOS, Android, and the website using that same login. Because let’s face it, some people just like to learn on a laptop and not on their device. If you felt inspired by Dr. Aditi Desai to learn more, then the best thing I can recommend wherever you are in the world is to attach or align yourself with your local dental Sleep Medicine Society. Now in the UK we do have the British Society of Dental Sleep Medicine, and they’ve got an event on the 4th of March. It’s like a member’s day. And if you’re interested in getting into space now, you should totally check this out. I’ll put the link in the show notes below. But like I said, if you’re in the US or Australia or wherever you’re around the world, there’s some lots of great societies to align yourself with. If you found this episode useful, please do leave a thumbs up if you watch you on YouTube, and don’t forget to hit that subscribe button. Thank you again, my friend. I’ll catch you next time.

Some dentists disagree with the use of Caries Detector Dye in Restorative dentistry. They say that they are experienced enough to know what is infected dentine and affected dentin. However, this episode might change your perspective— CCD can be an incredibly useful tool to provide objective data and increase your bond strengths! In this episode, Dr. Germán Dorgan spoke to us about caries detection dye and helped us understand how to use it properly. He also shared the evidence base behind this test and how to interpret the data that you get by using it. https://youtu.be/L8fScyRTet0 Check out the full episode here 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 Protrusive Dental Pearl: How can you remove the appropriate amount of caries to get the best bond strengths possible WITHOUT risking removing too much dentine and causing a pulp exposure: Use your perio probe and measure key landmarks. Measure 5mm from the cusp tip and 3mm from the adjacent marginal ridge – do not remove caries beyond this point. As a guide, this will help you not expose the pulp so you achieve very clean dentine for highest bond strengths, without worrying about ‘when to stop’. How to measure caries removal extent using a Periodontal probe and dental landmarks Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 1:20 Protrusive Dental Pearl 4:27 Dr. Germán Dorgan Introduction 7:32 Caries Detector Dye 9:40 Rationale behind Caries Detector Dye 15:14 When should you use Caries Detector Dye?  19:49 Literature for reliability of CDD 22:19 Difference between color gradient of caries detector dye  23:28 Caries removal guidelines using caries detector dye 30:22 Additional Literatures and Top tips Check out the 3-day course about Biomimetic Dentistry with Sami Sherif, Germán Dorgan, David Alleman, and Davey Alleman. Hosted by Get Bonded and Stay Bonded on March 3, 4 and 5, 2023 Check out the literature mentioned by Dr. Germán Dorgan Contemporary-concepts-in-carious-tissue-removal-A-reviewDownload A-systematic-approach-to-deep-caries-removal-end-points-The-peripheral-seal-concept-in-adhesive-dentistryDownload PHYSIOLOGICAL-RECALCIFICATION-OF-CARIOUS-DENTINDownload Bonding-of-self-etch-and-total-etch-adhesives-to-carious-dentinDownload You might also enjoy another Biomimetic Episode: I Can’t Believe This Sticks – EXTREME BONDING EXPOSED with Dr. David Gerdolle Click below for full episode transcript: Jaz's Introduction: Is CARIES DETECTOR DYE, BS? Like I know lots of dentists who've seen it and they think this is just a fad. This is as useful as those photos of people holding cucumbers between their teeth. Jaz’s Introduction:Is there actually any sign or useful applications because caries, as some colleagues would say, I just use my high magnification, my good lighting and my probe. I don’t need a fancy dye to tell me if I got caries or not. I’m experienced enough to know that I’ve removed caries. Now, you know what? I kind of felt that way. I was like, do I really need a dye? I’m think I’m pretty good at moving caries and too fair. Since I’ve been using it, it’s kind of confirmed that I’m pretty good at removing caries. Okay. I’m happy to say that I’m proud enough to say that. However, one in five, one in six times I see a pink haze where it shouldn’t be. You’ll find out what that pink haze means in this episode, but it’s really useful objective data. So we’ll speak to Dr. Germán Dorgan, all about caries deck to die, how to actually use it properly. What is the evidence space behind it, and how to interpret the data that you get by using it. Hello, Protruserati. I’m Jaz Gulati and welcome back to the Protrusive Dental Podcast. If you’re new to the podcast, welcome, it’s great to have you. Protrusive Dental Pearl:Every episode, every main episode, I do a Protrusive Dental Pearl, some good tip, often clinical, sometimes non-Clinical that’s gonna help you in practice tomorrow. The one I have for you today is very much linked to the theme of this episode. Ie how not to expose, how to remove the appropriate amount of caries to get the best bond strengths possible without risking, removing too much dentin and causing a pulp of exposure. So how do you do that? You use some landmarks, use your perio probe and some landmarks and the zone that should be ultra-clean. The zone where you should be aggressive in caries removal, if that’s a fair enough term to use, is if you measure from the cusp tip down five millimeters. In that zone, you’re not gonna hit the pulp, so please remove the caries and from the adjacent tooth. So let’s say you’re doing a first molar, you can measure from the second molar. The marginal ridge of the second molar, three millimeters into the first molar distal, then that is your zone that you should keep super clean. And in those ranges, in those five millimeters from the cusp tip and three millimeters from the adjacent marginal ridge, you’re not gonna risk exposing. And so therefore you should try to get this really lovely, clean peripheral zone. But you’ll hear more about that in the main episode with German. So next time you’re wondering, should I remove some more? Should I not, will I expose? Maybe you can use a perio probe. Just be sure to warn your nurse first because the first time you ever do this, you are sort of a perio probe out of nowhere randomly in the middle of caries removal you’re about to expose and your nurse be like, wait, why are we now suddenly doing a BPE or something? Right? So, make sure you maybe tell your nurse what you’re doing first. We’ll go ahead and join the main podcast now. This episode is suitable for 50 minutes of CPD. It’s via the Protrusive app. If you’re not on the app already, do download it. It’s on iOS and Android. Even on the web, you can just go to protrusive.app as a website and that will load the app as a web app so you can access it there as well. And for premium members, you can answer a few questions at the end and get your CPD as well as a transcript in pdf. And the premium notes that you see on the side will be given to you as a pdf. I’ll catch you in the outro. Main Episode:Germán Dorgan, welcome to the Protrusive Dental Podcast, my friend. How are you? [German]Very well, thank you, Jaz. Very excited and ready to go. [Jaz]Mate, you are. I know you’re buzzing. We had a little chat earlier about the, you’re still buzzing from that World Cup win. I can sense the energy. I was enjoying your social media sort of banter about you and how Argentina was doing. I was happy. I won 150 pounds. I had Argentina as one of my teams in the sweepstakes. So, I won and so I treated my practice to pizza. So I threw everyone a pizza party. So everyone was happy that Argentina won. [German]That was really fair. I only won eight heart attacks in the finals, so. [Jaz]Now that was, Epic. An epic final. I don’t think we’ll ever see a final like that again, so that’s amazing. But Germán, you are very active on social media. Uh, we’ve been connected for a few years now. What I see you do in terms of your passion for Biomimetic dentistry is amazing. And you got me hooked to caries detection dye. I love this stuff. Absolutely love it. When I first got the bottle, I was like, I have no idea how to use this. Read the instructions. And now when I use it, I’m like, wow, I was missing so much of it. And I guess we’ll talk about my experiences and your experiences with it. But for those of you who don’t know you, who don’t yet follow you, tell us a little about yourself, your journey when you came over to the UK from Argentina. Was that after qualifying or? [German]No, so I was born in Argentina, but I was raised in Spain. At the age of five, my parents moved, to Spain, to Madrid. And that’s where I grew up. And then I’ve got grandfather, dentist, mom, dentist father, dentist sister, dentist. So I had to follow the steps of everybody. So graduated in 2010, in Madrid after a couple of years of- 2010 was a very, very hard time in terms of economical crisis, and I wasn’t very happy working in Spain, so I decided to just like move to the UK. I actually came for a couple of years to try to make some money and improve my parents’ practice, but that was 2012 and I’m still here, start working on the NHS and then after a few years, as I was learning, I was finding a few struggles, unfortunately, in terms of use of certain materials. I’m providing certain treatments to my patients. That all started after doing Tipton’s, Paul Tipton, training. Luckily, I managed to increase my private work to provide this to most of my patients and I focus in restorative and adhesive dentistry with a big background of Biomimetics. 2019, I got in into Matt Nejad’s course when he came to London. That hooked me into Alleman’s mastership over a year. Then I had the opportunity to train with emulate, but also help them teaching a little bit. And currently I’m taking part of get bonded and step bonded with Sami Sherif . Great course. [Jaz]I mean, now, you’re teaching with these guys, right? You’re an educator with them, which is amazing man. Well done. [German]Yeah, that’s a great step. We’re doing a good job. We’re actually bringing David Alleman in March for a session, couple of days of Biomimetics and then taking also part of the Mimétika, long, it’s a one-year program. It’s a European program with three huge guides, in my opinion. Filip Keulemans, Hugh Byrne, and one of my great greatest friends and probably mentors, Raphael Wymann, which are helping me to understand adhesive dentistry, like what element will call, get bonded and stay bonded, if that makes sense. [Jaz]Amazing. And from speaking to Taylor Paton, the previous episode, it is really, you know, get bonded, stay bonded is such a great way to summarize the field of Biomimetic dentistry and part of achieving those great bond strength is actually your caries management, your caries removal. Because if you’re gonna bond the caries, it ain’t gonna stick. You’re gonna be disappointed. And we spoke on social media. You recommended caries detector dye I asked you about it and you told me which one to get. So let’s start with that. You know, what is caries detection dye? It looks pretty on social media, but is it BS? Is it any good? I know you have a bias, but the bias is led by literature and it’s led by some time of you using it and your mentors using it. So, just start from the very basics. What actually is it? [German]So, yeah, it’s a very good point, what you said. You cannot bond if you foundation is not good. Okay. So imagine building a house and the base is really soft. The house is gonna crumble down, so we really have to find a way to see what we have underneath. And caries detector dye is a disclosing agent, red fuschin on a glycol solution. The main purpose is to stain DENATURALISED COLLAGEN. Okay? And this is a very important point because it’s not a staining bacteria, okay? We’re not looking for bacteria. We’re looking for the naturalized collagen, okay? We know that the bond strength- [Jaz]So to make it clear, Germán, it is not a plaque indicator. It’s completely different from plaque indicator. [German]Correct. Exactly. So we know that if we have the neutralized collagen, the quality and the bond strength of that dentin is not gonna be as good as if we have sound dentin. So, the caries detector dye, basically it’s the excavation of the outer decalcified and infected dentin. Okay. And that basically allows us to have an optimal caries removal. Okay, so if we have a good caries removal, we are gonna achieve good seal and more important prevent issues like losing pulp vitality. So it could be a problem because if we are not sealing the caries properly, it will keep going down and eventually we’re gonna end up with irreversible pulpitis or farther problems. [Jaz]Yeah. Some people who are not very open-minded and me as a practitioner, I’d never been taught about caries, the use of caries detection dye. I’d only ever seen other people using it, and I’m quite an open-minded clinician. I tend to, I’m happy to try new things, as long as got a scientific rationale behind it, which obviously is caries detection dye does. I was very open to using it and I love it. But the same thoughts that go into my mind, go into other people’s mind, but I still give it a go. I still wanna give things a go. Other people are like, well, I have my probe. I’ve been using my probe for years. I can feel the dentin. I know that this is soft and this is hard. Why do I need some color to tell me that? Now, obviously I’ve been using it so I can answer that, but you are in a better place to answer that. What do you think? [German]Yeah. Okay, so, we are talking about how to be objective and subjective in this matter. Okay, so it’s perfect, that’s a good way to do the description. If we can see what we’re treating and we can identify the substrate by different colors, we’re gonna be able to know what is there, however, let’s say you use the probe. The first point I will have is like, how can you measure every millimeter square of the surface of the cavity that you’re doing? Good luck with that. You know, I’m not saying that you are not wrong by trusting, and I think it’s part of the clinical judgment that you’re gonna have. You have to feel what you are treating and that will be part of the guidance. But I think, it’s not completely accurate and I believe that you will get surprised. If you finish a caries removal just with your bur and testing with a probe, eventually if you try with a drop of caries detector dye things will change and they will blow your mind somehow showing that you probably left tissues there that are not gonna provide appropriate bonding and proper seal of the surface. And especially when we’re talking nowadays that the contemporary concepts are saying that we can leave caries behind, as long as we seal it properly to starve the bacteria and then kill it. Okay, so if you are having a leak, that’s not gonna work, and then it’s gonna bite you back eventually. I think another point is like, how subjective is hard for me. How is, like, I think, I explained this with in a talk with Ash is a very, very simple thing. You, me, go to the gym, but I believe that I go only twice a month. But you go every day. Okay. [Jaz]I wish. [German]Okay. Yeah. Well, I’m putting just an example, but 10 kilos for you. If you’re going every day, it’s not gonna be heavy. 10 kilos for me that I go twice a month might be super heavy. So we really cannot have always, all of us the same feeling. [Jaz]Tactile feedback. And it’s the same as perio probing, Germán, perio probing. You’re supposed to use 25 grams, I believe of weight when you’re doing perio probing. But when you actually get the test at alga meters, whatever they use, everyone’s actually usually a bit too much. But when everyone’s different and to achieve the Optimum is difficult. [German]How do you screw an implant? What do you use? Torque wrench. [Jaz]I don’t, I use a referral pad. [German]Okay. Fair enough. No, but it’s a good way to think it. No, but if you think about it, when we’re doing implants, for example, if we need to know how much torque we have to give to screw, we need something to measure it. And that’s why we use a torque wrench, for example. Okay. And if we want to be even more accurate, we’re gonna use probably a digital one. Okay. So I think having, especially when the main thing that we’re doing as general dentist is remove caries every day. We sure have a systematic or a way that we can really kind of standardize the way that we’re removing caries to achieve proper results. And I think it’s an important thing, and I don’t believe the tactile feedback, it’s not accurate. And there are papers from Fusayama that are even more important when we’re getting closer to the pulp, the closer that we’re getting. Okay. Acute and chronic decay. There is no difference in the elasticity and the hardness of that surface. So if we are dealing with the cavities and we want to prevent pulp exposure, the best way to address it will be helping yourself with something to visualize what you’re removing and having a little bit of knowledge of the anatomy of the tooth. [Jaz]Well, we’ll talk about that in terms of, once you do use the caries detector, I had to interpret that data. But I think, it’s a good first point. The data is good because it turns something subjective. You know, one of the first things I learnt was the color is unreliable. You know, we used to chase everything until it was yellow. We then know that, okay, it’s okay to leave brown and black based on amalgam staining, et cetera. And so that was fine. Yeah, I think people still struggle to believe that your probe and the softness even that can fool you because that is subjective data, and I completely agree. So, to give you my experience of using caries detection dye so far, In the last six months, I’m usually, now I’m using it. It’s validating, it’s giving me peace of mind. Okay, yeah. This is what I expected. I thought this was caries free and my caries detector dye is confirming that. However, the odd time, one in six times I’ve done it has like, oh wow, I’ve actually missed a bit there and I should go back. And it’s just, it made me feel really good. And it also gives me a zone that I know that, okay, this zone, and we’ll talk about these zones. I can be a little bit more aggressive here. I can lead a little bit more behind here, and it gives that nice zone, which I know we’ll get into. So, I’m so far, very much converted. I’m a big fan of it and odd timing, it has surprised me. I thought, thank goodness I’ve got this as objective data. So I totally agree that more people should use it. When should you use it? Should you use it for, do you use it for every restoration, every caries restoration, or is it only for the deep ones? [German]Everything. First of all, not disrespecting anyone, but if I’m replacing any restoration, I need to find out why. Okay, so let’s say there’s a recurring carries and we’re removing a fill-in. The first thing I wanna check if okay, it could be C factor, it could be something that, poor bonding protocol. Not enough light cure. Something has happened, but the first thing I’m gonna probably try to check and this is where I respect how open-minded you are. Cause as soon as you heard that, it was like, okay, I’m gonna try it. I’m gonna give it a go. And you clearly notice the difference when I started my Biomimetics and most of my adhesive restorative dentistry, it was because things were not going well in many of my treatments. So I had that curiosity to find out why. So I’m replacing a filling. Let’s say a patient is coming with some sort of sensitivity, there is a fill-in. The first thing I’m gonna do is an investigation. And the first step is as soon as I remove my fill-in, check with the caries detector dye and will say that in very, very, very high percentage of those cases, I’m finding effective dentin or even infected dentin in areas that shouldn’t be. So what we are basically saying here is there are areas that are not bonding properly. So therefore, that restoration is starting to fail, causing problems to the patient. [Jaz]So, that is, just to make it really clear for someone who might have missed, or you said that this is, as soon as you remove the restoration, you haven’t even now started to remove any caries yet, because I guess the point you’re trying to prove is, why did it fail? And if you use it straight after removing restoration, you can see that there is still caries near the sort of external margin it was leaking. [German]Correct, exactly. So, it could be probably the thickness of the caries, it could be the C factor, but definitely I want to check if there is upper peak caries removal. Okay. So because I’m taking over this treatment, so I need to sleep well, like you said, and I need to make sure that I’m gonna achieve high born strength. And therefore, longer prognosis of my restoration. Whenever I’m gonna do any caries, even if it’s like something that is a deep caries, definitely it will help me to prevent public exposure because I will have knowledge of my landmarks and I will know where I have to stop. But more important, how to create the famous peripheral seal zone that helps to seal the bacteria. I’m preventing them from going deeper. And in those cases, what I will probably do is as soon as I remove kind of like the dirty area, we will call it like that. And I’m starting to have my cavity. So I know that I’m starting to go a little bit deep then is when I’m gonna start using my first few drops. And I’m saying drops because it’s not one drop. Okay? Most of the people will say, oh yeah, I do one first drop clean, but they don’t check. So we will talk probably when we go into how to use it- [Jaz]Well, let’s just talk about that now or what is, how much did you, so I could tell you what I’ve been doing and I’m happy to say it out, you know, live on air if you like. I might be doing it wrong and feel free to tell me is at the moment, and I didn’t read the instructions in terms of the way it’s delivered. I just, I know it’s supposed to leave it for 10 seconds and that’s what I remember and that’s what I do before I wash it away. But, I have it in a dappen spot and I’ve got maybe like 2, 3, 4 drops in there and I’m mixing my microbrush inside there, and then I’m rubbing my microbrush into the cavity. Am I doing it wrong? Am I doing it right? [German]No, absolutely perfect. I probably, I use maybe a couple of drops in the brush, and that’s more than you know, or in the dappen. But what I’m doing is constantly trying, constantly try and so I clean and I try, I clean and I try. I always test it. Because one thing is a staining- [Jaz]So you’re talking about reapplication. So you’re applying it waiting 10 seconds, you’re washing it away, then you’re reapplying it. [German]I clean my surface. Okay? And then I will test myself if I clean it properly. Okay. It doesn’t have enough penetration sometimes, so we really have to do reapplications in the different steps that we’re going through the removal of the caries. [Jaz]Got it, got it. Okay. But in terms of the actual procedure of how I’m applying with a microbrush and just rubbing it all way around, uh, yeah. Okay. Right. Yeah. Leave it for 10 seconds. Wash it away. Perfect. Fine. So before we talk about how to interpret that data, which I think is so key, and we’ll talk about the peripheral zone and using your landmarks, what does the evidence say? Is there much evidence in terms of how reliable the data is that you, this objective data that you’re getting from the color, from the caries detector dye, how reliable is it? [German]This has been studied since 70’s, 80’s. Okay. And the most important thing, and especially I think, this is something that for me, it clicks a lot in a way of we’re measuring infected affected dentin so we know the bacteria’s going through, there is acid attack, and that’s producing denaturalization of the collagen, which is what create the good and the bad bond on the surface of the tooth. And studies are from late 70’s, 80’s, and actually showing that even without complete removal, so leaving infected areas, we’re getting high bond strength. Well, high bond strength, if we’re talking about infected dentin, we’re getting around 10, 15. But if we’re leaving affected dentin, we’re around 20’s. Okay, so 25. If we think about bonding to enamel, we’re getting 31. Okay. So even not complete removal is showing us that it’s high bond strength. Okay. And then if we are actually have sound dentin, we’re achieving up to fifties, how do you achieve it is a different thing. And I think it’s what you spoke with my previous colleague about how to bond to dentin and more the principle of Biomimetics. And it’s all about a matter of time allowing the bond to mature properly in order to achieve high bond strength. Okay, so obviously there is several papers that are shown that we’re able to bond to caries. And how effective is the fact that we can visualize what we’re bonding. How do you describe infected or affecting denting without having anything that is showing you? You know, it doesn’t go into my mind. It’s like infected dentin. We know that by discoloration we cannot differentiate the difference surfaces. So it has to be something. And in this case, it’s a caries detector what helps you. [Jaz]When you seeing the different colors. Now, let’s say you’ve got an large cavity. You removed the caries to the what you think should be removed. So, you know, you’ve gone by your usual subjective data and now you’re gonna rub in the caries detector dye. Then you wash it away after 10 seconds and you see what’s left behind. Does the color gradient, does the pink versus red tell you something? Assuming using a red one I’ve used you use a green one is different, but let’s go with the red cause that’s the one I have. [German]So yeah, the have a look to the first papers that are coming around the 80’s. What they’re saying is that the infected dentin stains, whereas the uninfected dentin or affected dentin, doesn’t sustain. Okay. The acid attack on the affected dentin has been more aggressive. Okay, so everything has collapsed and it allows the dye to penetrate. That’s why it will get darker. It’s not that- [Jaz]Wait, on the infected dentin. It’s been more attacked, right? [German]Exactly. Whereas the affected, the demineralisation is not so aggressive. So let’s think about the progression of the decay. There is acid at the front. Yeah. That acid attack hasn’t been so strong. Okay. That dentin still has the ability to remineralize, which is the important thing, why we can’t preserve it, and why we have a higher bond strength. Okay. If we are trying to penetrate with the Caries detector, it’s not gonna be so easy. So that is when you’re gonna get a lighter pink. Okay. So the red will be the affected dentin. Completely unmineralized, okay. [Jaz]The red is the infected. [German]Infected and the pink is affected. [Jaz]So the pink is affected. And then obviously if you get no staining at all, that’s obviously completely healthy. And, and that’s fine. Well, give us some guidelines now in terms of, if you have some pink, when is it okay to leave the pink? And what position in the cavity? Is it okay to leave the pink? I think that’s important as well. So we’ll come to the red in terms of when you’re getting near the pulp and stuff, but, let’s start with the pink. If I see some pink, which is the affected dentin, but it’s near the ADJ. It’s near the DEJ, then that’s affected dentin. Now we can bond to affected dentin better than infected dentin. But is it safe to leave it at the ADJ? [German]So that will be basically losing a 30 to 50% bond strength. Yes. Because we said we’re gonna go around 20’s, 25, 30. Okay. If I am not gonna expose pulp why will I leave it? I want to increase my bond strength for a more successful restoration. So therefore it’s basically, the idea will be to lift it around two millimeters inside of the DEJ of sound dentin, okay. So there shouldn’t be any pink haze near the DEJ. [Jaz]Perfect. And then when we get closer to the pulp, at what point can you leave red? [German]Okay. So the red, this is a bit of, If we go to that paper, the Pascal and David Alleman released in 2012, there are some landmarks that is letting us, I will share you the little pictures with the probe. I think, having a perio probe is quite important to prevent pulp exposure. Okay, so what is telling us is to avoid pulp exposure, we have to measure five millimeters from the cusp tip and three millimeters from that adjacent marginal ridge to create that peripheral seal zone, okay? So if you see that picture, we will have like a tooth. So from the cusp, we’re gonna measure five millimeters from the tip, and then three millimeters for the marginal ridge of the adjacent teeth, okay? [Jaz]Mm-hmm. [German]If we are not having adjacent tooth, which can happen, we have to think about the curvature of the tooth. So obviously if we are high up, those three millimeters that you’re measuring, predicting that there is a tooth next door, it will be different because the amount of dentin will dry. What I will have is those two millimeters of clear dentin. But we have to use the clinical judgment. Okay. We have to look at the x-rays. An older patient will have more retracted pulps, so we will be able to be a little bit more aggressive. Okay? So these are standard measures that we’re gonna, we’re gonna use, but we also have to use x-rays. Otherwise, and that’s the important part. You’re gonna leave a lot of red, that, again, doesn’t bond properly. So the reason why bonds is because it managed to get into the affected dentin, but in the middle, you’re not gonna get such a underloading teeth will have an impact or even fail and allowed the progression of the caries again. [Jaz]So in order not to expose the pulp, we wanna make sure that we have no color, no pink, no red in the peripheral zone of at least two millimeters all day round. But if you’ve got a particularly deep cavity and you’re worried about pulp exposure and you get your measurements, five millimeters from the cusp tip three millimeters from the proximal marginal ridge, and it is more acceptable to leave your pink and red in that zone. Is that a fair summary? [German]Exactly. And then obviously, this is just something, what half is my air abrasion unit so we know to increase bond strength. It’s a great tool. Okay, so paper shows that- [Jaz]Well, the literature is, quite mixed, right? There’s some maybe literature that says that abrasion doesn’t increase the bond strength. Some that says it does some that says it does it. Maybe it’s because of the plaque biofilm removal effect. what’s your stance? You are more well read up on this than I am. [German]At the moment, most of the things that I read are going towards using air abrasion to increase the bond strength, and that’s how you achieve a 50 mega Pascals on bond strength in sound dentin. Okay, so if you repeat- [Jaz]I mean, I swear by, are you anal about, like some dentists is like, it has to be 27 microns on the dentin and 50 microns on when you’re doing indirect work. Like it’s not practical sometimes. So is it a sin to use 50 microns on dentin? [German]So that’s dentistry. And there’s so many papers and everybody tests differently and that’s the problem we’re having, we’re all testing differently. So, in terms of, for me, if it’s something outside the mouth and I’m talking to zirconia, which I barely use it, it’s not a material that it’s a common thing that I use because of the low bond strength, I will use 50 microns outside the mouth. In terms of the mouth, I’ll stick to 25. And the reason is because it really doesn’t show any significant difference between one and the other. And what I will say, if you go quite handy, quite heavy on your hands, on a 50 microns, you’re probably gonna remove much more than what you want. And this is exactly what I was going to try to say. Sometimes when I get to my last stage, I’ve done my measurements and I do a nice thorough air abrasion to remove that kind of red that is there. And if pops quite a big amount and I end up with a pulp exposure, it’s very likely that my bacteria was already in in the pulp. Therefore, that pulp exposure. I will take it as like it was going to be needed. I was going to end up, or either doing pulp capping or it was going to end up doing a root canal treatment because the pulp was affected by bacteria. Bacteria was inside of the pulp. Okay. So I will go with 27 microns on that last part area gently, but enough to just like clean and see all that part of like soft decay coming out, if we can call it soft, if that makes sense that red area. [Jaz]Well, for those who listen to the Pulpotomy episode by Suza, they’ll be saying Pulpotomy, Pulpotomy, Pulpotomy. But, that’s a different episode. You guys should listen to that one. That was a really good one. Here’s an interesting one. Not interesting. It’s just something that’s annoyed me and I was really looking forward to this chat to speak to you about this is when I use the caries detector dye and obviously the pink and the red that’s in the middle, is it okay just to leave it? Because now that I’ve done my washing, I’ve done my air abrasion, there’s still a little bit of pink and red there, and I was thinking for the longest time, like, oh my God, how do I get rid of this stuff? Is it okay that it’s there? Please tell me you can bond to it. [German]Oh, of course. That’s what I said to you and if you see the articles, I’ll send you those two. Yoshiyama and Nakajima, that’s the name of them. They do the studies, bonding to caries infected and caries infected dentin using caries detector dye, and they’re getting those numbers of 25, 30. Will it decrease? Maybe, maybe not. We don’t know. But how do we know if we are testing that or not? And it’s still getting a 25 or a 30, on anomalous 30, so we’re getting on that pink haze a good number. If by that 10, 15 that I’m getting in caries infected, basically avoiding pulp exposure, I’m winning. I’m already winning. I’m preventing a root canal treatment. And what’s important, you now have the ability because the pulp is still alive to heal. So if there is an inflammation slightly to heal. But obviously we’re all different. We’re all different. [Jaz]Yeah. [German]Not everybody has the same immune system. [Jaz]Of course. So, but just to clarify, you’re not using anything to actually remove the pink or the red, once you- [German]No. [Jaz]Which is, yeah. I was just thinking about that. Was I supposed to do? [German]Remember what I said, the last thing I do, I test myself by another application, another drop of caries detector die, and then I rinse it and then I check if I have a proper peripheral seal zone. [Jaz]Okay. [German]Because it’s very often done that they clean, clean, clean, and on the last clean, they don’t check it, so they just go to proceed. But if you check that sometimes you might get surprised that you are actually left affected or infected caries in areas that are not affected dentin in areas that shouldn’t be. [Jaz]Sure. I’m using the Kuraray caries detector dye at the moment. The red one. I like it. I think next time when I finish this bottle, I’m gonna go for green because in case there is a pulp exposure in the future, I worry that if I’ve got something pinkish red and I might not notice. [German]Do not, when you see the pulp exposure is evident how the little bit of blood comes out. Many times I’m able to see how come the pulp horns are starting to show off. So that is actually, remember what said clinical judgment. It’s not only about my caries detector eye. It’s a few things that are coming together to find that caries removal endpoint. Okay? [Jaz]Mm-hmm. [German]So you will see that red coming out. It’s not often that I find a patient, oh, it’s hurting and I do everything, and someone just did a pulp exposure. 10 years ago, you can see the hole and it’s all dry. Okay? [Jaz]Mm-hmm. [German]So you can see the pulp horn was exposed, and that is visible and green or red. Most important thing that you have to have is the content of glycol. Okay? The glycol content is the only thing, because it’s what it helps you to penetrate. And I didn’t know exactly the brand. Basically Kuraray will have around a 90%, but there is one of the brands I can’t remember. I’ll try to send it to you. Basically the percentage is around a 45%. Is it actually penetrating? No. So it will tell you that you probably clean, but you haven’t. So as long as you have a high percentage of glycol to allow the fuschin to penetrate properly to allow the dye to go through. [Jaz]Awesome. I’m a huge, Panavia fan, so when I saw that Kuraray did that caries detector dye, I was like, yeah, I trust Kuraray. So, I gave my money to them. But yeah, if you find out the name of this Mickey Mouse caries detector dye, you let me know and I’ll make sure that no one ever buys that. [German]I’ll find it. I think it’s half a path or something like that. I think, Ultradent is also good content of glycol is another option that you can have, and I think that one is green if you want, but I haven’t seen it. I only have used Kuraray since I started, and one bottle of them will last me very long time. It’s a lot of caries detector dye, so. [Jaz]Yeah. For someone like you who’s using it very, very heavily. Yeah. I mean, it does last a long time, so, I mean, you answered all the questions, I had Germán tell us now. Anything that you think we’ve missed that you think is important to know before someone, for the naysayers, for the haters, for those who are still not convinced that, you know what, this is just BS and I’m still gonna rely on my probe cause I’m old school or whatever. Anything you wanna say to those guys or anything you wanna say to those who want to, who are gonna now maybe try using caries detector dye and they’re interpreting the data for the first time? Anything that you think we haven’t covered yet? [German]Yeah. I think the most important thing is that, and I have chat this with you so many times we’ll have to do what we do know best. Okay? So introducing new things, they will have a learning curve. They take time, and the best thing that you can really do is learning and have someone that can mentor you or help you and on the process, okay? Using caries detector dye or not, it’s a personal choice. I’m not gonna force anyone to do it. We don’t have to force people to do protocols that they don’t feel comfortable because the only thing that you’re gonna create is hate and dentistry is science not a dogma. Okay? So that’s the important thing. Important, important, important really is to share those cases with people that are probably knowledgeable in the matter, either I know Instagram can be a hit or miss, but there are lots of great gurus. That’s how I met you. That’s how I got in contact with you. And I learned a lot of TMJ thanks to you. So obviously we have to have a little bit of discretion on the matter, but, absolutely share those cases. Ask question, be active, you will not learn. And second thing, you will notice that when you’re using caries detector dye, you will be a little bit more aggressive than if you were not using it. So many times what I find with the students is that because they are not cleaning it properly or they’re not removing enough, they’re really leaving some substrate that is not bonding as good as they Cool bond just because they’re scared of having a pulp exposure. And this is where sharing those cases with our people will help you and will basically make you improve in using this caries detector dye. And there is an important article that talks about caries detector dye is too aggressive. And what they were testing actually was that they were leaving pink haze close to the DEJ, but they weren’t finding bacteria. Are we testing bacteria? No. [Jaz]No. Because you said it’s, it is not a plaque indicator. [German]Exactly. So it will become a little bit aggressive. And that’s the myth. And there is a big myth in caries detector dye being aggressive. And there is a restorative book that was used very, very frequently that was saying the caries detector dye was not good because it was too aggressive. I was removing too much tissue. But it was because the test, once again was done based on a different data or something that we should then be testing. So it was a mistake. And that person didn’t understood what we are tested with caries detector die and they tried to find bacteria and they didn’t find it. But we are trying to achieve high bond strength by having good dentin or- [Jaz]To get the best substrate possible. Yeah. It reminds me, Germán of something. My mom says, and she says it in Punjabis, a Punjabi saying, but it basically translates to, ‘The truth is always bitter.’ So sometimes when you use the caries detector dye, the truth is revealed. There’s no hiding from it. And what you see is that, oops, I have been leaving a bit of caries affected dentin in that peripheral zone where I should have been removing it all this time to get the best bond strengths at that, you know, first couple of millimeters of dentin. So, super important. So, Germán, thanks for covering this episode. You’ve got some exciting stuff coming with the Alleman’s coming and it out the cricket ground. I’m so gutted I couldn’t come because I’m on another course. Typical, tell us about that, my friend. That’s super exciting. [German]So we are, 3rd and 4th of March. David Alleman, we’re gonna spend either two or three days. It depends on what’s gonna be plan is, David and Davey Alleman both come in with Sami and me helping. So we’re gonna be at Lord’s Cricket G round, London. So we’re gonna review all Biomimetic restorative dentistry and the six lesson approach. And if we are doing the third day, it will be how to treat endodontically, how to restore endodontically treated tooth. It’s a very interesting heavy HandsOn lot of theory, which is what I find with David Alleman. If there is something that I have to really praise and really appreciate from him is that he make me read not just have someone that comes, and this is good. You know, like, this is good. This is good. I show you my keynote about this presentation. And it is heavily, heavily based on articles that are showing different things. And all of them will have a point why this, why not this? And why do I think, and why do I have this opinion? And I think this is one of the best things that you can have from Dr. Alleman. And from Davey cuz Sami as well is for me, one of the most amazing person, I would like you to have a conversation about whatever you want, because if you- [Jaz]Yeah, he’s been invited. He’s just gotta click on the link and then book in, my friend. He’s more welcome to join us to geek out on Biomimetic Dentistry. It’s a topic that I think is really exciting nowadays. It’s been around for a long time. We’ve known about it. For me, it’s a decent dentistry on steroids, right. It’s like that. [German]I do love Biomimetic, and I know word that, but I’m more, I like more my DC from restorative dentistry with a lot of background on Biomimetics. You know, I think it’s just I understand what you’re saying exactly is a perfect, perfect word. It’s a big intense thing. But I think what really kind of like enlightens it is the amount of literature that really provides student dentistry and for clinicians to learn. [Jaz]And I think what is provided based on speaking to my Biomimetic colleagues is guidelines and protocols decision making skills, based on sound literature that’s what I thought I’ve interpreted so far, basically. So, I think that’s great. I want you to tell the website and also how we can follow you on Instagram. [German]So my Instagram it’s a funny one, is a German T-E-K-I-L-L-A. So, it is @germantekilla. It’s nothing to do with tequila, even if people think that it is something to die. It’s just a funny thing that came from university mantequilla in Spanish means butter. So, I play with my name just like to do that when I was a university. So, it stays. So, it’s German, T-E-K-I-L-L-A. And then we can have a look at getbondedstaybonded.co.uk and you will find all the information about that course in the UK. If you wanna level up a little bit more and have a one year program, I will recommend you to have a look to Mimétika. It’s another great program that I recommend. Have a look to Raphael Wymann, Hugh Byrne, and Filip Keulemans , amazing clinicians, researchers that are also I’m collaborating with them and I’m gonna be in May. I’m gonna be lucky to be with, Junji Tagami. I’m gonna be lucky to be, with Ali Sadr these people teaching all of our is an amazing program, David Gerdolle which I think- [Jaz]Legend. [German]You’ve met before. Another great clinician. So if you are interested in doing something a little bit more a long year course, it’s another great option. And if you also wanna have a look, check, emulate is another restorative course based on Biomimetics and in incredible HandsOn with two amazing people like Fran and Stew, Fran Brelsford and Stewart Beggs. Incredible hands, incredible talent. [Jaz]And we have to shout out to, Taylor Paton again, the hybrid layer as a good resource to read up and introduction to Biomimetic Dentistry. I love what he’s done there. So there’s plenty of learning to be done there. Yeah. Thanks so much my friend, for giving your time. [German]Thank you. Thank you. Can’t thank you enough, honestly. Jaz’s Outro:Thank you, buddy. Well, there we have it guys. Thank you so much for listening and watching all the way to the end. Hope you enjoyed learning about caries detector Dye, and maybe you may start implementing this in your practice and you’ll be able to use it properly from the get-go and interpret the data so you can get the best bond strengths possible. Now that you’ve listened all the way to the end, do answer a few questions, get that CPD that you well and truly deserve by the end of the year, all those hours will rack up. And if you want to refer to some of the notes, you can always download that as a PDF as well by scrolling on the app. And of course, if you enjoy this episode, do consider leaving a review or a rating depending on which platform you’re listen and watching on. It really helps a lot. Thank you so much and I’ll catch you in the next one.

Hygienists working without nurses and feeling like scaling machines – it’s about time we covered this elephant in the dental surgery. I brought on my dear friends and exceptional hygienists Morgan Williams and Louise Brake – they have faced career struggles in the past in the quest to finding the right environment and have so much to share with us. The biggest takeaway of this episode will be to consider ‘leading from the bottom’ – if you are feeling stuck and don’t just wait around for good luck (I’m such a poet!) – take action. You’ll be inspired by some of the ideas from our discussion! https://youtu.be/X7GBKUawq4A Check out the full episode here Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 04:32 Morgan and Lou’s Dental Hygiene Background 07:25 The Importance of Settings Goals and Expectation 10:42 Hygienist as ‘Scaling Machines’ 14:09 The Best Advice to be a Better Hygienist 17:40 Good Communication to Improve your Practice 21:26 Nurses for Hygienists 27:20 Business Models for Hygiene 29:54 Preventive Focus in Dental Hygiene 34:11 How Hygienist Treat Perio 35:52 Optimised, Personalised OHI 40:07 Number One Trait to Look for in a Practice Check out Morgan and Lou’s Instagram, Dynamic Dental Duo! If you enjoyed this episode, you may also like another episode with Laura Bailey: Why You Need to Take Massive Action for Success in Dentistry Click below for full episode transcript: Jaz's Introduction: What's the best way that hygienists and dentists can work together? Well, when I was in Singapore, I didn't know a single hygienist. It wasn't really a model at the time that was used there. Jaz’s introduction:Whereas in the UK, we depend so much on our hygienists. I feel like we work together well with hygienists. However, I sometimes worry and hygienists I speak to worry that all they become is a SCALING MACHINE. And so, I talked about that today with Morgan and Lou. Two lovely hygienists I use to work with in Oxford and they share their struggles, how they had to work in quite a few practices where the environment just WASN’T RIGHT FOR THEM to thrive in as part of prevention minded hygienists. And I think what they have to say, well, if you’re a hygienist, listen to this. Or maybe a dentist has said this episode to you, then this is gonna be a real source of inspiration from two lovely ladies who’ve been in the game for a little while. They know what they want and they’re gonna tackle those difficult themes such as HYGIENISTS working WITHOUT NURSES like. Where does that stand now in 2023? My practice now where I work as an associate, only now is it starting to really implement a nurse working with a hygienist. Whereas I’ve worked with a few practices for where there is no such thing. It’s unheard of for the hygienist to have nursing support and I know lots of young hygienists who tell me that they feel really uneasy about working alone and really, is this the best way to deliver ideal patient journey that’s safe and effective? I don’t think so. But then again, a lot of you will say, ‘But Jaz, you are not a practice owner. You are not paying the bills.’ And I totally get that. I respect that. As an associate, it’s easy for me to say that, but I’m hoping after this episode with Morgan and Lou, though, you understand why it is so important for our profession to work together with hygienists to get the best outcomes, and I do believe that starts with a hygienist being provided a nurse. Now, what I don’t want after this episode is lots of hygienists handing their notice or dentist getting pissed off and saying, ‘Jaz, what the hell do you do? Why did you encourage my hygienist to think a little bit differently and inspire him or her a little bit too much?’ I mean, I want to inspire. I want to get the word out. I want to help these hygienists through Morgan and Lou and what they have to say in learning from their journeys. But I don’t want there to be friction between dentists and hygienists. I want there to be synergy, and I want us to create an environment where hygienists can be happy at the workplace because a happy team breeds a culture in the practice that’s palpable and patients can detect it, and I think it’s a big part of the patient journey. Hello, Protruserati. I’m Jaz Gulati and welcome to another episode. This is an interference cast. It’s like a nonclinical interruption. So we talk a little bit about clinical here, but it’s more about the bigger picture stuff, how we can work together with hygienist the best way possible. Let’s join the main interview now. Main Episode:Morgan and Lou, welcome, very warm welcome to the first ever hygienist to Protrusive Dental Podcast. How are you, both? [Lou]Good. Actually excited for our first podcast with you Jaz. [Jaz]I’m just excited just to see your faces again and then just have this connection and catch up with you. So those of you who don’t know, I probably said in my intro, but we used to work together in Summertown, Oxford, and you know, Morgs because you reached out to me on Instagram, cuz I think you heard me mention about how much I loved working with you two. Right? And then I said, listen ladies, you have to come on the show because like what I do for dentists and I’m a little bit shameful in the way that I do very much make the content for dentists, and I do sometimes feel as though I’m leaving our cousins, our brothers, our sisters, our hygienist, therapists out a little bit because some of the themes I cover are just slightly different to the themes that perhaps you guys want. But then, what hygienists have been doing, they’ve been DMing me, saying, ‘Jaz, can you just cover this one thing for us about how we can work together better?’ And I think, who better than you two? And I’ll just start from the top. I guess. Let’s have a couple of introductions first before I give you, my introduction. So Morg, start with yourself please. Tell us a little bit about yourself, how you got into hygiene, and you are interest in that regard of working in the capacity with dentists. [Morgan]So, I was a dental nurse for seven years before I got into hygiene. Yeah, we were talking about this the other day about how we think it’s a really great base because you already have that background knowledge. So yeah. Then obviously met hygienist on route and thought, hang on a minute. I think I would like to do a bit of that. And then lucky enough- [Jaz]Did you find that jump difficult? Because a lot of dental nurses consider that move and then something comes along and they don’t do it, they don’t commit. Did you find it a big jump? A big hurdle? [Morgan]I mean, I was young, I was 21, I was at university, studying hard, playing hard. So, I actually think I had it really easy. We had women on the course that had children, families back home, and they were sacrificing that time away from them and studying, and they were working way harder than I was. That was for sure. So, I think I did it an easier time in my life, but I have real respect for people that do it later on. And you know what? Great, because I have even more experience. So, yeah, I would say if you are considering it, go for it. It’s a great flexible career. [Jaz] And one of the themes we’ll talk about later, is a common theme I’ve spoken about on the podcast Morgs, which is finding the right place of work and how you have to kiss lots of frogs before you find your Prince Charming. And I know we had that chapter four. I’ll talk a little bit about; we’ll talk about that. Right? We’ll talk about the state of the play and the situation and stuff. But, Lou, let’s hear from you. Tell us about your background, how you got. [Lou]It’s, yeah, pretty similar to Morgan’s actually. I, after leaving school, I worked as a dental nurse, for a little bit longer, about 10 years. And I used to always pop in to see the hygienist and see how she worked and offer some help sharpen her instruments and ask if she wanted some charting and everything, because she worked without a nurse. And I really loved what she did. It really, really interested me. And she said to me, ‘Lou, you must gone do dental hygiene. You know, you’ve obviously got an interest for it.’ And that’s what I did. I started applying. I was a little older. I was 26, so it was, no, and I’ve never looked back. It’s been the best thing ever. I always knew I wanted to go into some form of dentistry, but I never quite knew why. Or what. It’s been absolutely amazing. Never look back and I would never have a different career. I love it. [Jaz]Brilliant. You know, that shines through when I used to work with you two, like I could say it now, I don’t want to offend any hygienist listening at the moment, but you two are just the best hygienists ever worked with, honestly, the understanding, the culture at work, just you two, just amazing, and I want to bottle you two up and spray you around the country in terms of your, just how you work together and this is what this episode’s about, right? Because, and before we delve deeper, I’m getting so many thoughts and questions in my head already, but Morg, you said something really important before I hit the record button, and I guess it’s kind of like a disclaimer before we talk further. Do you want to just say it, go on. Just spill it out, get it out your system. [Morgan]So we work in a really, really lovely practice in Norfolk, Oxford. It’s a very affluent area. We were very fortunate to be hired by an amazing dentist called Guy Duckworth who was very, very prevention savvy, forward thinking and the ethos of that was carried on through the practice. But we are not stupid to know that it’s not a cheap practice. What we can offer and the people that come here, a lot of them can well afford what we’re offering so we can completely tailor make their treatment for them. And we do appreciate that there are practices where it would have, the way we work would have to be very adapted because affordability is definitely an issue, especially in the times we’re living in. So yeah, I didn’t really want us to come across as a couple of divas that just said, this is our way enough highway in the way that everybody should be working, but what we can offer is the best of the best because of the- [Jaz]And it works in your business model. Lou, is there anything you want to add to that? [Lou]I think that you can, I think it works. We can tell patients what they need, and they obviously take up the advice, they take up the appointments. So, we find that we have the best success rates, you know? But I would think even if you haven’t got affordability and you have got reduced time, it’s actually about set what your goals are. Your expectations and work to them. I find a lot of the time people think that, you know, oh, you’re just going to become an, you know, it’s all about removing the calculus. It’s all about removing, you know, the staining. But actually I think that’s very, very shortsighted, basically. That’s a short, quick fix, but actually it’s not helping anybody. It’s just actually you are stressing yourself out. Your expectations are never going to be met doing that. So actually, I think you’ve got to play the long game, you know, like I said, goals, expectations, definitely in any capacity. You know, if you’ve got 30 minutes, then I think adapt that appointment. Two, what is the most important thing? What is the priority here going forward for that patient? [Morgan]I was just going to say, giving a patient value for money does not just mean scaling their teeth. So, you know the whole give a man a fish for a day, you’ll feed them for a day, but teach them how to fish and you’ll give them a lifetime’s worth of achievement. That’s exactly the same with what we do. Us offering somebody educational on how to clean their teeth is going to mean that they’re going to get so much less issues further down the line, just scaling them. No clinical benefit. [Jaz]And as we explore this episode further, that’ll become clear in terms of messages we’re want to send out. But I’ll give everyone an example straight off the bat, is that the way we worked together in Oxford at the time was when patients would come to see you Morgs, there were some patients and you know, you got into heated confrontations because you’d refuse to do any calculus or plaque removal until they sought them. So, you just spent in the least patronizing way as possible. Patients always be like, wait a minute, I’m paying you x amount, clean my teeth and you are just telling me how to clean myself and you’re doing the right thing. You’re doing it by the book. But you know, you are ready to have your purpose. You have your purpose in terms of their overall health and actually sorting them out, prevention base so that they can look after themselves rather than just being a scaling machine. You have the holistic health in mind rather than just, let me get the scaler out and stick it in as soon as possible. So that’s the kind of what we’re talking about here. The bigger picture. So taking a step back, I know about your journeys now and you did nursing first and you got into hygiene that way. And it’s nice to know your individual, journeys and then let’s talk about actually finding the right environment and the struggle that you found to find the right place. And it’s very much ties into what you said morgues. That the young hygienist who’s listening to this, who’s just, a couple years out, and if we didn’t say that disclaimer, first up, they would listen to this, and they might feel really disheartened that they’re just a scaling machine and they get miserable. But what you’ve made very clear is that actually you work in a very specific practice. They’re set up for this, but the second thing they’re not hearing or seeing until now we’re going to reveal it now, is that it took you a long time or a lot of practice to find the right place. So Morg, let’s hear your journey of the frogs that you kissed along the way. [Morgan]There’s been many, and in one practice I did five hours in their practice, and I said, ‘This isn’t going to work.’ You either get on board with how I want to work, which looking back as a newly qualified hygienist with very big head, you either get on board with how I want to work, or I won’t be here on Monday. Guess what? I didn’t go back on Monday. [Jaz]Well done. [Morgan]I think I left 12. Yeah, I left 12 practices when I first started. This is the only practice I remained at. And I remember Louise saying to me at the beginning of my journey, there are enough good practices that you’ll be able to leave the bad ones. But I would say to the newly qualified hygienist, working as many different practices as you can. Because eventually what will happen is you’ll get offered more days in the good ones and you’ll be able to leave the bad ones but choose to be the clinician you want to be. If you feel undervalued, if you don’t feel listened to, if you’re made to work 20 minute appointments with no nurse, move on because obviously on the forums all the time is these poor, newly qualified hygienists, they come out of university so full of enthusiasm and I can remember that feeling. You just want to go and like spread the word about all hygiene and change the world and you feel so limited and unsupported. And when I see those conversations, I just think you are literally flogging a dead horse. You need to leave that practice and move on. [Lou]What I was going to say, I think what we are finding is happening is because if you are working in these practices where you are not feeling valued, where you are not being able to utilize all of your skills and make that difference, then the stress levels are high and people are actually leaving the profession. And that’s not what we want. You know, they’ve spent a long-time training and we want them to stay. I think they do have to find the right practices and be the hygienist and dentist that you inspire to be when you actually started your journey of actually, of the education, of the training. Definitely. [Jaz]I mean, that applies to dentists and hygienists. And Lou, just to give us your background in terms of how many practices until you found where you are at now. [Lou]Wow. I qualified, 23, 24 years ago, and one of my tutors actually said to me, do not become a scaling machine. And she’d said to me, you love the oral hygiene side of it. Find the right practice for you. locum first. And that was the best bit of advice that I had. I locum first. And even though they had permanent positions, but what I’d said was that I will lock them. So, my day, I was traveling two hours one way, two hours another, but it was worth it because then I could see whether it was a practice that I wanted to be in, whether they got me and whether I got them basically. So yeah, I lock them first. And then even when I came to Diamond House, my interview with Guy was very, very relaxed and we just had a chat and he’d said, ‘ We’d like you to start working for us.’ And so what I’d said was actually, ‘How about we actually have a month together?’ I said, ‘Just as a locum, I will do a month for you and then we’ll have a conversation at the end of the month. If you like me and I like you and we’re working well together, we’ll then you know, we’ve got a deal we can go forward.’ And that’s actually what I did. And it was the best thing. It was the best thing ever. But I think if I haven’t got that advice at the start by saying, ‘Be the hygienist, work the way that you want to work.’ Then I don’t think I would’ve had maybe the confidence to actually say that right from the beginning. A lot of people, a lot of my colleagues that actually started qualified at the same time. Within months, they were stressed, burnt out, saying, I’m not going to be able to do this forever. And that’s even after a few months, you know? So, I feel very, very fortunate that I took on board the advice that I was given right from the start. [Jaz]So the theme already we talked about is, you know, I have to kiss a lot of frogs before you find your Prince Charming. The second theme based on that is date them before you marry them. And that was a great example. [Lou]Yeah. [Jaz]Even though you’ve got this great vibe from Guy Duckworth, you said, ‘Hang on a minute. You know, I like this, but I’m going to do a month first.’ I love that. And I think that’s great. It’s a little bit brave. But I think, it’s good to have that and the themes I’m seeing here, I don’t know if you listened to an episode I did with my good friend, Laura Bailey. She is a therapist I work with in Richmond and she’s doing a lot of bonding. And the common themes we’re seeing here is you have to take massive action. You have to put your best foot forward. And that can sometimes that map, that journey can look very uncomfortable. That’s a very squiggly line from point A to point B. It’s a lot of tough conversations to have along the way. A lot of goodbyes, a lot of upsets, a lot of new places, new environments. A lot of commuting that you did, Lou, these are the real-world issues until we found it. What I don’t want on the back of this episode is a mass exodus of any hygienist who’s unhappy. And then this episode comes out on Monday and by Wednesday, all these principals are calling me up saying, ‘Jaz, stop podcasting! You just ruined it for everyone.’ [Lou]And then you’re getting hate mail! [Jaz]Hate mail, and love mail. I’m sure what you’re saying is resonating with a lot of hygienists. So really, if a hygienist is feeling stuck, rather than taking a big risk and being out of income and out pocket and struggling to find new work. What is the first step that you could use, but perhaps you employed but it didn’t work because maybe the principal wasn’t receptive, wasn’t open that communication, it wasn’t the right environment. Whatever. What is the first step a hygienist can do to open that conversation to improve so that’re no longer a scaling machine? [Morgan]I think evolve. The biggest thing that everybody has to do in practice, and that’s not just the hygienist, that’s the dentist, the practice manager, everybody, nurses, we all have to learn to evolve. So, I think, if you’ve got good communication in the practice, we definitely don’t work how we first worked when we lost each other. Yeah. Communicate. And you need to be in a practice where you can evolve. So yeah, I mean, definitely don’t do what I did and just walk out after five hours. I think try, have communication within the practice. [Jaz]Give it a shot. Give it a chance. [Morgan]Yeah, give it a shot and try and communicate and air your views as to how you feel that things could be improved and in then at that case, if you think that things aren’t improving and you have it what you are feeling, then maybe it is time to move on. [Lou] Mm-hmm. I think good communication. We say that we are a team, actually be a team, actually converses a team, get everybody together and actually find out what everybody’s expectations are. Set some goals. Set some action plans together. Go on some courses together. Go on some, you know, so everybody has a really good understanding because I kind of think a lot of the time we think that the other person knows all about the subject. Okay? I’ve had dentist, said to me, ‘You know what, I had six weeks perio.’ I haven’t got a clue what I’m doing kind of thing, you know, holding their hands up. You know a lot more than me. And when it comes to decay and occlusion and everything like that, I’ll say, ‘You know, that’s your skillset.’ And recognize everybody else’s skillset and actually utilize it in the team, and don’t be afraid to say, ‘I don’t really know much about this, but can you tell me about it?’ And, you know, every day’s a school day, we don’t know everything about all subjects, so actually educate each other as well. You know, maybes have regular meetings with each other, even if it’s just a 20-minute coffee and just say, ‘Can you tell us a bit about what you do? Can you tell us a bit about motivating patience? Can you tell a bit us about what you’re doing, what your successes are, what your failures are?’ [Jaz]We used to go out for Chinese food and curry and that kind of stuff a few times that we went out as a team, back when Amme and Yiannis and whatnot. So that was good actually. So, it’s nice to have that team building, you know, team building gets into everyone, but also suggest the changes and have that open conversation. Right. [Lou]Absolutely, and don’t be afraid to actually say, let’s do something. It’s almost like it’s positive criticism, you know? And I think take it as a positive. This, just saying that actually I think we could improve on things, I think is monumental for every practice and for ourselves as well. Everybody wants to like you said, evolve. We need to evolve as people, but we need to evolve within our work as well. [Jaz]Like you don’t just go into work one day and then hope that’s a day that the principal’s going to have an epiphany and be like, you know what? We’re doing it all wrong. How about we change the model and do this? No one’s going to do that. You know, things are going to not just change miraculously overnight. You need to be suggestive. You need to plant some seeds; you need to arrange some meetings. You need to come up with, you know one of my favorite things is, don’t come to someone with problems. Come to them with solutions. So don’t be that person. That hygienist would be like, ‘Oh, this is not working. That’s not working. I want a nurse, blah, blah, blah.’ How about you come up, if we have a nurse, so this is one awesome thing that Laura did when she approached the principal Hap, who’s very open and receptive and great leader is, she said to him, ‘I want to use EMS airflow. I know there’s a huge expense, but I’ve done a calculation that if we raise our fees to this amount, we can cover it.’ And then they had that conversation. And what a great way to approach someone rather than, ‘I want an EMS airflow.’ You know what I mean? Yeah. So, so I think that’s a great tip. Any examples of when you two might have done that? [Morgan]Yeah, we were told at one point that when the practice couldn’t afford to have a nurse, we couldn’t have nurses. So we took a pay cut to retain having the nurse because we feel like well, it makes our day so much easier. We hugely value the girls and we want to offer the best service, and the only way we can offer the best service and give a hundred percent of our time and attention to the patient is to have a nurse. [Lou]And to utilize the nurse as well. Yeah, definitely it is. [Morgan]It’s the best decision we ever made. [Lou]We accepted taking pay cuts for the better machinery and to have the nurse and we enjoy our day. We enjoy what we do. And it’s because of I think of making those changes and making the sacrifices as well of it’s less financially, but actually we have a less stressful day, and we enjoy what we do. Patients are happy and everybody’s happy and it’s a win-win. [Morgan]And we can justify our costs because if a patient set, they’ll even come in and say, ‘Oh, no nurse with you today.’ And you’ll say, ‘Oh yeah, they’re just processing the instruments. They’ll be with you in a moment.’ And we make them fully aware that yes, we’re not the cheapest, but it’s because we’re using the best equipment. We have support a hundred percent of the day, and our focus is solely on them. [Lou]It’s that patient journey. I hear that word banded around a lot these days. You know, the patient journey. But it is the patient is our business basically. [Jaz]Mm-hmm. [Lou]Isn’t it? [Morgan]Yeah. Yeah. [Lou]So to make them feel really cared for and important and that they are getting the best treatment, then everybody’s a winner. [Morgan]I was just going to say, the biggest litigation in dentistry is perio. [Jaz]Mm-hmm. [Morgan]So the only way we can do our notes fully and all of that kind of stuff is with that support. So, yeah, we love our girls. [Jaz]And what you did, those were so selfless, like, you know, taking a pay I didn’t expect you to say that. I was like, that took me by surprise that you said that, and that’s just amazing. Like those who are listening on the podcast, who are driving on their commutes, and they didn’t see me. You might have noticed my hair’s raising, right? Because that was a like, listen, listen. I was like, wait, what? You took a pay cut? That’s like, that’s such a selfless thing to do. It was like that is amazing. I don’t know many people who would do that. So, kudos to you. Like, you know, the reason why you two are in environment that you are happy is because you’ve made this environment, you’ve fought for this environment. And I was, you know when I said, give me an example. What a great example. Then having that conversation like, wait, if we can’t have our nurses, then we are willing to have a pay cut. But for you to do that and show leadership from the bottom is just amazing and absolutely kudos. So, let’s cover that topic now of nurses, because that’s one of the questions I want to cover. Where do we stand nowadays? Right. In terms of nurses, I think it’s having worked with you two. I think it’s fundamental. Cause obviously before I joined you guys, I was already used to hygienists not having nurses. So, this is a huge topic now you can see it from both aspects, right? As a business for a principal to change their business model overnight and pay nurse, additional nurse wages. Especially with a shortage of nurses at the moment. We talked about earlier as well, before we hit record button. That’s a big thing, but in terms of a difference, it makes for your clinical longevity, clinical enjoyment, what you can do for patients to patient journey. How can we find a balance? This episode is brought to you by Enlighten Whitening, the premium brand of teeth whitening. Not only do they have the best trays in the business, the patients really perceive it as a high quality product, and it’s really clever how the whitening gel itself is separate to the desensitizer, and I know Payman talks about the importance of that and how it’s beneficial for whitening system to have those two products separated rather than squeezed into one formulation. So, if you want to do some training online, head over to protrusive.co.uk/enlighten and check out what they have to offer as free training on teeth whitening, and you get to see what the fuss about enlighten two, back to the main episode. [Lou]Me personally is that without your nurse, it would be substandard treatment. Basically it’s, you know, to be able to personalize your treatment, do plaque scores, bleeding scores, have fantastic cross infection and be able, like Morgan said, to actually give the patient your time is paramount to really good oral hygiene and really good patient experience and really good outcomes basically. I think everybody needs to know their value. Basically. Education does come at a cost. So actually you know, patients might say, oh, like you are talking, I don’t know whether I’m going off subject here, . But anyway, it’s patients might say, ‘Oh, you know, well, I’ve paid 110 pounds for this and no has taught to me.’ You know, but like I said, that was invaluable information and all of these in order to actually measure and motivate all of these indices is so important and they have to be recorded, like Morgan said, for the legal aspect of things, but also for the patient motivation. If we do plaque scores on every patient that’s measurable, we can say- [Jaz]But what you’re saying, Lou, is that without a nurse, it’s almost impossible to get good records. And to, you know, the reason you mentioned about the fees is because yes, if you’re going to be working in the model where about you have a nurse, You can’t expect to just for that to work in your current business model. The entire business model needs to change. The prices need to reflect that, but that’s not necessarily, you know, I think dentists and principals are scared that if they raise their prices by 20 pounds to be able to cover the nurse, that they’re going to lose their patients. But, from any experience I have had so far whereby we’ve introduced that model and increased the hygiene fees, I haven’t noticed a mass drop, and I’ve only noticed that the team are working together better. The hygienists are so much happier, and the patients are getting better care now. That’s what I’ve noticed. [Lou]Definitely, I think you just have to take that leap and actually believe what you want to offer patients, how you want to deliver that and just take the chance. And it will be absolutely fine. But like I said, it’s just taken that risk. Some people don’t want to take the risk, but I think really, really push for it because if they take the risk, a few months, years down the line, you will not regret it. You will definitely not regret it. [Morgan]From an education point of view as well have everybody on board as to what it is that you are offering. So when a patient rings up and they say to reception, oh gosh, that’s expensive, that you haven’t just got the receptionist saying, yeah, it is, you know, our receptionists are fully versed in knowing that they are telling a patient what is offered at this practice, which they’re not getting at other practices. [Jaz]Just to make that clear to a young hygienist who hasn’t worked in the kind of environment that the lovely work that you do. What are patients getting for their money in terms of, you know, you’re working in a place where both of you have an important role and have had an important role in designing the protocols of how you’re going to treat perio in the practice. And you two are fundamental, at the top of that actually. So what is it that you offer that stands you out and is able to justify the piece of fees to the patients when they pick up the phone and call reception? [Lou]I think it’s definitely; it’s tailored to the individual. It’s not just come in every six months and have your teeth scaled and polished basically. It’s tailored. So, do you want to say what we do? [Morgan]Yeah. I think as well because we’re given free reign, we’ve never been told this is how you must work. We were trusted enough that they would say, you know, you need to go off and see Morgan or Lou, and then we would tailor make the package of the hygiene as to how the patient needed it individually. It was never, you’re going off for a scale and polish. It was, you are going off to be educated about how to care for your mouth and in doing that they will clean your teeth. But fundamentally the long term is that we want you to keep your teeth. The more you see Morgan and Lou, hopefully the less your dental treatment you’ll need. So, you were big on that Jaz. You were big on saying, you know, I’d like you to have a better relationship with your hygienist than you do with me. [Jaz]If you’re seeing me too much, things are going wrong. You know, you keep seeing the ladies and they’ll sort, then they make sure you’re on the straight and narrow. Very much true. Very much true. And do you feel as though you have been well supported at the management level when you’ve suggested to have a preventive focus in the practice. [Lou]Absolutely. I think because when we started this practice, it was very a prevention led anyway. I think we’re really fortunate that actually what we had to do was maybe have difficult conversations with new clinicians coming in and even we were getting them to shadow us to actually say that this is how we work and equally, I’m really happy actually shadowing dentists as well to say, actually, I want to see how you work as well because obviously, you have lots of different patients, lots of different personalities. And so, it’s quite good actually. I always find that the patient have the best relationship with people that suit them as well. [Morgan]I think information is key and our appointments are very information heavy. There’s not a single appointment, patient doesn’t leave with a plaque or a bleeding score and god forbid we’d forget to do that. A patient as they’re exiting, would say, oh, what are my scores today? They want to know those numbers. [Lou]Yeah. [Jaz]Do you still do your A5 card with the traffic light system and the percentage of the bleeding score, plaque score and the smiley face, et cetera? Do you still do that? [Lou]You know what? We don’t. Since I left. Actually, no, that actually stopped. But I tell you what we do is actually, well, I always vocalize what there, I always get the nurse to actually say, what was their bleeding score last time? And she will shout out. So obviously the patient can hear, I can hear, and then I’ll say, and what is it today? Because, then obviously, you know, you can say which whether it’s improved, got worse or stayed the same, and that leads you into what you need to do. We need to focus on these specific areas as well. I think it’s a great motivational tool. [Morgan]We are making the patient realize that they need to take ownership of their disease. It is not about coming and having a quick cleanup every six months to a year. It is about them realizing that what they do at home is so much more important than what we do. And that’s the difference. I think that we have the support to push forward in this practice, which I definitely didn’t get in another practices. It was about get them in, get them out, get the money. And the education was just really not that important, but that’s what’s kept us at this practice. [Lou]Yeah. I tell you what I find very, very interesting as well, is that when the clinician starts with the seed of you’ve got inflammation, starts to talk about the health of the gums with the patient and even shows them a TePe, it’s that the patient has heard something and then they came to us. And then we get them to, obviously, we educate them to understand what was meant by that. And then they just get to know, obviously the whole picture of what’s happening. You know, plaque bleeding scores, six-point pocket charts. We found that, you know, if they’re perio patient, there definitely should be having full mouth Peri-apicals as well. And actually, so courses are good. Keep up to date. And actually, if you haven’t got that information, if you are qualified, take the PAs yourself, tell the patient, why you are taking it. Bring them over to the computer, talk to them about their bone levels. Tell them why they have bone loss in certain areas but tell them what they need to do to actually stop that and actually to halt the disease. If you are not qualified to take the x-rays or confident in doing so. Actually, don’t be afraid to actually go back to your clinician and say, I would like full mouth PAs, please, get the patient booked in. And I’m sure the clinician would be more than happy to do that for you. But I do think communication and actually building some bridges and working together is- And singing from the same hymn sheet. Because like you said, the clinicians are saying it and you are enforcing it and you are saying it and we are enforcing it. So, you have to work together. And I guess that brings in the whole perio approach. Cause I got my last two questions are how do you treat perio in your practice? And it sounds like a stupid question in a way, is that what do you mean how do you treat perio? We treat perio like we’re supposed to treat perio, but you’d be amazed ladies about, and you’ve experienced these different practices. You know, some practices don’t talk about how we treat perio and you guys like, this is how we treat perio. We have a protocol in place. So, tell us a little bit about what that looks like in your practice. [Morgan]So number one, OHI, as you know, and obviously we’ve discussed a lot. We spend pretty much the first appointment with every patient, and this is whether they’re direct access or sent from the dentist. The first appointment is spent showing somebody how to brush their teeth, and then often two weeks later, we are reviewing and seeing how they’re getting on. We’re not just sending them off and saying good luck. We want to know that everything we’ve done with them, they’ve understood. We do a lot of tell how, do lots of literature, leaflets, flip charts. We can send them videos, whatever we can do to support helping them learn about how they can care for their teeth themselves. [Lou]Oh, the mouse map. I found really good actually getting a mouse map and actually saying which TePes or which incidental aids suits best for that area as well, and that’s where the tailormade care comes into place as well, so they know exactly they’ve got something to take away with them. Put it up in their bathroom so they can actually reflect and say, because obviously I think it’s being found, hasn’t it? On each appointment, isn’t it? Audio-wise? They actually retain very little knowledge of what we say. So, if you give them something as well, then that just supports and reinforces exactly what we’ve been saying to them. [Jaz]Perfect. We’ll talk about locum cause that’s for me is really important, but something that maybe you ladies now maybe take for granted because you are working, you’ve been working this way for so long, but just remind me if you still do this and everyone who’s listening is TePe brushes. You are actually getting out the long handle ones. You’re actually putting it in their space, you’re showing them, and then they get to take that one as a sample to go home. And is it single tufted as well? What tell us the kind of things they walk away with. [Morgan]Definitely we’re big into single tufted brushes, bending single tufted brushes with a burner if you need to. So that you’re adapting it for specific areas, showing patients how to use them down the pocket. Yeah, we actually, we don’t just give the patient an electric toothbrush. We are actually showing them in their mouth how to use the electric toothbrush. Because so many times you’ll hear, oh yeah, I’ve been told to brush for longer, or brush harder or soft, whatever. That means nothing to anybody. We’re actually showing them in their mouth how to use it. [Lou]And I find what’s really good. I mean, the IO it’s absolutely amazing. I think that’s been a real big game changer. [Morgan]Yeah. [Lou]The technology behind that is fantastic. And actually, having all the heads show the patients what to do, basically we tell them what to do and actually getting the patient to actually brush, you know, give them a mirror, sit them up, get them to brush. You’ll actually find the reason why they actually, that they haven’t been getting anywhere for years kind of thing, is basically because, you know, the angle of the toothbrush is not right. The technique is just completely right, but they think that they’ve been holding the electric toothbrush and moving it, but the majority of patients actually use that electric toothbrush, like a manual one, you know, and but you need to just stop them, show them, and just say, you know, how does that feel? You know, can you see- [Jaz]Do you ever get worried or scared that by asking them to brush in front of you that they might feel patronized? Is that something that ever crossed your mind in the early days of, of doing this protocol? And have you ever had these encounters where the patient’s personality type is like, what do you mean brush? Like you try and say, I can’t brush, tell us about some of those encounters. [Lou]Absolutely. [Morgan]Yeah. [Lou]Quite, quite a few. [Morgan]We’ve both been shouted at over the years. [Lou]Absolutely. Yeah, we have definitely. [Morgan]And I will say to a patient, especially if they’re older than me, please don’t find this patronizing. I do teach people in their nineties how to brush their teeth, but I am only here to help you. But yeah, you get pushback, and one size doesn’t fit all. I have had very rarely, but I’ve had an occasion where I’ve said, look, I think the way that we are working together doesn’t work. Why don’t you try and cover hygiene? Visit with my colleague and I’ll say to Luke, can you take one for the team as well. [Lou]Vice versa if I’ve had somebody where I’m just not getting anywhere, or we haven’t been looked that good rapport. But like I said, you know my way of working my way advising them things, they’re just, it hasn’t, kind of got through or it just hasn’t worked for them or for me. You know? Then yeah, Morgan’s seen them as well and it’s amazing because even sort of, it’s such successes with some people that I haven’t, so actually be fine and just saying, you know what? I think you might be better suited to see my colleague; you know? And I think that’s absolutely fine to say as well. And I think at the end of the day, the patient, even though they might, you know, obviously yeah. Have a few grumbles at reception and things like that. I think they’d depreciate just. The honesty as well really. [Morgan]But you can’t please everybody. You are not going to have a hundred percent success of every single person loving your practice. But you know, as long as you retain 99%, I think you’re doing okay. [Jaz]Yeah. But then you attract the like-minded people, right? You attract the people that buy into the health philosophy, that buy into prevention, that understand that ‘Hey, I’m paying a little bit more. Yeah, but this is way more than what I’ve ever had before. And these two, they actually care about me and my health outcomes, and I get an objective score at the end.’ And those people who value that will say those who. Well won’t, and, and you probably are happy that way, I guess. [Morgan]Mm-hmm. Yeah. True. [Jaz]It’s self-selecting. [Lou]If our prices have gone up kind of thing, people have actually gone and said, you know what? I can’t afford to come here anymore. I’m gone somewhere else. I would say within a year they are back and they just said, you know what kind of thing, we’ve been to other practices and actually we can see where hygienist’s going? [Morgan]Yeah. [Lou]And what you do different. And we are back, which, which is quite nice. And sometimes you have to lose a few patients and if they come back, then that’s fantastic. You know, then patients will be the patients for life. [Jaz]What is the number one quality or trait that hygienists should look for in a practice or practice manager or a practice principal? Anything from the practice of the management team? What is the number one trait or quality? Is important in finding the right place. [Morgan]I think they need to be a human first and a dentist second. I think when it’s just solely business and with the management as well, then you don’t feel cared for, because most of us spend more time at work than we do at home. That’s just a reality of life. So, you need to enjoy yourself. I mean, yeah, we are not scaling from nine to five. We have a lot of fun on route as well, and you need to feel looked after and we really, yeah, coming to this practice was like working for my parents. I’ve never experienced anything like it. And it’s just carried on, hasn’t it? It’s just a lovely, happy environment. We actually have a nice time and I wish that for everybody, and when I see the forums of the unhappiness, it is heartbreaking because there are so many good practices out there. So please don’t quit the career because it is an amazing one. Yeah, seek out good practices because they are out there and you will find lovely practices and environments to be in. Don’t lose the faith. [Lou]And just make little changes as well. Like I said, drop the seed in and make little changes, you know, because like I said, it’ll have that snowball effect. [Morgan]Yeah, definitely. [Jaz]For me, I think a really important fact for me, if you ask me that question, I would say and you know, you say human side, which is lovely and I love that. I also think leadership, just having a good leader, okay, he or she should be a good leader. They should be a good leader because that really trickles down, leadership is how the culture is brewed. It sets the tone of the practice. Having a present leader or the presence felt of leadership, I think is the most important thing. And sometimes, if you are not getting that from the powers above, then I’m very much a proponent that leadership can start from the bottom. And then you could start being the little mini leader in your sort of capacity to try and drive the changes from the bottom. And that looks like a much rockier road, a lot of resistance and uphill battle, but it is one which does have a pot of gold at the end, if you like. So, I think it is worth fighting that battle. And sometimes it means you to change mountains, change course, go off piece, all the themes that we discussed at the beginning. But I think it’s worth, you know, if you are feeding the lack of leadership, then become the leader that you want to drive the changes that you need. [Lou]Absolutely. [Jaz]Yeah. No, totally agree. [Lou]And I kind of think be a leader. I’m willing to listen to people as well, you know? And obviously make the final decision as the leader, but I think actually being open to other people’s ideas even if you tried something and just that actually we’ll try it for six months, and if it’s not working, then we’ll think about something. You know? [Morgan]Yeah. Yeah. [Lou]I think it’s better if you tried. [Jaz]As a final point, you’ve got the microphone to dentist and hygienists in an episode, which may become viral. I think it’s going to become viral because it’s such a- The face he made everyone, anyone know who’s listening and not watching the face that Morg has made was not one of joy [Morgan]It’s like love island, we’re just these two little hygienists slip kind of thing. [Lou]Jaz, do we need to start organizing our merch or what? , [Morgan]Water bottle. [Jaz]Ladies? Yeah, you can totally do this. You know, your own EMS airflow kind of thing. You can do this. [Morgan]Jaz, on a serious note, what I do want to mention though is refer big, big point of the perio, which we haven’t discussed is have an amazing relationship with a periodontist that you trust. You’ve seen their work and that you have open communication with. We just pick up the phone to our periodontist or ring them, whatever. But we’ve got that open communication. How do you think this is going? How do you think that’s going? Should we refer at this point? As a hygienist, we are not the end of the road. We know that. So yeah, seek out good local periodontists. That is also a massive, definitely piece of advice. [Lou]Yeah, definitely. And I think as well is, you know, I think a lot of the time, because we’re in different rooms, you know, everybody works independently, but actually, you know, I think supporting each other as a team is paramount to a happy practice basically, you know, support each other, be there for each other and help each other out. Definitely. [Morgan]Buy your nurse lots of cake and coffee. [Jaz]That’s something I already do. That’s something I already do as well. So, ladies, honestly, I’ve loved seeing you both again. I miss you both so much. I wish you all the best. Thanks for inspiring. I think a generation, because I think, you know, believe it or not, people hygienists have been messaging me on Instagram saying, because I promised this episode a while ago, and hygienist messaging me on Instagram saying, is that episode out yet? Is that episode out yet? And they’re really what they need. I think what we need in dentistry because look, the BDA aren’t doing it right, is leadership. And I think if this is a small step to get people to start thinking about that and how we can get some sort of the change in the right direction, then so be it. And I look forward to hearing people’s feedback. How can we send you roses, flowers, chocolates, cakes? How can we reach out to you? [Lou]We’ve got our ins, we have got actually the Instagram page. But because we’re a bit dinosaurish of the old technology- [Morgan]We’re going on a course. [Lou]Yeah. We’ve gone on a course to actually see how to actually market ourselves and actually how to actually get the word out there. So, we’re doing this course in February? [Morgan]February, it’s called Thrive, and it’s the hygienist and therapists to market themselves. So, if you could just use our Instagram names on your podcast. That’d be great. [Jaz]I will do. [Lou]Instagram names. Is it the- [Jaz]Here’s what I’m testing you because you didn’t say it because you probably forgotten your Instagram name. [Lou]We only go on it once a year. It’s the diamond, the dynamic duo. Yeah. I’ll message you. [Jaz]Is it actually @dynamicduo? [Morgan]Something like that. Yeah, but honestly there’s only about three posts on it. We’re so terrible. [Lou]We’re not that dynamic on Instagram. But in the surgery, we are. So, we’re ready to evolve. [Jaz] But after February you’re going to see lots of more posts and stuff. So if you wanna show your appreciation, if you want to ask some questions, if you want to engage @dynamicduo or the equivalent of where, whatever it actually is, I’ll put it in the show notes as always, ladies, thank you so much. [Lou and Morgan]Thank you, Jaz. We love you. Jaz’s Outro:Well, there we have it guys. Thank you so much for listening all the way to the end. A lot of the episodes are eligible for CPD. This one isn’t. There wasn’t enough substance, but that doesn’t mean there wasn’t enough juice, right? So, there wasn’t enough substance for questions and CPD, but I’m hoping you found that as a stimulating and inspiring episode with your hygienist. I’m hoping you’re feeling like you can leave from the bottom, and if you’re a dentist, I hope that’s opened your eyes to the struggles of some hygienist and an opportunity for you to put yourself in a hygienists’ shoes who’s working alone day in, day out, and how they’re not able to operate at their highest level when they’re not in the right environment. If you know anyone that will benefit from this episode, whether it’s your principal or an associate or a hygienist that you work with, please send them this. And I’ll catch you in the next episode.

You asked, we answered! Q&A with a Dental Technician – everything you wanted to ask (but never did) from our Facebook community. A legendary Dentist once told me that an average dentist working with a good technician will do well in their career. This advice has always stuck with me ever since. I recorded this episode with one of my technicians Graham Entwistle of Trueform Dental Laboratory who has been a pleasure to work with. From shade matching to getting the occlusion right, we made quite a geeky little episode which was well worth the 200 mile round-trip to his lab! https://youtu.be/tMiC_18fiqc 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 Protrusive Dental Pearl: It’s high time that you find your ideal dental technician, build a relationship and grow together. Whether you are using a big lab or small lab, try to visit and meet them and be open to getting feedback and criticism from that ONE technician that will elevate you. Don’t forget to give credit to your technician for their craftsmanship – take a photo of their work being fitted and email them – credit them on social media! Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 2:32 Protrusive Dental Pearl 7:55 Graham Entwistle’s Introduction 13:41 Q1: Analogue vs Digital? 17:11 Q2: Impressions or Scans for Veneers? 18:32 Q3: Is Digital good enough for high-end work and multiple crowns?  21:12 Q4: Are our impressions and scans good enough for you? 26:15 Q5: To break contacts or not to break contacts for veneers? 29:09 Q6: How does Graham create digital models with unbroken contacts of veneer preps? 30:35 Q7: What is the best material for masking discolored anterior teeth? 36:16 Q8: Shade matching for a Single Incisor Crown – the hardest thing in Dentistry? 42:06 Q9: How do you overcome contact point issues with digital as opposed to stone models for single crowns? 48:55 Q10: Digital Triple Tray or Full Arch Scans? 52:32  Q11:  Getting the occlusion right for crowns 55:26 Tips for dentists to help the technician to get the bite right Dr. Mahmoud Ibrahim and I are currently working on a huge project called OBAB, Occlusion Basics and Beyond – it will be the best occlusion resource in the Milky Way…and that’s our mission! We want to finally demystify Occlusion and make it Tangible! Join the waiting list HERE! If you enjoyed this episode, you may also like another episode with Graham Entwistle: 5 Things your Technician Wished You Knew Click below for full episode transcript: Jaz's Introduction: An average dentist working with a good technician who will do very well in their career. This was some advice given to me by a legendary dentist called Raj Rattan. Jaz’s Introduction:It was about nine years ago now. I remember exactly where I was, who I was with. What I was wearing is just like, really emphatic advice to me at the time. It’s just stuck with me throughout my career, and it’s not too different to the advice that Finlay Sutton gave. A few episodes ago. If you scroll down and listen to that episode about Scandinavian Design of Partial Dentures, and he said to find a technician who’s a similar age as you, who’s got a similar appetite for dentistry as you do and grow together. Hello Protruserati. I’m Jaz Gulati, and welcome back to another episode of Protrusive Dental Podcast. This time, it was actually a rare face-to-face episode that I recorded. I drove over a hundred miles to see Graham, my technician, and the theme was to answer your questions that you’d sent on the Facebook group, everything you wanted to know from a technician. But NEVER ASKED. We covered things like digital versus analogue. Is digital there yet? Should we be opening contacts for veneers? Heck do technicians like it when we open the contacts for veneers? Their answer might surprise you. It certainly surprise me how to match the shade for a single central incisor and a huge mammoth topic of how to get the occlusion right. Now, we covered that in good depth in this episode, but me and Mahmoud go into in loads of depth in our upcoming occlusion course, we’re almost done. It’s being Beta tested. It’s something we’re super stoked about, but it’s covering all these scenario-based themes to make sure that it’s extremely practical and tangible occlusion tips. I also took the opportunity while at Graham’s lab to film some content for OBAB. OBAB is Occlusion Basics and Beyond. And if you wanna join the waiting list for this course, head over to occlusion.wtf. That’s occlusion.wtf. Actually, it’s a real website on a browser you can sign up to updates for when our occlusion course is ready. Hopefully coming in March, April time. So this is huge. It’s like in the final, final phases. This episode with Graham is eligible for CPD, so you get one hour of CPD. If you’re part of Protrusive Premium, just download the app. If you haven’t downloaded the app, what are you waiting for? If you are true Protruserati and you enjoy these episodes, that’s well worth joining the app. And you’ll be able to download the Premium Notes. So if you’re already used to watching on YouTube, you see the notes coming up on the side. Well, those notes are neatly presented in a PDF that every premium user can download via the app, and it’s just a nice summary and it solidifies your learning. Protrusive Dental Pearl The Protrusive Dental Pearl for this episode is very much relevant to this theme of working with your technician. It is time, my friend, that you find your IDEAL DENTAL TECHNIQUE. Just like I said at the beginning of this episode, the average dentist working with a good technician will go very far. And it’s been critical for me. Funny story, actually, I posted a case recently that me and Graham did together. It was like a single onlay. It was a beautiful onlay. And so I posted the step by step, what I did, what my prep looks like, and one of the photos was actually bonding the ceramic with Panavia and taking the occlusal photo. And I wrote on there, Graham did an awesome job. And remember Ahmed from Australia? Hope your hand’s feeling okay. I know you post on social media that your hand was injured. I hope you get better, my friend. You are a true Protruserati, sending my love your way. And anyway, I made comment to saying, wow, I’m just amazed that you know your technician’s name. Now I agree with him. I think it’s pretty cool that I know my technician’s name and I get to be on a WhatsApp basis, and leave voice notes. And that’s why I love communicating with Graham so much and any of the technicians I work with. But most of my colleagues that I speak with, they use a big lab. And it doesn’t matter if you use a big lab or a small lab, but the person on the other end who’s making that crown, making that onlay, making that veneer, making that denture, they don’t know that person’s name. So if you don’t know their name, how are you gonna build that relationship? How are you gonna grow together? With that technician, Protruserati, how are you gonna find your Graham? This unicorn, this good technician I was referring to. Well, the guess what today is Graham Entwistle. He’s a brilliant technician I’ve been working with for coming up to just two years, so not mega long time, but I’ve been really impressed with our communication, the voice nodes, the loom videos that I sent to him and how he responds back and how receptive he is to my advice and how open I am to receiving his. I tell him, Graham, if I send you some junk, you tell me I’ve sent you junk. And likewise, if there are any protocols, we’ve adjusted. We worked a lot on vertical preparations and getting the vertical crowns with the correct emergence. And he was really good to take my advice on board and change a few parameters. And together we’ve got some great results with vertical. But the funny thing is that I found Graham by accident. He DMed me on Instagram. We started talking and he started listening to podcasts and I knew some really great dentists like Rustom Moopen, Elaine Mo, Kiran Bhogal. I know, I knew these guys were using Graham. So then he had just about enough capacity to take me on as a client. And boy am I glad he did. And I think every restorative minded dentist should have a good technician that they know by first name basis that can just pick up the phone and give a call or leave a cheeky voice note. I think it’s absolutely imperative. So Protruserati, don’t do what I did. DON’T WAIT AROUND for your dream technician to DM you on Instagram. It’s not gonna happen. That’s like a unicorn scenario. Now, Graham’s not the only technician I know. Graham, sorry, I am cheating on you with another technician, also called Graham and the Dan as well at Precision Dental Studio. So, I use a couple of labs. Graham’s one of my main guys I use. But even though I use the second lab, which is my local lab, I still visit them now and again, they know me by my face. I know them by their face. I know what their voice sounds like. I leave voice notes. They leave voice notes back. We have REALLY GOOD COMMUNICATION. The tip I can give to any dentist who’s working with a bigger lab, maybe a chain of labs or just a lab with lots of technicians, and you don’t know who’s making your crown, it’s just go in one day, meet them, try and get the same, try and ask for the same person to send back your crowns and then grow together. Be open to getting feedback and criticism from that technician. That is scary, but it will really, really elevate you. In fact, I urge you to make it your mission to visit your lab. Perhaps you’ve never visited your lab before. Show your face, shake some hands and agree to who is gonna be your dedicated technician and just watch the magic happen. The best time to find the ideal technician was once you qualified. The second best time is right now. And one last thing with your technician, because they do all the hard work and sometimes we get the glory. Once you’ve delivered a case, it’s nice to sometimes take a photo and email it to your technician, say, ‘Hey, we nailed this together and your craftsmanship was amazing.’ And it’s great for these technicians to see their work fitted. I don’t think enough of them get to see that. And I can tell you they really appreciate it. And so with that, let’s join the main episode with Graham Entwistle. Main Episode:Graham Entwistle. Welcome back again to the Protrusive Dental Podcast. How are you my friend? [Graham]I’m actually quite good. [Jaz]It’s nice to see you. Nice to meet you in the flesh. So, just to set the scene guys. I’m at Graham’s lab. Where are we? Romney Marsh. Where the hell is this place? [Graham]It is literally the middle of nowhere, but it’s Romney Marsh, Kent, East Sussex border. Pretty much. [Jaz]Well, I was like trying to find my way here. I was like, where on earth is this? So I’m glad to have discovered a new place. It has been amazing to work with you in the last couple of years. I’ve learned a lot from you. Communication, like is exactly what I wanted. Like I think as a restorative dentist, one of the tips I wanna give to everyone is find a tech who you get along with, who you like preferably, who you can just exchange on a daily basis. I pick up the phone, I can call you. I feel at ease about picking up the phone calling you. Although our favorite mode of communication is WhatsApp voice message, which is much more real. Well because you know, you might be busy doing something and just get back to it. There’s no pressure. So we do lots of, you see our WhatsApp trail images. I do lots of loom videos, which I’ll ask your opinion how you find those, cuz it might be hit and miss. You might hate those and you know, might be tolerating them. I’ll ask you that in a moment. If you guys haven’t listened to episode 74 already, that was Graham with five things your technician wished you knew. So that was helping us dentist. Today I’ve been asking on the Protrusive Dental community Facebook group about what is it that you guys want to know when it comes to anything you wanna know from a technician working better with our technician. So, Graham, just for those who perhaps didn’t listen to episode 74 yet, a little bit about yourself in terms of what drives you, why you became tech, how is it that you’re able to run this lovely facility with five kids, work-life balance. [Graham]Blindly. I dunno where to start. So what was the first question? [Jaz]First question my friend Is a little bit about your background. Like what got you into being a lab tech basically? [Graham]So first of all, never really been the type of person to get an office job sitting there in front of a computer, day in, day out, doing the same thing. It’s monotonous, I’m autistic and yeah, it just doesn’t suit me. So found a job, King’s Collage Hospital and went for the interview. They got me to carve a whistle out of chalk and do a few other bits and got the job and I loved and hated the job throughout the time. And I went into cosmetic dentistry after I left. And I was only doing that for about a year. Then I run bars and nightclubs for about four, four years. [Jaz]You left for being a cosmetic lab tech? [Graham]Yeah. [Jaz]Right, for bars and nightclubs. So tell us a little, tell us about that. What happened there? [Graham] So I was working in Basildon in at the time for a well-known technician and I’m reliable. I didn’t drive, I was relying on ferries, I was cycling and it just got a bit much. So we kind of parted ways amicably, and I just found a bar job to make ends meet while I was looking. Within four or five months I had a bar manager’s job. Four months after that I was an area manager and four years later I was like, let’s get out of this. Go back to what I’m good at. So, yeah. [Jaz]So do you not miss being a lab tech or perhaps you were still early in your career at that stage, and perhaps you didn’t quite know exactly what kind of a tech you wanted to be. I mean, tell us a bit about that. [Graham]I didn’t really know what I wanted to do, so I had to go out and taste the world for myself. And I think being in the bar industry enabled me to do that and learn a little bit about myself, but it came with its own problems. [Jaz]Mm-hmm. [Graham]So, yeah, I got back out of the industry and I struggled to get back into dental technology actually, because nowhere wanted to pay any decent money for a technician is, we still find that these days that, you know, we kind of price ourselves down in the market because everyone wants cheap. [Jaz]You wanna compete in dentist world. [Graham]As a result of that trying to attract technicians if you’re not charging a decent price is very difficult. So the price is then driven up again. So yeah. You either find unskilled workers doing your work for cheap, or you to find skilled workers is now very difficult. Cause we haven’t trained our own for a long time. [Jaz]But what I, what I found is on the main dentist Facebook groups, I found that a lot of the comments and threads are like, where is the best price or where is the cheapest to get X, Y, and Z for lab work? That’s the kind of conversation that’s happening. [Graham]Yeah. [Jaz]I also see where is the best. So I see two different polar opposites. I see where is the best price is not an issue, price, tell me where’s the best. And the other half is like, I need the cheapest, but still good. I want cheap but good. [Graham]It all depends on your business model. At the end of the day, I think, you know, it’s not down to what it is you want from this, that, or the other. It’s your business model that counts the most, I think, when you’re selecting anything and then you adapt to that and you try and find the best you can for that budget. So yeah. [Jaz]When you were working in a bar and in the nights industry and you were working with people, you were seeing people all the time, people in your face, and now I look at your lovely little laugh. It’s as little are you watch a chocolate in the corner there and just you and your phone do WhatsApp, voice messages and waxing up and stuff. [Graham]Yeah. [Jaz]Is that like a big shift in change in terms of your working life? [Graham]It is a big change, but I’ve gone through a lot of big changes. Like since having my first child, I had struggled with addiction for a while at points in time, a little bit about myself. [Jaz]Mm-hmm. [Graham]And I’ve managed to overcome that and this has been part of my journey and I now enjoy my own company. So yeah, without the bar industry, I wouldn’t be who I am today. I learned how to run business. I learned a lot about people, I learned a lot about communication, how to be a host, and kind of got a bigger picture of who people are. I try not to take away the humanity from the business side of things as well. So yeah, it’s kind of a difficult balance. [Jaz]What I love about you, Graham, is I said it already, the communication side. I think, I just think I would really urge all dentists who care about their restorative dentistry, who are really aspiring to be the best they can be. You won’t get nowhere unless you’ve got good lab tech on your side. I genuinely believe that, that some advice that was given to me when I was one year qualified by Raj Rattan is an average dentist with a good lab tech will really do well. [Graham]Oh yeah, for sure. [Jaz]And it makes a huge difference. So I think I’m grateful to have you in my sphere and grateful to be able to work with you as well as some of the other labs I’ll work with. Like shout out to Precision Dental Studio and Alan and the team there. I use you guys for different things. I know where me and you get along well, like your vertical preparations. We’ve talked a lot about that on calls and WhatsApp stuff, so you’re my go-to guy for that. A lot of my splint work that I do will go to another Graham, so if you are a technician wants to work with me, your name has to be Graham. Fun fact. [Graham]Alan. [Jaz]Yeah, Graham, that’s true. That’s true. So, look, we’re gonna, firstly thank you for sharing some admissions there. You know, I really appreciate the human side of that and that’s really good of you to do that. I think it really makes, humanizes us and I think we need that in life and work and stuff. So I think that’s really great. Another feature about you, I’m gonna go and just find those questions that were on the group that the Protruserati already had for you. Some of these are like my own little questions and some of these are from everyone. So, let’s start with some of the things that I was talking to you about as we were coming up the steps, which was, you took me to the plaster room and you said that’s hardly being used nowadays because a lot of your work is now gone digital. So I said to you, well, you know, I’m very digital, but when I get like a bigger case, multiple units, I still pick up the polyether. I still like to do that. And you are like, well, you know, it depends. So where do you lie on this? The benefits or the advances of analog or do you really think that actually the advantages aren’t really there of analog anymore. So it’s that you read can do everything digitally. Where are you on that scale? [Graham]It just entirely depends on what your technique is with both. So analog impressions, I dunno if you’ve noticed, but if you’ve ever had an analog models for myself, I do not split models. So it’s always a solid model single dies. So single dies come out the first pour cuz that’s the most accurate pour. And then the solid model, master model goes into that. And what I find with that is you’re not stripping away the gingiva off of your model so you know where the gingiva actually sits and you’re not, you’ve got more an idea of emergence profiles. So we’ve got that and then we are not spliting the model. So we’ve got no expansion contractions, sort of like differentials there because you’ve actually just kept it as a one piece. So you can wax everything, wax up little copings on your single dies, transfer them over to the master model, finish your wax in, transfer them back, seal the margins, reseal the margins, then take it off, invest, press, get them back, and hopefully crossover. Everything’s great. [Jaz]Did you like find it? [Graham]I find the same with digital. Okay. So if I’ve got a large case, sometimes I might design the models twice. So I’ll design the first one as a solid model and then I’ll design the second lot, get removable dies and I’ll print them separately. [Jaz]Or let’s just explain what this is, because there might be some like young dentists who just, this is all in a different language that for you, you know, being lab tech. [Graham]Yes. [Jaz]A lot of people probably don’t know what a solid die means. So let’s just break it down. Okay. What do you mean by a solid die? And then what do you mean by split? Just, just really dumb it down for us. [Graham]So a die is basically the prep. So you’ve got prep that you can remove from the model that is a die. So all of those removable parts of dies. When you’ve got a solid model, it’s an unsplit. No saw cuts, no saw lines or anything that’s moving within the market. [Jaz]So you like to work with that unsplit model where the full model without the splits without the dies, right, with individual dies, yeah. And do you think that if someone’s working with the technicians are using, sending back everything on a die, so everything’s split, is there a disadvantage though? [Graham]Well, yeah, cuz when you put a saw cap through your models, you then got expansion, contraction. And as much as people say, oh, I put retention slots and this, that and the other, when you take a model out and put it back in, dust on the undersides of things and little bits of wax gets stuck and it doesn’t always go back where it should exactly. Because obviously things have expanded contracted, so you get little discrepancies between your contacts and sometimes even occlusion. Whereas if you’ve done it on something that doesn’t move, then it hasn’t moved. [Jaz]It’s just more moveable bits and I can completely get that now. That leads us very nicely to it. Another question, which was on the group, one of the questions that we had was veneers, like we mentioned while we were walking up the stairs about, we actually mentioned, squeeze a lot of conversation, geeky conversation and just in that one small stairs, but veneers, a lot of people have a bias towards impressing towards analog because they believe that to get the highest quality of veneer work back from the lab tech, it has to be analog. What do you think about that? [Graham]It depends on what type of veneers you’re looking for really. So feldspathic, obviously you can need to produce an analog impression because you need refractory dies. I don’t offer that service here, unfortunately. [Jaz]What is a refractory die? [Graham]A refractory die is a die that you can stick in your furnace basically. So it’s a heat resistant material that you can layer your ceramic on, putting the furnace with it. [Jaz]And so you don’t do that because you don’t work with that anymore? [Graham]I just don’t work with that type of process. My prices don’t reflect that type of work. So, I like to consider myself quality laboratory, but I’m not really a top end laboratory. And I don’t cater services towards that. That type of restoration. [Jaz]But you do veneers, but you do mostly like, lithium disilicate. Pressed? [Graham]And pressed and layered [Jaz]Okay, now we’ll do a little deviation from that. So, we established that, okay, if you want to do a feldspathic, then you need to really go analog, right? [Graham]Yes. [Jaz]But if you are doing a big case, lots of crown preps, traditional chamfer, shoulders, vertical margins, et cetera, do you feel there’s a difference in terms of the quality that you can produce or the quality, the end result, the end product between analog and digital? What I’m really trying to say to, you know, is digital there yet? [Graham]Digital is there. I do believe printers these days have made massive advances, but it also depends on what printer the lab’s using, what settings you using, you know, and if you are outsourcing your models, are you really getting back what it is that you want? You know, are the dies you know, retentive enough as they go in? But the more times the dies come in and out of the models. The more loose they become, the more give they’ve got, the more inaccurate they become. [Jaz]But you just said, and I know the answer, but I’m just saying everyone else. But you said that you don’t like to work with individual dies because you like the whole model to be together. Therefore, it’s a Geller type setup, right? Is that the right term for it? Is that the right term? When you can actually take the prep out, but the model itself is still the same? Is that what you’re referring to? [Graham]It’s just a scale model. [Jaz]Yeah. [Graham]Yeah. You’ve still got removable parts. [Jaz]Yes. So, in case someone got confused about you take something in and out. When Graham sends my work back to me, if there’s multiple units, for example, or even single unit, the model is a whole, there’s no splits, but you can take the preps out. [Graham]Yes. [Jaz]And that’s unique to digital, right. In that way. [Graham]No. [Jaz]It’s easier? [Graham]You can set that with analog as well. [Jaz]Is it a lot more harder to do that? [Graham]It takes a bit of tweaking to get your parameters right and every single sort of type of tooth. So my settings for getting a molar in and out of a model will be different to an anterior tooth coming in and out of the model because of just like the surface area that comes in and out of the model and the friction that’s caused there. So yeah, there’s a lot to think about. It’s a minefield and obviously if you do choose to use that type of model system, then the more you take the die in and out, the less friction that’s there. The more give that’s in the model and the less accurate it becomes. So like I said, sometimes I print two dies to go into one model. One can come in and out, one just sits in there. [Jaz]And that’s like the master where you check everything. . [Graham]Yeah. Master. [Jaz]Yeah. Okay. Very good. So the whole debate to summarize, you do feel that digital is there for like feldspathic kind of veneer work? Maybe? Yeah. We still need analog, but for most other work, for even for my rehab kind of stuff, you’ve got clients sending you all digital scans? [Graham]Yes. So I’m getting all digital scans and had good success so far. [Jaz]Because, I haven’t made that leap to full digital. I’ve got like more than maybe eight units. Okay. Not that I’m doing, I’m not prosthodontist, I’m a general dentist, but when the more units I have, the more reason I’m gonna go for analog. But that might be changing and I think, you make a good point that nowadays digital is really great. So yeah, it was actually, Cheng was your question. What percentage and one of the things that you mentioned, what percentage of analog impressions are excellent? What percentage are acceptable and what percentage are unusable? Now obviously you’re more digital now, but based back on your time at Kings and your previous sort of reincarnation, what kind of quality of impressions are we getting? [Graham]Okay, so let’s take it back to when I came back into dentistry. I worked at a predominantly NHS kind of driven laboratory out in Canterbury. The boss was a really nice guy, but the work that we were getting from dentist was kind of slap dash, you know, that you couldn’t really see margins. No one was using cords. And sometimes you’d go back to the clinicians say, look, this isn’t really good enough. They’re like, do your best. You know, and it’s just like, okay, well, okay, I’ll do my best. You know? So, and then even when you do your best, sometimes it’s not good enough, it comes back. It’s like, well, I did say. So I’d say the percentage of success with impressions and digital is again, based on a business model. So if your business model is high end, sort of like top quality restorative work and you’ve spent a lot of time as a clinician on your work, refining what you are doing and taking nice impressions or nice scans [Jaz]And long appointments using they’re not short appointments [Graham]Using cords, then your success rate is much higher. Whereas if you are cutting corners doing knife edge margins that are not readable and you know, just doing a quick scan without checking and there’s a lot of people who still don’t check their scans even with top, top end work, you know, find that people aren’t quite checking their scans thoroughly enough and you know, there’s a bit of moisture somewhere and it’s caused a bit of a defect in the scan data and I can’t then extract the die with the margin intact in areas. [Jaz]And you’ve sent me a WhatsApp image when I’ve done that before. [Graham]Yeah. [Jaz]When in one distal corner. And it is good. It’s great to be able to work with the technician who will send you your little minor clock ups. Right. It’s great to have that and I think, I really appreciate that. I think more technicians should not be afraid to message that dentist like, oh look. And, the screenshots you send, the photos you send, I think that is wonderful to help improve us. [Graham]So look, a word of advice is always check your impressions. Always check your scan it, you know, an extra 20 seconds could actually save you an appointment. [Jaz]So the advice I would also give to dentist is if you’re new to digital, a lot of people who’ve been in the digital game for long enough, you guys know this already, but if you’re new to digital, remember that for digital actually you need a slightly more aggressive retraction compared to analog. Cause with analog impressions can seep into the nooks and crannies, right? The wash impression can seep in. Whereas if the light can’t get somewhere, it can’t record that. So I’ve found that I need more aggressive retraction when it comes to digital to get an acceptable model. [Graham]Yeah. [Jaz]I dunno what you found with that. Do you feel as though when you see some digital models come back and you feel as though, okay, this really needed more retraction. Do you often say that to yourself? [Graham]Sometimes, yeah, sometimes I don’t. And sometimes you’ve already told the person three or four times and by the fifth time, you know they’re not really gonna change. So, you know, you start letting things slide as a technician, because you touch your time, do your best, you do your best. You know, there’s only so much advice you can give somebody before it then becomes just an everyday practice that’s how it’s kind of gonna be. And then you put up with it for a little while and then you’re sort of like, after a few months you might just drop that little nugget again, just hopefully plant a little seed in their brain.  Like, do you remember talking about this? And it’s like, oh yeah, yeah, yeah. I think you’ve gone away from doing that. You know? [Jaz]But it’s good that you do that. Technicians are your colleagues might be afraid to say that- [Graham]Badgering people is bad. But if you can kind of just drop little seeds every now and then, hopefully people will start to realize, actually, I could be doing this better. [Jaz]I think one thing that dentist can do right now, not even tomorrow, right now, pause this episode and do this. If you don’t have your technician on WhatsApp, get your technician on WhatsApp, firstly. Secondly, WhatsApp from the following VO voice note saying, ‘Graham, if you find that I am slipping in my standards, or if there’s something I can improve, please tell me. I’d love to know. I welcome any feedback. I take criticism very well. I really appreciate to grow as a clinician with you as a technician.’ If you say that to a technician, wouldn’t they feel like much more at ease to give you more feedback? Right? [Graham]Yeah. Yeah, for sure. And I ask the same with my clients. If they find that my work is slipping or it’s not right in some sort of way, and it’s like more than one occasion, please tell me and I can do something about that. Or we can take a look at what we are doing as a whole. Because sometimes it might be the fact that you’ve changed a material that you are using or you’ve changed the way that you are temping or it could be anything. Just get down some nitty gritty, get to the bottom of it straight away, nip it in the bad, and then hopefully we’ve got no problems. [Jaz]Awesome. So firstly, Zane, Risby, sends his love. Okay. [Graham]Hi, Zane. [Jaz]Bikram nice to CMS from you, buddy. Bik’s, fantastic dentist. I’ve seen a lot of his works. Brilliant. To break contacts or not to, for veneers, like to me, that’s more of a clinical decision making, I think. But in terms of, for you, like if every veneer prep came back with a broken contact, perhaps it’d be an easier thing for you. I don’t know. Where do you stand on this? [Graham]As far as I’m concerned, getting contacts, right with veneers is a nightmare. They are fiddly, they moved, they pop off the models every time you’re trying to adjust the contact. So for me, breaking contacts is a bit of a pain, so I prefer it if you didn’t as a technician. [Jaz]Really? Okay. [Graham]For ease of doing a restoration. But I would say it depends clinically on where the contacts are actually are in your patient’s mouth. If we’re looking to realign things and how it’s gonna be realigned, obviously also, are we gonna have enough room for the restorative work that’s needed or the quality of restorative work that’s needed? Because if you are doing a lithium disilicate, for instance, if you’ve got a full contour, then you know you’ve got a certain amount of emax that’s minimal. But then if you’ve got a dark core, you need more space. And then if you’re gonna layer it, then of course you need even more space. So it just completely depends on the case by case. [Jaz]That surprised me a little bit because I thought, in my mind, I thought you might have said, I prefer broken contact cuz then give us the freedom to recreate everything. But actually you made raise a good point that actually it’s so fiddly to actually recreate the contacts that if the contacts of that- [Graham]For ease of use. It would be great if I’ve never had to touch a contact. [Jaz]Yeah. [Graham]My job is to do that. But if you’re not gonna break contacts, then the shape of the veneer prep is obviously, and the margin is kind of paramount. So you kind of need to come round the contact and go underneath into the cervical and kind of break that area down. And that allows the technician to gain that nice emergence profile. Especially if you wanna try and close any black triangles whilst having that contact stay. If you can understand what I mean. [Jaz]Just rephrase it in a different way. Cause I’m trying to envisage what you’re saying as well. Do you wanna draw something? I can show it and I can describe it. Okay. So Graham’s now, for those listening, right now he’s pointing and he’s pointing to the mesial of an upper left central incisor. And what I would refer that to is the interproximal elbow, isn’t it? [Graham]Yes. That’s correct. You need to go into the interproximal elbow. In order to not break the contact. And literally it is just the contact you’re leaving. [Jaz]Yeah, you’re leaving just the contact area only. But even then, you know, contact areas aren’t huge often they’re just minimal there. But it’s important to prep that bit to allow you to cover that bit because if you don’t, you have that scenario where someone looks at the veneer, the side, they still see the prep and then they still like a discover- And you get a discoloration over time from your bonding. Yes. And you wanna hide that, that margin as best possible cuz yeah, margins do stain over time. So, yes. So great point well made about that. Now here’s just a technical question is if a dentist sent you some veneer preps and they haven’t broken the contacts and let’s say they’ve scanned it, then how do you create the digital dying models whereby they’re sort of you could take the prep on and off cuz don’t you have to then digitally make a split or something, right? And compared to when you used to this analog or is that also a nightmare to do it? [Graham]Yes, it’s a nightmare both ways. And it’s another reason why I’ve always chosen my method of doing things because with the analog, you’ve gotta stick your saw blade through, and by the time you’ve stuck your saw blade through, you’ve already taken off 10 microns of that margin. So what I would do in this scenario is I’ll pour up two sets of die models and then I’ll just take every other and trim them out. [Jaz]Yep, yep. [Graham]It’s a bit of a prolonged process for me, but I know it’s right. [Jaz]But digitally it’s the click of a button. You just set your line and then it will just print it in that way. [Graham]It’s still difficult sometimes because if the margins are that close together, you’ve still got discrepancy there. But at that point, that’s when I’d switch to the solid model, single die thing and I would then do three designs of the models on exocad. [Jaz]Okay, cool, cool. Maybe if you’ve got some the show later, I can use my Sony camera and go around and make a extra feature to add to that. But that’s a really good question. Thank you Bikram, best material for masking discolored teeth anterior. So your clients that send you photos of discolored teeth over the last few years, what material are you finding has given you good result? Like recently I sent you a case whereby we use MO or HO? Did we use HO or MO in the end for these crowns and veneers? [Graham]I do try not to use HO. [Jaz]Yeah, can you, I think you can use MO. What is HO for those dentist, dunno what is HO? [Graham]It’s high opacity. So basically- [Jaz]Lithium disilicate. [Graham]Yes. So it’s an ingot, high opacity ingot, Lithium disilicate. So basically it’s just masks things with very, very minimal thickness, but it kind of has a tinge in color that isn’t very nice to work with. So the background itself. Should I say is not very aesthetic. So if you haven’t left enough room for some nice layering on top and the patient wants it to be in line with all of their teeth, then you’re not leaving yourself much of a chance to get- [Jaz]A set of compromise. [Graham]Yeah, it’s aesthetic compromise. So depending on how dark the actual tooth is, so unless it’s actually black or gray, then I tend to try and use the medium opacities and they can block out about 0.5, 0.6 mil. And then I’ll try to layer on top of that. It just allows me more scope. It’s much brighter, it’s more fluorescent and you tend to get nicer restorations using those. So avoid HO if possible, it is the last possible resort for myself. And then also you’ve got zirconias, if you’ve got a crown and you can use the high opacity zirconia stones, which are quite old school now. They’re very hard. , but you can layer on top of them. But also now there are liquids you can use just to kind of opaque the internal surface of zirconias. And as long as you’ve got a decent thickness, it doesn’t really affect the shade or the color of it because if it is thin still it can affect the shade because it just shines through the bright white. [Jaz]So the misconception that zirconia will block out everything underneath, you can still get some shine through with zirconia, right? [Graham]If done properly, no, but what I’m saying is you can get shine through of the O layer, so, which is quite bright. So if you are going for like an A three and you’ve put this white layer inside an opaque and block out your metal core, then that can then influence the A three and actually make it look more like an A 1.5. Even though it looks A three on your shade tab, when you send it out, when you put it in the patient’s mouth with all the lights, reflect differently. It actually looks about a shade and a half lighter. So, it’s hard to get it right with any material, but yeah. [Jaz]What’s your bias? Zirconia, lithium disilicate when working with clients who send you discolored teeth in terms of you being able to deliver? [Graham]It depends on where it is in the mouth. Okay. So if it’s anterior, I prefer to use lithium disilicate as long as there’s not lots of space around the prep. So if the prep’s very small and there’s lots of space, I would probably say go for zirconia if possible. If there’s enough, you know, retentive sort of form there. But obviously then you resort to emax, but then you looking at MO ingots, HO ingots in order to block out the light so that they don’t look gray. [Jaz]Well you mentioned emax, but I know that you’ve actually moved to LiSi. [Graham]I moved to LiSi a long time ago, so I used two types of lithium disilicate. I used the GC LiSi. I find it’s a bit more color stable. It’s got a bit more fluorescence in it than emax. And I also use, VITA AMBRIA [Jaz]okay. [Graham]Which is a zirconia-reinforced lithium disilicate can get finer margins using that material. [Jaz]But you’re no longer using emax product by Ivoclar? [Graham]I still use it certain occasions. [Jaz]Okay. [Graham]But yeah, it’s not my go-to. [Jaz]Okay. [Graham]So like if I’m gonna match in a restoration that’s already done in emax 10 years ago, I’ll use emax. If there’s a certain shade that somebody’s looking for, then I’ll order some emax in for it. You know, like if someone wants B4 and the patient has really high demands and they’ve chosen that color and they’re gonna want nothing but that color, then I’ll have to order that in because, otherwise I’m just setting this up for failure. [Jaz]Yeah. For those maybe younger dentists who, you know, the reason I mentioned this is because lithium disilicate is the material, but then you’ve got, you know,  Ivoclar does eMax. GC does LiSi. I didn’t know that. Vita with Ambria. There’s lots of different brands. [Graham]Yeah. [Jaz]Even with zirconia, there’s like lava. There’s Kanata, is it? Japanese? [Graham]Yeah. Katana [Jaz] Katana. That’s it. [Graham]There’s vintage Press, which is a shofu [Jaz]so this is Shofu lithium disilicate [Graham]this is Shofu lithium disilicate [Jaz]I didn’t even know that. [Graham]This is Ambria [Jaz]That’s VitAmbriayo. Yeah. [Graham]This is LiSi Press. [Jaz]Oh, lovely. [Graham]And of course you’ve got your classic, original emax. [Jaz]Oh yes. The OG emax. Cool. All right. Love it. [Graham]There’s lots and lots to choose from, it’s a minefield and they’ve all got their pros and cons. Some are harder than others. Some have more fluorescence than others. Some you can fire more times than others without losing. [Jaz]But LiSi, I think you can fire more times without losing. I think Emax grays a bit, is that right? [Graham]It does gray. The microparticles are actually slightly bigger than with GC LiSi. [Jaz]Cool. Amazing. Okay, next question from Zhe. Zion’s got a couple of questions. So, Zik, man, I love you so much, man. I love your work that you do produce. It was great to meet you in Porter when he came to the vertical preparation course. You’re top guy. Thanks for sending this question in. So, just start with the easier one. What information, it’s kind of bigger picture. What information do you require for an upper anterior single crown?Just the basic information that you require and what other information that is desirable for you. [Graham]So I think at this point, photography is a must. You can’t just send me a shade unless, like, literally you take the shade and it matches exactly a shade tab. So if it matches exactly a shade tab, I will accept that A3 [Jaz]the shade tabs are acrylic, right? [Graham]Yeah, but maybe not, because at the end of the day, this is where you still really need a photograph as a technician to start anything, because the enamel is always different. Where the enamel starts on the tooth is different on every patient. So some tooth have got high chromatic content or high value content. So it’s the brightness and the contrast in the tooth of color and the light that goes through it. So the translucencies can be different. So cross polarized photograph. [Jaz]So this is a filter. So dentists out there, so firstly, apologies because I didn’t really make a big enough deal of this as I should have, because to match a single anterior, whether it’s upper incisor or lower incisor, is the most difficult thing in dentistry. Right? That’s firstly, I didn’t build it up enough that this is really tough. And that’s why you know, Graham mentioned the importance of photography and cross polarizing filter is something that you can get on your camera. I’ve got one but I’ve got one by accident years ago. And it removes a specular of flash so you can see the details and so that is wonderful I think. Do you use the eLab protocol? I think I must ask you the last time. [Graham]I don’t use any protocols like that. I just haven’t got the business model from it. [Jaz]Yeah. But you see the different images that they’re saying and cross polaroid you find that helpful, so that’s good. [Graham]Yeah. Cross polarized is helpful. Try not to use a ring flash. Try to use a dual flash. Because you know, you get the shine back from the teeth. Especially with a ring flash. So try and use a jewel flash. [Jaz]Now if someone has a, done mentioning someone has got a ring flash only. Like for me, I have my jewel flash, but it’s sometimes annoying to change. Might even get a second camera just for that reason. But, one thing you can do is you can detach your ring flash and just take a photo with the flash from the side. It gives a technician a different perspective. [Graham]Great tip. Yeah. [Jaz]It’s a really good thing. And a couple different sides from the bottom. From the side. Takes you a few seconds to do. We’re still using your ring flash. [Graham]Yeah. And it also helps establish surface textures. [Jaz]Absolutely. [Graham]And so, yeah, photography and the patient smiling, just how that tooth is looking in the mouth, how they smile is also a key, you know, where that tooth’s gonna sit on the lip line. [Jaz]Yeah. And to get the bigger macro features of the smile to get your hub, to get your anatomy right. So obviously the primary, secondary tertiary anatomy, so to copy everything in the adjacent teeth. But in terms of getting, cuz the real difficult thing here is the shape you can copy. Right? It’s getting that shaded recipe correct, right? It is the trickiest bit. And, very often when we’re doing cases like these, tip to dentists is charge more. You just have to charge more for an upper anterior single unit crown. You must, must, must charge more. And I would imagine Graham, that you are charging more for that as well. [Graham]Well if I’m layering it, yes. Yeah, for sure. [Jaz]Yeah. And then the reason we need charge more is because we don’t do this as a one, you know, prep and fit you actually build into the, you know, call it business models. The term you used a few times now is you tell the patient there’ll be a first try and maybe even a second try and need to build that into the fee. That’s why it takes a long time. Now, if it’s perfect that try and visit then fit it, great. But you know, I know that these can take 2, 3, 4 sometimes, depending on how demanding your patient is, it can take a lot of goes at it. So good photography, micro aesthetics and macro aesthetics, different flash settings, cross polarized photos. [Graham]Yes. [Jaz]Is that everything or is there anything else that you wanna pass on as advice a dentist who nail single anterior unit? [Graham]So your actual shade tabs. So your position of your shade tabs in the mouth, they must be in the light and you must be able to see the shade tab clearly against the adjacent to the one that you are gonna match is the one that you’re actually shade taking to. So it needs to be close to that and not just one shade. Show me the closest two shades, which you think that match closest to the tooth. Now, so for some of my clients, I do actually provide a set of shade tabs that match my materials for high aesthetic work. And I ask them to kind of pick out what they see all of the colors that they see, send me the photographs and then I’ve got the basis for what I’m actually putting into them. [Jaz]It’s calibrated because you’ve got the same exact shade guide. So I like the idea of calibrating your shade tabs with your technician. I think that’s wonderful. I think we spoke about it last time as well actually, but it’s such an important topic. And, just to add onto that, if you’re using a shade tab photo, if you have the shade tab, two or three millimeters in front of the incised ledge like labial. Right. And you’re taking a photo, the light reflects differently. So I make an effort to, whether it’s whitening photos or shade photos in general to make sure that my shade tab is at the same level as the tooth I’m taking photo of, so that the lighting is gonna have more chance of being similar on that tooth. [Graham]Mm-hmm. [Jaz]Just a little clinical point to make. Anything else on shade matching before we move on to the next question. [Graham]It’s a minefield. [Jaz]It’s tough isn’t? [Graham]Getting everything right all the time is impossible. [Jaz]Yeah. [Graham]It doesn’t matter who you are, how good you’re- [Jaz]Manage expectations. [Graham]Manage your patient’s expectations, you know, actually try and sell it as we might not get exactly right. You know, try and manage- [Jaz]I say, we’ll not get it perfect. There’s no such thing as a perfect, I’ve never done- [Graham]Make their expectations low. And then, if you perform highly, then they’re gonna be very happy. [Jaz]Yeah. Top tip there, Zahid’s asked another question, and this is because there’s a string between little discussion on the Facebook group between Cheng and Zahid about getting contact points, contact areas on like single crown. So he says, how do you overcome contact point issues with digital as opposed to stone, stone models for single crowns? And then Cheng was like, well, what issues are you having? And, Zahid was like, well, my lab having issues with sectioned printed model being a little bit more flexible than a rigid stone model. [Graham]Yeah. We covered this earlier. [Jaz]We covered that already. And then what he’s having is that when he’s getting things back. The contacts are too tight and he’s having to adjust the contacts a lot of times. Now, I’m not shy, I do a check with the floss and if it’s proud, if the floss not going through, and sometimes, I don’t tell you this, but a few times comes back and I do an adjustment. I’m totally cool with that. I expect to do that because you are never gonna nail it every single time. A lot of time your work occlusion is brilliant and contact’s very, very good. So a lot of time I have to touch your work, but I think the worst thing for a dental student, especially young dentists, many years ago, you put it in and it’s not fully seating where you haven’t detected it because you haven’t checked with floss. So these little basic checks are really important. But I guess the question I wanna pitch to you is any advice you have to other technicians or dentists in terms of getting the right contact points? Or what you do cause you do a good job, what are you doing differently that, you know, why are other tensions struggling maybe? So basically you’ve gotta set yourself up for success from the start. So your models are the basis of everything that you do, get your models correct, print out a second set of dies, ones that aren’t gonna start wobbling. So have some that are fixed in the model and work on a master  for margination and anything that you’re gonna do off of the model. [Graham]So I know some technicians, they like to take the die out and they work around the die and they twist, you know, if they’re doing any layering or marginal work or anything like that, they like to take it in and out. They like to have that freedom and I used to like to have that freedom as a technician until I worked at it was Lab 39 in Harley Street. And I started learning a lot about the model systems and they still work with split models themselves. But when I set up true form dental with a guy called Lee Stringer, it was mainly Lee at the time, but we set up on Harley Street and he taught me the way that I now use. And I just happened to agree with everything that he had to say about it. And I was just like, do you know what? I’m gonna incorporate this. It saves me time, you know, throughout the whole procedure. So set yourself up for six success with the model system. And then once you’ve got your contacts right, polish your contact, getting them right and then don’t touch them. [Jaz]How do you check- [Graham]Every time you fired them, I don’t touch them. When you glaze things, glaze around it. Don’t touch those contacts. [Jaz]Once you’ve got the contact how you want, don’t touch it. Make sense. What are you doing to check that this is the level of contact? Because to floss through a stone model is different to flossing in the mouth. What kind of checks are you doing to see if you’re happy with your contact? [Graham]So I use shim stock. [Jaz]Mm-hmm. [Graham]I actually use a 32 micron shim stock. [Jaz]Okay. So what are you hoping to see when you put your 32 micron shim stock in? You put the crown on and they’re pulling, what do you wanna see? [Graham]So I want to see it, I want to feel a slight pole. [Jaz]Mm-hmm. [Graham]Just a very slight pole. [Jaz]Like a drag? [Graham]Yeah. Slight drag. Nothing too- [Jaz]It’s not too loose. [Graham]Not too loose. But not too tight either. [Jaz]Yeah. [Graham]It’s hard to gauge. But once you get some feedback from your client, that was nice, you’ll know exactly what it is you’re looking for. [Jaz]And I guess feedback, feedback, feedback, until you refine your protocols. [Graham]So find a couple of dentists who are willing to give you the feed for every single case for a few months. And then hopefully by the time you’ve finished that feedback, you’ve tweaked everything and everybody’s happy. [Jaz]Mm-hmm. Now, clinically, I’ll just talk for a minute. Clinically what I’m doing to check the contacts is firstly when I try the crown, is the margin seating all the way, the margin seating all the way. That, okay. The contact will not be a potential reason to stop your margin seating. So if the margin’s meeting all the way, I know that, okay, it, it’s not necessarily that the contacts are so tight that it’s not allowing you to even seat the crown. So that is the first thing. Then I’m checking the floss. Can I get floss through? If the floss is too loose, which never happens. This rarely happens. So usually with technicians I work with are not having this open contact issue, which is thank goodness for that. Am I able to take the floss through now? Sometimes so tight, I can’t get floss through. I know I’m too tight. Now what I used to do is I used to take off the crown. This is the way my consultant taught me at a hospital is I used to put I think it was like 40 micron arcticulator paper in red arcticulator paper, put the crown in and then pull just like you are on the model. And then the problem with that is get gets really fiddly, you know, one hand in the mouth. Okay? And, you know, the first time the consultant showed me, the crown fell out into the patient’s mountain. And so my little joke I make with every patient is, if I drop it, don’t swallow it and they have a little nervous laughter, but I mean it to them. [Graham]Okay. Yeah, for sure. [Jaz]It doesn’t happen very often, but, you know, they need to know that. So, I switch from that to something else, which is what I created. A doctor, Ricky Bophal crosses on his top guy, and essentially, instead of now putting the articulating paper in and then seating the crown, the mouth and pulling, I’m actually coloring the red arctic paper on the floss. And now I’m forcing the floss through. And wherever it’s too tight, the contact, the red articulating paper is rubbing off on the contact area. Bullseye. That’s where I’ve gotta adjust. So then I will usually get like a yellow stone or something, just polish a bit. I’ve got my ceramic polishing burs and whatnot as well. And I’m just checking. It usually takes minute and minute half to get it perfect. [Graham]Yeah. [Jaz]And then I move on. So just a little clinical tip for those dentist who may be struggling to find a way to check their contacts. [Graham]But obviously like from a clinical point of view, it could be coming from what you are doing as well, the way you temp things paramount. What material are you using? Has it got an expansion to it? Are you actually gonna be pushing those adjacent teeth further out so that when that comes off actually they spring back in and then you’ve got something that’s tight. [Jaz]Like clip clip and tell you that kind of stuff? [Graham]Yeah. [Jaz]Over time it can expand and especially if you’re doing like a quadrant of work, you know that. And then can you imagine that little bit of movement between each one? [Graham]Yeah. [Jaz]That might be the reason why you’re having contact issues really. It wouldn’t have happened if you use different material. So do you know of any materials that are safer or better to use? I couldn’t possibly tell you. [Graham]Yeah, I don’t really know clinical materials. [Jaz]Yeah. So with the clinical site, I just know that some materials have more, so if you’re having repeated issues, maybe it’s worth checking the expansion of whatever temporary material you’re using. I think it’s a great point well made, Graham. Okay. This is a really good one. Okay. The penultimate question, cause the last question is how to get bite spot on, right. The occlusion. That’s really important for me, as you know. But we’ll first cover the one from Victoria. Hi Victoria. Hope you will Victoria’s, someone who’s come to our splint course live before. She’s a pleasant, dentist deal with. Thank you so much for being a Protruserati. Victoria said, I have noticed some labs are using only part of the quadrant to produce their work. Although full arch impressions are sent, I always thought that it’s best to use full models, even not mounting for better occlusion management, even in single units. So essentially the first paraphrase question is essentially half an arch, top and bottom and bite check versus a full model and low model and getting the bite right. Which do you prefer and why? [Graham]Well, I prefer to receive a full arch, every time. Whether I use it or not for my models, depending on how I go about doing a case is questionable sometimes. So if I’ve got a full arch, if I put it through a vertical articulator, if I design it digitally, for instance, I would be putting it through a vertical, call it vertical digital articulator as such. And I’ve got the excursions there, so I’ll design it digitally and then I know that those excursions are clear. [Jaz]How do you check your excursion? Is that digitally or by hand? How are you checking the excursions? Because if someone send you with no facebow, they’re just sending you an upper arch and a low arch scan. How are you checking? [Graham]So basically you’re just kind of set your virtual articulator to like an average values. So you just kind of check the levels of the teeth and you know, to where you think would probably match. And nine times out of 10 you’d get an excursion correct. You know, on a single unit. because all of the functions already there in the teeth. [Jaz]Yes. So you’re using, and this is really important, guys, is that you’re using the adjacent teeth and the angles and the slopes of those cusps- [Graham]Correct. [Jaz]As the reference on your virtual articulator. They’re- [Graham]So, the attrition, the articulator on the digital articulator, we’ll use that natural attrition to plot the function. So you then design your crown using that, and once you’ve designed the crown, you then design your models. So you don’t need all of that models because you’ve already done that procedure. [Jaz]Mm-hmm. [Graham]Now, some labs, they might just chop it off because their business model says we can’t spend that much money on the models, so they just chop it down, save money. Myself, I like to prudent at least the pre-molars on the other side, if possible. [Jaz]Oh, wow. [Graham]So if I get full arches, I will take from six to four or five, depending on where the contacts are. So if I’ve got a positive contact on both sides, I’m happy, but I need both canines in order to get an excursive process. [Jaz]But if someone’s got an anterior open bite and there’s no contact three three, and you’re doing even a lower molar crown, you want the full arch top and bottom right? [Graham]Correct. [Jaz]And in those cases, if it’s like very specific occlusal scheme there, then perhaps you probably want it on a physical articulator, or you happy to use the virtual one for more complex case where the occlusion isn’t really straightforward. How do you manage those cases? [Graham]I tend to hand mount a lot of things still on so yeah, I put a lot. [Jaz]And if someone doesn’t send you a facebow you’re just using average values to mount that. Right. But you’re still able to check things better, which makes a lot of sense. So Victoria, I guess the answer is, the technicians would prefer as much information as they can. So they prefer the full arch and still send you a full arch. If that’s what you’re doing, that’s fine, but what you do in the model is your decision. And sometimes you might actually print it, but you seem to be in the mindset that you like to print it for at least to the other side pre-molars. Whereas what Victoria seems to be getting back, she’s sending the full arches but she’s only getting half the mouth. And so that’s why her queer question stems from. [Graham]It should only really be an issue. If she’s having problems with excursions when it comes to fitting, then you need to talk to your lab about what they’re doing. [Jaz]Absolutely. So it is a conversation to have with your lab, but ultimately it should be results driven if you’re getting the right results in terms of your occlusion. [Graham]Correct. [Jaz]It doesn’t really matter what the lab are doing always matters what you are doing, but that kind of feeds into the results you’re getting I think, so great. Final question, big one is getting the occlusion spot on. You are very good at doing it. Okay. So I found that your shim holds, cuz what I like to give you often is I’ll tell you the shim holds and lower left four, lower left five, lower left seven. And I tell you to copy the sort of cuspal inclines of the adjacent for a single unit and you pretty much nail it. But one thing I like to do now, I dunno whether you use this or not, Graham, but one thing I like to do is that quite often I’ll give you the pre-prep scan so you know what my temporary looks like or you know what the tooth look like before I prepped it. And if we’re doing conform dentistry, which mostly we are, then I try and get you to copy the features. Now do you disregard that and completely or starting? I’m gonna strangle, I’m gonna strangle you. [Graham]Off with that. [Jaz]Okay. So tell us about that then. [Graham]Mainly I disregard that because we’re looking at making something better at the end of the day. [Jaz]Mm-hmm. [Graham]So the tooth has failed for reasons whether it be like contact issues or occlusal issues. So this opens up a whole can of worms of why we do these single tooth restorations that tooth has failed for a reason and it’s normally because of something else. [Jaz]Mm-hmm. [Graham]Because they’ve got no guidance, they’ve got none of this. They’ve got no balanced force across their whole arch. So by replacing one thing- [Jaz]With an exact replica. [Graham]With an exact replica, we’re just setting something else up for failure or this restoration for failure. So I tend to disregard anything that we’ve had before. I might look at where the contact was originally and see if we can improve it or keep it where it was. But that’s it. [Jaz]The only time I would disagree with you, the only time I disagree with that is a time whereby and this is in your lab, there’s a different lab I used once and I had this patient on a temporary for many months. It was a very specific occlusion and I wanted to nail it, and I did and I got it working beautifully. And I specifically said, you must do a copy of this cause I’ve nailed it. And they completely disregarded it. But what they sent back was completely outta the bite. Like it was completely shallow where I had these, and I sent them a photo of my temporary and their definitive and they saw that, okay, we kind of cocked up and you gave us that information. You gave us the scan and we didn’t use it. So I think if you’ve test driven something in a temporary, and that temporary is not an exact replica before the temporary has been purposely built to serve this patient. Then I think technicians should use it if the dentist has asked. [Graham]Yeah. If specifically asked, sorry. [Jaz]Exactly. [Graham]Then yeah. [Jaz]Whereas otherwise I really respect the fact that you are wanting your conform to dentistry to actually add something rather than just be an exact replica of the thing that failed. So that makes a lot of sense. So Graham, this is Alexandra Kal. Alexandra, thanks so much for being Protruserati. It’s always lovely see your engagements on the group and whatnot in the podcast. I love her question. It’s like, why on earth is the bite never spot on? Like, it’s a tongue in cheek thing. And I know Cheng was like, it’s slightly our fault. Trust me on this. So Cheng is saying that it’s slightly the dentist’s fault, not your fault, but it’s good to hear your perspective. So what tips do you have for dentists to make to helping you to get the bite spot on? [Graham]Well, we kind of covered it earlier in some respects. So the way you temp is paramount because obviously if you’ve got a higher temporary, you’re gonna push that tooth further apart, and then you’re gonna end up with something that’s shy or if you, obviously you take too much off yourself, then the tooth opposing is gonna over erupt. [Jaz]Mm-hmm. [Graham]So then that makes your lab technician’s restoration high. [Jaz]Yep. [Graham]And you have to adjust obviously other things that can affect this is your temporaries is coming off. You know, you’ll be surprised just an overnight how much a tooth can over erupt. I had it happen to myself. So this is personal experience. I had a crown prep done in an evening by a top dentist above where I used to work. His name is Ma Rashard. And I thought to myself, right, I haven’t really got the time to make a temporary and a crown for morning fit. So I thought, right, make the crown. Don’t need a temporary, it’s only overnight. So I made a nice bonded crown, finished it in the morning, glazed it, went upstairs for a fit. It’s high. [Jaz]So you made your own crown high. [Graham]Yeah. Yeah. High, high, metal. [Jaz]Humble pie. [Graham]Humble pie. Yeah. So my tooth had actually over erupted about 0.5 of a millimeter. [Jaz]Wow. [Graham] Just overnight. [Jaz]And so to me as a, with an occlusion background, what I’ve been taught by Rob Kirstine and these guys is that that tooth, perhaps the reason why it failed is that tooth was in chronic overload. And finally, now that there was no temporary anymore, it was able to passively release that pressure. Okay. And restore itself. So it apparently takes about 17 minutes for the PDL just to recoil and get to where it wants to be. So it happens very quickly. Right. But in those cases, my predecessor whose list I inherited, he was famous for crowns, come back high and just cementing them and sending patients off and come back and everything was perfect. And so I think lot dentists do this and we get away with it because we adapt. [Graham]Yes. [Jaz]The body is good at adapting. I’m not saying we should- it’s not why I teach either occlusal course, we should strive to be conforming the best way possible, but sometimes these things happen and you have to look at, again, lost temporaries is a good point. [Graham]Lost temporaries. So you’ve got temporaries impressions are a big thing as well. Like you look across the arch, like you say, about giving full arch impressions and only small impressions. Now these can make a big difference to the bite. If you’ve got any sort of distortions on your impressions, any drag on, anything, even on scans, you can end up with scan data that isn’t quite correct and you’ve got slight warp in it can affect the bite that the technician works from. So that’s another reason why technicians sometimes chop a lot of your scan data out because it’s just not usable. [Jaz]Mm-hmm. It’s making it worse. [Graham]They’re trying to make well something work for you. Yeah. So yeah, it’s difficult. It’s a minefield. And then of course, You’ve got the lab technician side of things, and it could be a whole number of things in the laboratory as well. Is that technician experienced enough? Has it been quality controlled by somebody? You know, depends on the type of lab you send it to. If you send it to a lab where you’ve got people working in a process, it goes through the ceramics last, he should do the quality control. So it basically comes down to that ceramics. But everyone else have, they set him up for success to the point where he’s come to. So yeah it could point to a number of people. [Jaz]Well, I mean, with all the processes on the dentist side and all the person on the lab side, it’s a bloody miracle that anything actually fits. It’s a minor miracle. [Graham]It is a minor miracle. [Jaz]The occlusion’s even. And your occlusions usually very good. And we’ll take a few snippets some video content of the virtual articulator. I think everyone will be quite happy to see that. We’ll show that in a moment. But yeah, I think getting the occlusion right is a partnership between the dentist and the technician. And another tip that I can give is, one thing you mentioned earlier, Graham, was that when we’re doing our scans, just take a second, just check the bite is how it should be. Cuz you know, one time of a hundred you might say to me, is this actually how the bite is? I’m gonna hang on a minute. No my photo show something different. So at the time in haste you might have not scanned properly or the patients just shifted their bite a little bit as you’re scanning. [Graham]Yeah. Correct. [Jaz]Important to check that. [Graham]And it’s very detriment, especially if you are using like a quadrant scan. And your patients bit down in the wrong place. You’ve got no real attrition to have any guidance with, even if you’re trying to put it in like habitual position and working with the attrition there. If you haven’t got enough surface area you’ve got nowhere to work from. And you’re just literally working off of excursions only, and that’s it. So you can make a crown that’s flat in order for it to fit. And that’s probably the best you’ll get. [Jaz] The times where I struggles as a dentist to and I blame myself as a dentist rather than the lab is deep bite patients, right. Who don’t have much of an anterior stop. So they completely, they’re almost fighting onto a gingiva. Right. So, very, very deep bite that’s almost like an open bite in the sense that you’re relying a lot on the posterior anatomy cuz anterior isn’t really giving you much. And what I’ve found is that these crowns often come back very proud because of that deep bite element, the technician has perhaps not been able to control exactly what the bite is like because of the fact that it just over closes. It’s got so much play at the front because the deep bite nature. So I’ve always found these cases a lot more tricky to get the occlusion right in. So I always go back to basics, get a full arch in that sense. Give a couple of different bites, use bit of you doing reference points and give as much information to technician as possible. I would never, in a deep bite case, give a half an arch only. Any other tips on that? To me? [Graham]None that I can think of. Continue. [Jaz]Okay, fair enough. Well I think we’ve covered a lot of ground there, Graham, I think we’ve covered a lot of top tips there and we answered a lot of the Protruserati’s questions. I’ve always enjoyed talking to you, but- [Graham]I do have a tip for digital dentists. [Jaz]Yeah. [Graham]Though about getting your bites right. Now, one thing that I do is when I receive a digital case, I will then go to design the models, et cetera, et cetera. I know dentists don’t do a lot of this, but if you go to a model design first before you then design your crown could be an advantage to yourself. Now what I do, I always check for the contacts and where they are. Do they match up? You know, is it evenly balanced? Are they in the places where you thought it was? And if not, then I changed where the antagonist positioning is and I will bring it down as if the patient is actually biting. So I’ll bring it down like 10 microns and then another 10 microns until we’ve got contact. [Jaz]Digitally. You’re doing digitally? [Graham]Yeah. This is digitally. And then and only then when I’m happy with the way the patient is biting to know that when I build the restoration, that’s the position it’s gonna be when the patient’s biting down and it’s not gonna be high. [Jaz]But this is because the scan, the bite scan that you’ve been sent is kind of in deficient. [Graham]Yes. [Jaz]Yeah. And so what I appreciate about you, Graham, here, and it’s important to note this, is that you’re taking this time to check and, you know, do these pre-op checks rather than just make the crown fit in what you have and make it all just fit. You’ll actually taking time to check that which is wonderful. So I think part of the reason why we get a lot of success, you and I with our occlusion is because you are doing these checks. I’m doing my checks and we work in synergy together. So now at this point people are like, okay, I wanna use Graham as my technician. So I’m gonna say piss off. All right. Hands off. No, I’m joking. I’m joking. So I’ve already had this chat with Graham, and Graham is too busy. You could say what kind of work you are willing to accept. Cause I know you’re not taking any bigger clients. [Graham]I can’t take any aesthetic work on, I’ve got enough clients that are sending me that to keep me busy. I can perhaps take on some single units, mainly emax like onlays, overlays, veneer lays, kind of what we specialize in. And quadrant work, posterior quadrants, but yeah, anterior work and full arch is, I can’t take anything. Jaz’s Outro:Yeah, anything fancy buzz off. Yeah, he’s busy. Enough as it is. So, Graham, thanks so much, man. Really, really nice to see your lab today. We’ll take a few more bits of footage and stuff for the occlusion course, but also, just to add on to this video for the virtual articulator and that kind of stuff. And we’ll go around seeing some things. So guys, thank you so much for tuning in as always. And to the outro. There we have it, guys. Thank you so much for listening all the way to the end. I hope it inspired you to pick up that phone and arrange to go visit your lab, see your technician eye to eye and GROW TOGETHER. Maybe even take them out for lunch, #taxdeductible. And if you’ve listened all the way to this point and you’re Protrusive Premium member, all you have to do is answer a few questions and get your one hour of CPD. Because if you are listening every week, and many of you are, then by the end of the year, you would’ve got 30, 40, maybe even 50 hours of CPD by certificate ready to upload as part of your personal development plan, as part of your annual quota. Answering these questions super easy and it validates the learnings. Make sure it’s all fresh in your head. In fact, one of the questions for this episode, I’m just gonna read it out, is, which of these is a cause for your crown being proud or too high in the bite at the time of delivery? So is it A, a temporary material that is dimensionally unstable, B, a lost provisional crown, see a distorted impression or scan D, a lab error such as a lack of quality control, or E, all of the above. If you know the answer, you are pretty much almost there to get your certificate. So please do answer it. And if you haven’t already downloaded the app, that’s the first step. Either access the app online, on your browser, on your laptop by going to protrusive.app or downloading an Android or iOS. If you found this episode useful, share it with your lab technician. That’s maybe one way how you’re gonna grow together, that one way that you’re gonna build a rapport with your technician or maybe send to a colleague that you like. I appreciate you listening all the way to the end, and I’ll catch you same time next week, same time, same place.

Which type of sedation is best for my patient? Are Temazepam tablets good enough? Is that even allowed? How can I safely provide Sedation in my practice? We are joined by the calming tones of Dr. Roy Bennett who busts some myths and guides us clinicians on Sedation in Clinical Practice. https://youtu.be/F6tf6HqqxD8 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 Protrusive Dental Pearl:  Communicating Risks to your Patient: Be calm and SLOW your pace down when communicating with your patients to EMPHASISE certain words. Becoming a visual educator to the patients is also a really good way to communicate risks – intra-oral camera is the best investment you will ever make. FocusDent MD740 Dental Intraoral Camera Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 1:07 Protrusive Dental Pearl – Communication 4:27 Dr. Roy Bennett’s Introduction 5:40 Pre-medication – is Temazepam any good? 9:27 GDPs entering the world of Sedation 13:48 Which Type of Sedation, When? 15:12 Level of training required to provide sedation in practice 17:32 Sedation and Clinical Dentistry at the same time? 19:09 Learning Sedation 21:48 How long can we Sedate a patient for? Is it just 1 Hour Max? 23:41 Offering sedation in YOUR practice 25:41 Ideal personality traits of operator-sedationist 28:15 Thing to know about implementing sedation 32:21 Two good qualities that an operator-sedationist should have:  34:24 The “New Drug” – Remimazolam Check out Dr. Roy’s training site: Web: mellowdental.co.uk As a senior clinical advisor – Webinar and Presentations: uksedation.com  UK Sedation will be presenting at the Royal Society of Medicine on the 15th of February on the new drug If you enjoyed this episode, you may also like another sedation episode: What Every Dentist Should Know About Managing Dental Anxiety  with Dr. Mike Gow Click below for full episode transcript: Jaz's Introduction: What's the deal with prescribing Temazepam as part of oral sedation or pre sedation? Are there any concerns about giving this to your patients or maybe sometimes the doctor, the general practitioner has given this to your patients? Jaz’s Introduction:And what about deciding whether inhalation station, AKA gas and air versus intravenous sedation is best for your patient, and what is the correct path you have to take to be able to safely provide sedation in practice? These are all the questions we’ll be covering in today’s episode. Hello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. It’s not often we do an episode on sedation. It’s quite a niche thing, but it complements some of the previous episodes we’ve done such as the one about hypnosis with Mike Gow. You have to listen to that one. And Mike and Roy, today’s guests are actually really good friends, and it makes total sense. You know, Roy was a fantastic calm communicator. I would feel very safe in his hands as a patient. And that’s what we all want. We all want our patients to feel safe around us, and that come from how we communicate to our patients. So, before we start on this episode about sedation, all those things that I just discussed, let’s get to the Protrusive Dental Pearl. Protrusive Dental Pearl:So, if you’re new to the podcast, every main episode, every PDP episode, I will share a Protrusive Dental Pearl. One tip that you can apply straight away. And this one is about communication. I very often like to do well communication one and this is not because I am some sort of master of communication. This is far from it. This is just something that I’ve been very much in tune with myself. I try to reflect on my communication skills and try to improve, and I try to look at other clinicians when I shadow them or when I see them in practice. What can I learn from them? So, the example I’m gonna share with you today is I had a dentist shadowing me recently, and I like to ask dentist, what did you learn today? What did you gain from today? And she said to me, ‘Jaz, I like the way that when you were explaining risks to a patient, you just slowed down. You just really slowed the pace down and emphasized certain words.’ And through doing that, I think you are a more impactful communicator and patients will remember. And I’m very intentional when I do this, in fact, after a deep restoration or a really nasty crack, and I take a photo with my intra or camera and after the procedure. I’ll sit the patient up and I’ll say, wow, that was really tough, Mrs. Smith, or make some sort of comment and I’ll also compliment them, ‘Well done. You stayed open really well and I appreciate how still you were.’ Or something like that, and then I’ll say, ‘I’m happy with how everything went, but you do have quite a nasty crack in there. I’m hoping that your nerve will survive, and you won’t need something called a root canal treatment, but in case you do, here are the things that you’re looking out for. I want you to get in touch with me, if you get a severe throbbing ache, any sleep disturbance due to toothache or just sensitivity that doesn’t settle.’ And of course, I’ll show them on the big screen the photo of their crack, and now the patient has owned their problem is their crack. I’m just the communicator. I’m just passing on this message. I’m just showing them what I’ve found in their tooth. And I know that in 99% chance that they’re not gonna have any issues. They’ll think, ‘Wow, you know, this is amazing! Jaz, a great dentist.’ I didn’t get any of that horrible pain that you described. But equally, if they do get irreversible pulpitis or get into trouble from this tooth because of the crack, they remember that part of the episode. In fact, it takes me back to a really good episode we did, which called Consent is Like An Onion, with Shaun Sellars and Zak Kara, do listen to that because Shaun summarized something called the Peak End Rule. What parts of the consultation do patients remember? What parts of an appointment do patients remember and they remember the peak? The most significant thing of that appointment and the end. So, if you end on a high, and if you’re nice and calm in your approach and you slow down and emphasize and be a visual educator to the patient, you show them the crack, for example, in this example I’m sharing with you, then I think that’s a really good way to communicate risks to your patient. Main Episode:Now let’s join Dr. Roy Bennett. Talk about sedation for the wet fingered practitioner, Dr. Roy Bennett. Welcome to the Protrusive Dental Podcast, my friend. How are you? [Roy]Yeah, really good, thanks. How are you? [Jaz]Yeah, great. And it’s great to have a rare sedation speaker. It’s not something we’ve covered that well on the podcast or on that much depth. So, I want to cover it in a way that’s gonna, those burning questions that we have around the world as dentistry. As I do believe, and I’m sure you’ve seen as trends, and we’ll talk about it, is that. The USE OF SEDATION is perhaps UNDERUTILIZED in various countries, and it’s only gonna go high and higher, but you are the expert in that. For those who are unfamiliar with you, Roy, please tell us a little bit about yourself as a practicing dentist and yourself as a sedation. [Roy]Okay, so I’ve been in practice about 34 years now. I’ve spent about 15 years of those with special care dentistry at the university background. And then I set up my own teaching facility back in 2011 to teach a postgraduates around the country sedation. Cause as you said, there’s an absolute need for that. And I teach IV sedation. Okay. So, I’ve actually do a little bit of oral sedation, bit of inhalation sedation. And also, I’m quite a holistic practitioner, so I do off hypnotherapy as well. [Jaz]Brilliant. [Roy]So quite a well-rounded sort of sedation if you like. [Jaz]You showed me some videos of someone who, I believe for some reason you couldn’t use IV sedation, but then you were using hypnotherapy and you showed me how relaxed that patient was and so that was really cool to see. So I’m sure we can, even for those practitioners who aren’t using drugs of any sort or gases of any sort to sedate, there are some things that we can perhaps share to help put their patients at ease a bit more. So I’m very excited for today’s chat and so it’s great to hear you’ve been teaching dentists about this kind of stuff. So I’m gonna start with my basic level question before we then escalate to IV and whatnot, is oral sedation. A lot of my patients in the past have obtained Temazepam like oral from their GP. Prior to the appointment with me, and that made me feel awkward because I was a little bit uncertain about where that puts me in terms of, okay, a patient is technically under sedation, I’m not sedation trained. How could something go wrong? Okay, so I wanna know from you, medical, legally, what are the rules and the laws in terms of me being able to, A) give out Temazepam? And then what level of training do I need or what are the requirements? And B) that goes along with that. What if the GP gives Temazepam? Am I in still some way responsible for the sedation during the dentistry? Interesting, isn’t it? [Roy]Okay. Okay, so let’s go back to basics. Basically, the temazepam is a benzodiazepine, right? It’s one of the family of the drugs, quite traditional in the sedation world that I work in. But you know, things like Temazepam is a premedicant, so it’s pre-medication. It just takes the edge off people that when they’re slightly anxious, okay? Now I prefer my patient to be open with me and as they’ve been with you to let you know that they’ve taken that. But one thing you’ve gotta know about that is one thing you’ve gotta know is that your consent process then is not valid. If you wanna change a treatment plan when a patient on Temazepam, then you have to go back to when they’re not on Temazepam. So you can’t then launch into a different treatment profile once they’re slightly sedated. If we’re doing sedation on site, we wouldn’t give Temazepam, we’d use oral sedation. So to me, Temazepam, to be clear or  Diazepam given by a GP or prescribed by you, would be just to take the edges of somebody. It’s just to relieve the pre-treatment anxiety. [Jaz]And do you think it’s a useful thing to- You’re not a fan. Okay. Just coming onto that. [Roy]No, I think it’s an adjunct. I think if you’ve got somebody who’s particularly anxious, sometimes they’ll double up on the dose. They may take alcohol with that, but you’re not in control. And I’m a guy in sedations likes to be in control. So when you take a pre-med, you’re sort of fixed into gear. You can’t go through the gears, you can’t titrate the drug. The Temazepam is a one fixed dose, as it were. And then it’s also dependent on what they’ve eaten, how they’ve slept. what their demeanor is. So it’s, a lot of clinicians will use this, but I’m not a fan because you’re not in control. You’re not controlling the sedation now. So medical legally, I’m not a fan, I have to say. [Jaz]Okay. That’s useful to know. [Roy]It has its place to give the patients a reasonable night’s sleep the night before. But to be honest, when you get a very anxious, it’s not gonna hit the side that controllability is not- [Jaz]So it’s not enough of an anxiolytic it sounds like. And also it does mess up your consent process. So for those listening who do have a patient who didn’t know was taken Temazepam and they come to you and say, ‘I just, I was so nervous my GP gave me Temazepam and they’re kind of drugged up in your practice, then a great point made by Roy that actually you gotta be really careful about changing the course of treatment. [Roy]And also if you go outside the remit of what a GP does, which is usually about, you know, two to five milligrams of Diazepam, or 10 to 20 milligrams of Temazepam. You’re really straying into more high sedation levels. So pre-medication, before the procedure or going to sleep, it’s quite low doses. So really those low doses are just gonna just take the edge off people. If they’re really anxious when they come in to see you, that anxiety will still be there in some way. So you might be disappointed as a clinician that hasn’t done what you thought it would do. [Jaz]Okay. You’ve done a good job of pulling me off Temazepam. What is the level one, so you know, what is the next level up from that, that you think that GDPs who may be entering the world of sedation could start to do that you feel has its place a more widespread in clinical dentistry? [Roy]So one of the important things is to assess the patient correctly. So I use a pre-visit questionnaire, which I send out to the home address. They fill that in. I get a level of the anxiety that they have through the modified dental anxiety score. We get a score, which is more valid, and then I can work out what kind of approach that we’re going to do with that patient. Now it might be inhalation sedation. It might be a little bit of hypnotherapy. It might be the language you use with the patient. We’re gonna put topical on. We’re gonna look after you. It’s the language that’s really important. It’s a bit like NLP language. Okay. So we don’t use the words obviously, pain, injection, excavator. We talk about things like comfort, how comfortable you are. We’ll put cream on that will make you feel more comfortable. And then we’ll present the treatment plan and decide which route we take the patient down, whether that’s inhalation, sedation, or just sort of normalistic programming you like. Or we’ll go down the IV sedation route. [Jaz]Okay. So it sounds like really in terms of lowest anxiety to highest anxiety, like level one, we’re talking just really good care in terms of communication and being selective of your words and creating a nice calming environment. One level up from that, which might need a bit more investment in the practice. We’re talking about scavenging and stuff like inhalation sedation. The level up from that would be intravenous. Are all of those that are used in general practice by general dentists or are there any others? [Roy]Well, you could use intranasal sedation if somebody’s quite phobic, and you could use some oral sedation, which is onsite sedation. Not outside the practice, really take a tablet. So they come in the practice and then you would mix an elixia or a drink of benzodiazepine, Midazolam, and that would then calm the patient. Now, if you are gonna go down that route of them having a drink of oral sedation, then they do need to be cannulated. So you’ve gotta have the know-how and the core of knowledge to be a IV Sedationist to give all sedation. Does that make sense? [Jaz]It does. And is it a myth that inhalation sedation is just for children? [Roy]Correct. Absolutely. So, I’ll do a myth bust here for you. [Jaz]Please. [Roy]So basically, I do inhalation sedation right from sort of five-year-olds right up to 95-year-olds. Okay. It’s a really, really good system. It’s a really safe system. When we do inhalation sedation, we’ve always got 30% oxygen flowing through in that background, which is even better than the 21% air that we breathe. Isn’t it? So very safe system, titrateable. So, you can go up and down. As with IV sedation, which is what I like Titrateable, we can dose it to the end point and the reaction of the patient. So I’m going through my gears, going through the inhalation sedation of percentage of the drug, the sedative of nitrous oxide that we would give so you are safe. Underused in the UK, 50% of American GDPs use it in the states which is amazing, isn’t it? When you go, when you visit the states, you’ll notice every practice or every other practice has an insulation sedation unit. And why is that? Because the public expect it. They expect that kind level of option or care when they need the treatment. Okay. So it’s an expectation of the American public. So inhalation sedation absolutely underused in the UK shouldn’t just be used in community care or special. So it’s a really good thing. Sometimes I don’t want to sedate an elderly patient or they’re on certain medicines. We’ll just use a little bit of inhalation sedation to take that impression. If we’re not doing a digital scan, whatever, or they’re just little bit phobic, it’s limitations, if you like, are probably where the patient is extremely phobic or extremely anxious. And then the inhalation sedation, the nitrous won’t be enough to get them from A to B. So we really do have to go back to what I said at the start, which is to be, let’s assess this correctly. Where does that patient lie in their anxiety score? [Jaz]I’m gonna ask you a tough question now, Roy. Assuming all things being equal with a patient, patient A, and patient B, that their medical health history is that they’re ASA grade 1 fit and healthy but they’re slightly different in the anxiety level in terms of MDAS, is there a magic score in terms of, okay, after 21, I consider inhalation sedation not to be effective. Is there a magic score or is it still an art form? Is it still arts and crafts? [Roy]Yes. Yeah, it’s a good question. Sedation is an art form. It’s bringing the science together with your personality on the demeanor and the personality of the patient as well. So absolutely, as we always said, in any kind of sphere of dentistry, whether it’s implant dentistry or whatever, there is an art form. It’s that discussion which is pre sedation discussion with the patient, which is critical. So I’ll always book 20 minutes. I’ll sit down with the patient, not in the dental chair. We’ll sit together, we’ll go through it and we’ll find out what ticks the box for that patient. Where do they lie? Because some patients who are controlled type patients type a behavior probably might resist the sedation and it might be a bit of a sedation failure for you. So we have to see that patient has to trust you and they have to be on board with the sedation, we’re not gonna do the sedation of the patient because we’re ticking an MDAS score. We need the patient to follow us on that journey as well. [Jaz]Got it. So there’s no, yeah, I mean I expected that to honest. I know there’s no magic answer. Magic number. [Roy]Yeah. [Jaz]In terms of the level of training medical legally required, and if you know about the US and Australia, cuz got lot of listeners from US, Australia, and New Zealand around the world, but obviously I’m sure you know about the UK, but if you know about the world as well, it’d be great to know from you what is the level of training that you need to be able to provide inhalation sedation in practice? [Roy]Okay. So, you need to basically do a core of knowledge over one or two days, like the 12 hour CPD, which is didactic teaching, and then you’ve got to be supervised through your 10 cases of mixed variety inhalation sedation. If you are gonna do that, then you would do some assessments as well, just so you’ll have a supervised colleague standing next to you, and then they’ll go through the 10 cases. So you might take one or two or three days to do that if you’ve got all your cases together or over a matter of weeks or month, and then you will revisit those cases and discuss that with your supervisor. So IV sedation a little bit more in depth. Again, a two day beginner course, core knowledge. And then we need to do 20 courses- [Jaz]20 cases, yeah. [Roy]20 cases of mixed ability. Again, so from extractions, fillings, or whatever. Okay, so you do need that 20 cases. Now, that just gives you a basic sort of understanding in my view. Then you really start learning as all things in dentistry. You start, you have some failures, you have to accept that, you have to revisit that. So, but basically, the ISCD, the Intercollegiate Advisory Committee of Sedation in Dentistry 2015, revised 2020. The standards, and that’s what we follow and what the lawyers follow is 20 cases, logged cases. [Jaz]Mm-hmm. [Roy]Now, when you carry on as Sedationist, you must keep your log cases, the log book in case the CQC ever decide to walk in and say, ‘Oh, tell me about your sedation cases.’ [Jaz]Oh, that just makes sense. Fine. That’s the lovely, nice, clear guidelines to follow in terms of being able to implement this. I remember doing some restorative cases and then I essentially, I hired a sedation to come to just manage the sedation cuz I had so much on my plate. I was raising the vertical dimension. It was my early days. I was still, very much engross in my restorative density. There’s no way I could expect to do anything beyond what I was doing in the mouth. Now I’m at a point where I’m a lot more comfortable with my restorative dentistry could I, is it naughty if I’m doing the restorative entry and the sedation at the same time? Or should there be someone else doing the sedation always? How does that work? [Roy]Okay. So, my philosophy is if it’s a straightforward thing that you’re doing in dentistry, if it’s a simple thing, if it’s a straightforward extraction, if it’s straightforward restorative, if your head space is not too overused as it were, then go ahead and be the operator sedationist, and that’s the term that you were mentioning there, operator sedationist. Now, if it’s not simple and it’s not straightforward, or the patient is challenging or the patient has some medical comorbidities, or the general situation is a bit more stressful for you as the operator, then I’d always get a dedicated sedationist. [Jaz]Got it. [Roy]Okay. And that’s what the standards say actually, if things are a bit more challenging, step back, take two steps back. Well, I’m gonna concentrate on my occlusion today. On the restorative, I’ll be placing the implants. My head’s gonna be pretty full. And this patient’s a bit challenging actually. So do you know what? I’m gonna have a good team member with me. I’m gonna have a dedicated sedationist in who’s gonna take that pressure off. And also that’s best care for the patient as well because we need a dedicated sedationist at the other end of the chair who’s just gonna monitor the patient, look after the patient while you, you can do your excellent dentistry. [Jaz]Brilliant. Now, if we dentists start thinking about sedation training, and let’s say they get some cases under their belt, they build their portfolio, they get their 20 cases, and we’ll talk about the end, about how to go about doing that. I’m sure you have a great help that you can give us all. When dentist, maybe your delegates or a dentist that you’ve trained run in trouble, cuz everything’s got some failures. Just like you said, you know, we get failures, I get restorative failures. You get sedation failures and that kind of stuff. What are the most common lessons to be learned for those starting in sedation that you could share with us? [Roy]Okay, so I think the first hurdle that most people sort of have to leap over, if you like, is on their first few cases when they are giving the drug. Okay, so giving the drug is via cannula, obviously in the back of the hand or in the arm, and actually cannulation skills is a big hurdle for most people. So it’s a learned skill. Bit like when we’re trying to find a, you know, second MB canal and a molar. It’s a learn technique, okay? So cannulation. The more we do, the more we learn, the better we become. So that’s a little bit of a hurdle. Second hurdle that we come across is we administer the drug under supervision with our colleague. But then we say to our colleague, when do you think I should start to numb the patient up? When do you think the patient’s ready? And that’s where the art form from. You’re looking at the patient and saying, ‘Right. I’m gonna say to the patient now, are you okay if we numb up now? Are you ready to proceed?’ And the patient may go, oh yeah, nod or not, and we know we’re at the right level of station. Then what we don’t want to do is jump the situation and the patient be under sedated and then start numbing the patient up and that can dissipate the good effect that we’ve achieved already. So it’s the timing. The timing of numbing up, the timing of administration, the drug. So that takes a learning curve of sort of five to 10 cases to see that- [Jaz]It’s turning that knowledge into wisdom, isn’t it really, Roy? [Roy]Yeah, absolutely. And then keeping that patient, you’ve taken the patient to a nice level of sedation and as I say, cruising altitude. We want to keep the patient nicely, comfortable and it might be a long procedure. It might be 2, 3, 4 hours, implants, whatever. So we want to maintain that patient at a nice level of sedation, let the patient learn and become to a nice recovery and a safe discharge. So it’s like taking that patient on a sedation journey. [Jaz]One question I’ve got already, Roy, cuz you’ve sparked my interest now, is I had this another myth busting, let’s call it then a misconception that I had. But previously when I asked you about inhalation sedation for adults, that was a previous myth that I had that was corrected and me and Mike Gow many episodes ago discussed that and then we confirmed that. So if you guys haven’t listened to that, Mike Gow episode, it’s brilliant. Roy, you and Mike are good friends as well, so that is nice to hear. Hello Mike if you’re listening. And so another misconception I had with sedation is that, I dunno where I read this, but like the golden hour, the golden 45 minutes once you start IV sedation, you’ve gotta get everything done in 45 minutes. And I actually remember doing restorative cases being like, okay, I’ve got 45 minutes. Prep, prep, prep. Oh, so you’ve actually just busted that myth. So what is the truth there? How can we, how long can you safely go for? [Roy]Okay. Okay. So if we think about the drug that we are using, that can have an effect. So if we are using the basic drug that we use in the UK, which is Midazolam currently, okay? Benzodiazepine then, and we titrate to effect and we get the patient in the first sort of three or four minutes at the right level of sedation. We probably, and I agree with you, we’ve probably got a window of about 30 to 45 minutes of peak sedation. If we want to extend that, then we need to have a bit of experience, and then we need to, I don’t like the word topping up, but we need to add some more Midazolam after about 30 minutes. Okay. So we’re topping up. We’re topping up. But what we have to understand is that patient’s gonna have a longer recovery then. [Jaz]Mm-hmm. [Roy]Because we’ve added more drug than what we started with. Okay. So now the drug profile is changing. Some of the things that we have to think about is how long can I keep the patient titrated at that level? Okay. Now some clinicians will use maybe a different drug that we can touch on, but which is appearing in the UK, which will give you that top of level continually. Okay? So there’s different drugs out there, and there’s a anesthetist that use different drugs like propofol, and that’s the continuous infusion, which sort of gets around this problem of the drop up after 30 or 40 minutes. But that’s advanced sedation. [Jaz]Got it. Now we’ll talk about this new drug because I see you’re doing lots of lecturing about it, so it’s worth touching on at the end in terms of some nitty gritty details and making it tangible for the dentist. What this podcast is all about is when dentists are starting out implementing sedation in their practice, what are the hurdles that they have to jump through? Like I’m thinking it’s such a useful thing and I’m thinking already. In my practice, we don’t have anyone that provides sedation and we always have to reach out to someone. So I think it’ll just make business sense and also how much more we can serve our patients. If every practice had one dentist who was trained in sedation. So what are the hurdles? Like one automatic one I’m thinking of Roy, is that perhaps our nurses then also need to be sedation trained. Is that a hurdle? [Roy]Yeah, that’s correct. So there are two route you can go down in the practice. One is that you’ve just mentioned, you’ve touched on, which is you bring in a dedicated Sedationist and that sort of complies with all the regulations and the standards. They would be purely administering the drug and monitoring the patient. So it’ll be nice for your team to have some core of knowledge, but it’s not absolutely required. So that dedicated Sedationist will take all of that sort of paperwork and sort of administration off you. Okay. The other route is that you actually become the operator sedationist and treat some of your patients. And yes, you would need to have a dedicated nurse who you pick out of your team who you think would be suitable to become the monitoring dedicated sedation nurse. And she would need exactly 20 cases core of knowledge, and that’s what you’d need. So you’d need, I tend to, if I’m doing operating sedationist in my practice, I’m having me as a clinician treating, and then I’m having my sedation nurse who does all the monitoring dedicated, and then I’ll have my four handed nurse next to me. So I have a good three member team. Okay. [Jaz]Got it. [Roy]So the minimum is having an operator sedationist and a dedicated sedation nurse, but that then stresses because you haven’t got your 400 nurse as well. So I always say have three in the room if you are the operator sedationist. [Jaz]That’s a good rule actually. Yeah. Rule of three. I like it. It’s also same in crown lengthening. Rule of three. But that’s another time to tackle. Roy, is there a ideal personality trait or an ideal type of dentist that lends himself to being a operator sedationist or doing sedation training? Like me personally, I love the idea cuz I like getting people out of pain. I like making ’em feel at ease. I like to learn new tips from people like you to make my dentistry calmer experience. So I love all that, but equally, I am like, when I’m doing my dentistry, I am like in seven and a half magnification. I’m so engrossed on every enamel prism and every retraction cord and I’m loving it, right? I worry about then splitting my attention to something else. So is there an ideal candidate? [Roy]So I think, well, let me take you back in time. The reason I got into sedation was a little bit of self-preservation room. I’m quite an empathetic guy, but in life you’ve only got such petrol in the tank and you can be so empathetic and that can, if you’re being caring individual, you need sort of systems in your practice. You need- [Jaz]Need drugs. [Roy]Well, not always drugs, but it’s useful to have, isn’t it? So, yeah, so I just needed a toolkit into my bag to sort of approach these very anxious patients that would find me to get referred from colleagues. Go and see Roy Bennett, you know, we don’t wanna do this sedation case, you know, Roy, you can use short. [Jaz]It’s a great practice builder. [Roy]Absolutely. And we became a referral hub for doing the cases that nobody really wanted to do. So I had to build a very experienced team around me. So it’s not just me, it’s my visiting anesthetist. It’s my sedation nurses that I’ve trained over the years. It’s the receptionist. Everybody in the team is really important. It’s a holistic thing. It’s a whole team that’s important in giving that patient that journey from being very phobic to being accepting the treatment. Okay. So my mission really is to take them off the drugs. It’s not to be a sedation dentist. It might be of the first few appointments, but if I follow the standards, it’s doing the simple way, simple things for patients. So it might be to wean a IV sedation onto inhalation sedation, and then hopefully one day just by talking to them. Okay, so that’s the mission. It’s not always about one tick. Everybody gets IV sedation. That’s not the way to do it. [Jaz]Well said, and I love that. That’s really good. An individualized approach. And I like, a bit like endodontists, they always tell me, oh, preventive endodontics, we want to do pulpotomies. You wanna preserve the pulp, you guys you want to, yeah. Get them off the sedation, which is very admirable and very good. I like that very much. Before we talk about the new drug and then how we can learn more. And actually for those whose interest has been peaked by learning, wanting to learn sedation, which I think is such a great thing to offer. Any other key points that you think GDPs, wet-fingered GDPs out there right now should know about sedation and our patient base and how either something scientific you want to share, or a top tip. [Roy]Okay. So, I would all say that I think any new patient that comes to me, we get a proper sort of prequestionnaire profile, a good assessment, and then decide what anxiety levels they might have. Okay. I think the advancements in sedation will probably be on the monitoring. So for me, for the last 10 years, I’ve sort of always looked at those advances and most of sedation now we use a pulse oximetry. We check the blood, we check the blood pressure. I’ve always wanted a bit more than that. So I have a entitled carbon dioxide monitoring as well, which is five stream monitoring, which is on the nasal. And that can assess the ventilation of a patient because in primary care you’re not in a hospital setting. And it gives you a little bit more confidence of safety. I’m all about safety in the safety aspect of sedation. If I was saying to somebody starting out in IV sedation, like, is that something you really want to do? Cuz it’s not suitable for every practitioner. It depends on your mindset as well. And is it something cuz you will attract certain patients that will be challenging? And difficult, so I think, I’m very like Mike Gow. I look at the whole patient. Is this patient suitable for sedation? Okay. It’s not just a tick box mentality. Okay? So it’s very important to use good language. I think hypnotherapy really helped me in my career, and that’s just using some words and relaxing the patient. And I’ve been on some courses for, just to help with that, to use the right language and speak to psychologists and hypnotherapy because as we know, dentistry is, you know, there very lots of anxious patients out there, about 50% unless of those patients that are gonna need maybe inhalation or IV or oral sedation. So, it’s finding out really going back to basics from what the patient is. [Jaz]What really struck a chord with me there, Roy, is be careful of what kind of patients you would attract and make it a considered thing for you. So I don’t actually advertise directly to patients that I treat TMD I quite like doing that, but if I advertise, I know that my diary would be booked up six miles. I still get people driving hundreds of miles to see me, which is great, you know, very flattering. I’m very happy to help them. I loved this field, but I still want to get rubber dam on. I still want to do my restorative density so I don’t advertise. But if you invest in a skill like sedation and you want to go in to be able to offer that to your patients, then if the word gets out and then you start seeing more challenging cases, then yeah, you have to be kind of prepared for that as well. So I think that’s a excellent point there that I can definitely relate to. Roy, yes, please. [Roy]So I would say, you know, a good mentor once said to me many years ago, you know, if you’re about to sedate a patient, always expect the unexpected, okay? [Jaz]Mm-hmm. [Roy]So it’s like going on stage. You never know what the audience is gonna be like to, so you’ve got to be ready and you’ve gotta have a team of people ready and what’s my plan B? What’s my plan B if the sedation is a failure or I didn’t complete the treatment, what am I gonna do? So you need to think ahead a bit and think about, okay, my plan B is, I’ve got some colleagues that can come and help me who do advanced sedation. So that’s my plan B of plan A, which is the simple plan fails. [Jaz]Mm-hmm. [Roy]So I’m just always one step ahead and I’m thinking, okay, this patient may be challenging. But I’m surprised we get through it with just basic, safe sedation. Everybody’s happy, but I can let you into a statistic. About 4% of my cases end up being sort of a dance sedation where I’m having to use different team members or different drugs or so 96% of the time, we’re following straightforward techniques in most of my career in 34 years. [Jaz]Excellent. I’m thinking of two. I mean, based on our chat now, I really enjoyed this, by the way, Roy, of two qualities. I think then just what I’ve interpreted, this is my artistic interpretation of what you’re saying. Two good qualities that a sedation operator or someone who wants to start doing sedation should have is, A) emotional intelligence or stroke, a good communicator, and B) is leadership skills, Roy, because you gotta be quick to think on your feet and then you’re managing and you’re leading a team and you need to instill confidence in your team when you’re doing this. Any other attributes or anything you wanna add to that? [Roy]So I would say, well, let me tell you a story. A practitioner rang me up a few weeks ago and said, look, I’m interested in starting it in my private practice. I’ve converted to private practice. I really don’t want to refer the patients out. I’ve thought about sedation. I’m not sure whether it’s for me or not. Okay? So I said, okay. So what we’ll do is I will come to the practice, I’ll show you the systems, we’ll do the management, we’ll give you the leadership, but here’s the thing. Why don’t you bring in a dedicated sedationist who you’re comfortable with and you can interview them, that they fit in with your practice and that in your ethos. But why don’t you sit in with those cases and watch the dedicated sedationist do that and then get a feel for it and see if it’s for you. Because all this guy ever had was some just experiences, an undergraduate, you know, he’s only done about 10 cases from over the last 10 years. So, and those cases might been challenging. Why not experience that before you commit a lot of time and energy to a course that what we don’t wanna do, like in dentistry, and I’ve done myself, you’ll go down into a course, you’ll go off left center and you’ll make. I must do that and then end up maybe not using that. [Jaz]I hate that so much, Roy. And what this podcast has become is a constant reminder to implement and therefore be very careful about your next educational move. Do the education. It’s amazing for fulfillment from your career, but have that mindset that you’re gonna go all in. [Roy]Absolutely. So, you need to sort of pace it really. I would get somebody in, is this gonna work in my practice? Is this for me? It’s quite a commitment for a principal to do that. [Jaz]Well said. And that new drug. Before we talk about how we can learn from you, just tell us about that new drug. How new are we talking? Is this something that’s been around in other countries and now just been introduced to UK? Or tell us more about it. [Roy]Okay. Yeah, so, this is a benzodiazepine, very similar to Midazolam that we’ve used over 40 years, but to me it’s a bit of a game changer. So I’m quite excited about this new development. It was patented in about 2020. It’s been authorized in the UK 2021. I’m using this drug now. I’m still using Midazolam, but this drug is called Remimazolam , okay? Not to be confused with anaesthetist drug called Remifentanil. That’s a completely different drug. Okay, so this is Remimazolam. It took me a while to learn to say it. [Jaz]Who comes up with these names. Just pick something more catchy, you know. [Roy]Ah, so the trade name is by Favo, B-Y-F-A-V-O. And so, so why do I think this is useful? Why do I think this drug is useful? Okay, so this, the onset and offset of this drug. So how quickly comes on board and how quickly it wears off much faster than Midazolam. So this enables us to have a quicker induction for the patient. The patient will sedate more quickly, so we’ll then be putting the local in much more quickly. But the thing that we have to watch is that the drug then profile is offset is much quicker. For example, after about eight minutes, for 10 minutes of me giving the last in increment of this drug, the patient will be up and about recovered, walking safe discharge. Okay? Now why is that good? Because in my experience over the years, some cases midazolam, the patients be quite groggy. The discharge has taken a while. We’ve had to book a full hour. To make sure that the patient recovers well. So we might have finished a straightforward extraction phase that took me 10 minutes, but we’ve had to make sure with the drug profile that the patient was safe to leave for an hour. So with this drug, I can, if it’s straightforward procedure, I can be done and I can be inducted, treated, and finished within, say, 30 minutes. [Jaz]Mm-hmm. [Roy]And as safe patients leaving the premises in a safe way. Okay. They still need an escort. Still need a chaperone. I, like I term it as a soft drug, a clean drug. Its profile to me is really exciting because compared to, say, Midazolam have the occasional patient who will have a aggressive, idiosyncratic odd reaction to Midazolam, and I’m sure people out there may have had that in their careers. We don’t tend to get that through this drug. It seems to be metabolized slightly differently. And also with obese patients who are overweight and sleep apnea, they worry me when we have to do sedation. So this will seem to get better outcomes with. So all in all, I’m about safety, so I like the safety aspects of this drug. I like the pharmacology of this drug, so it’s gonna be in my repertoire. Definitely. Yeah. [Jaz]Is this the future of sedation? [Roy]I think it is going to be one of the mainstays. I don’t think Midazolam is going to disappear. I don’t think some of the anesthetic drugs gonna disappear like propofol. That’s all gonna be there, but isn’t it nice? For a dentist to be able to go, ah, well for this case we’re gonna choose. We’re gonna use that because we know it’s safer. We’ve got an elderly patient in, we don’t want it to be confused at the end of the sedation. Cause that’s quite frightening for them. Whereas with this drug within eight minutes, 10 minutes, it’s like clearheaded recovery. Good discharge. So I think it certainly, I wish I’d have had it 25 years ago, I think. [Jaz]Well, it sounds very promising. Roy, thank you so much for this really educational episode. Please tell us, for those who, who may be interested in learning more, who are implementing sedation into their practice, you’ve been doing teaching for years, how can we learn from you, which association are you attached to? How can we find out more? [Roy]Okay, so I’m attached with the two associations. One is my own web training site, which is mellowdental.co.uk and you can find me on there. But I’m also a senior clinical advisor to UK Sedation and we’re doing webinars and presentations. So be on to uksedation.com, and we’ll be presenting at the Royal Society of Medicine on the 15th of February. Next on the new drug that we just talked about so you can come and learn about that and be excited about that. [Jaz]Please send me the links, Roy, and I can put them in the show notes so people can jump on to learn more. And guys, even if you don’t, even if you decide it’s not for you, but someone in the practice may benefit, please send them this episode. But equally, I’m sure you gained something of value in terms of maybe you had this misconception about sedation or one of those myths that we busted. So I, it certainly helped me, Roy, I love your clear, calm communication style. Thank you so much. [Roy]Thank you. And thank you for inviting me. Jaz’s Outro:Well, there we have it, guys. Thank you so much for listening all the way to the end because you have listened and watched. If you’re on the app, you get 45 minutes or 0.75 hours of CPD credit. So now that you’ve got this far, why not answer a few simple questions to validate your learning, to ingrain your learning, but also to get a certificate that my team will send that to you. And that’s on the app. If you haven’t already downloaded the app, it’s on iOS and Android. It’s a free app. If you wanna rinse it for all the free stuff on there, go for it. Be my guest. But if you wanna gain CPD and get exclusive content, become a Protrusive Premium member, I would love to have you as part my community. Otherwise, you know how much I love connecting with you guys on Instagram. So if you have any ideas for episode, or you just wanna share some love? It’s @protrusivedentaland I look forward to hearing from you. I’ll catch you same time, same place next week.

I think self development and emotional intelligence is foundational to our relationships with others. It’s how we interact with our patients, significant others, children and family members. Investing in your personal development makes you a better communicator. That’s why you should listen to Dr. Agi Keramidas in this episode! We discussed how to begin your self-development journey and what are the important areas for dentists to focus on. We hope you’ll apply just ONE THING whether it’s a book title that we recommend or implement one tip to better yourself or your interactions. https://www.youtube.com/watch?v=HzItyEV3x_c Check out the Video for Free on YouTube Need to Read it? Check out the Full Episode Transcript below! Highlights of the episode: 4:58 Dr. Agi Keramidas’ Introduction 10:57 Getting started with self-development 14:05 Important areas to develop for Dentists 21:04 Dr. Agi’s communication style 30:03 Roadmap to self-development 35:13 Practical tip for self-development Check out these books recommended by Dr. Agi Keramidas How to Win Friends & Influence People by Dale Carnegie Rich Dad Poor Dad by Robert Kiyosaki The Biology of Belief by Dr. Bruce Lipton The Daily Stoic by Ryan Holiday and Stephen Hanselman Check out Dr. Agi Keramidas’ podcast: Personal Development Mastery for more personal development episodes Website: agikeramidas.com Podcast: personaldevelopmentmasterypodcast.com If you loved this episode, you will like 12 Rules for Dentistry Click below for full episode transcript: Jaz's Introduction: One of the most common questions I get to the podcast is, WHICH SCANNER SHOULD I BUY? 'Hey, Jaz, I'm starting to make this venture into digital dentistry.' And it's overwhelming, right? Jaz’s Introduction:There’s so much out there in terms of different types of scanners, different requirements, so which is the best scanner? Which is the most appropriate scanner for your clinic and your requirements? Well, that’s exactly what we’re covering today with Dr. Gulshan Murgai. If you haven’t listened already to IC027, it was his story that we covered and it’s titled, ‘He got Sued and he won.’ So essentially, it’s his entire legal case how it led to that. And we learned so many different medical legal lessons and it was just great to hear about his triumph. So, if you haven’t listened to that, please do listen to that. But if you’ve clicked on, because of the title of digital dentistry in which scanner to buy, there’s so much meat in here because Gulshan has tested and tried all these scanners, and now he’s gonna summarize for you which scanner he thinks is the best and why that might change depending on your needs and the needs of your practice. Now, Gulshan doesn’t keep it a secret or hide it or anything. He has got some financial interest in a digital scanning company. But I still think there’s so much of meat in terms of gaining the knowledge to know what are the differences in the different scanners and how you can choose which scanner to invest in. Let’s join Dr. Gulshan. I’ll catch you in the outro. Main Episode:Dr. Gulshan Murgai, after that really enlightening episode about how you triumphantly won the case and so many lessons shared. Welcome back to the Protrusive Dental Podcast. This group function today is to answer one burning question, and I’ve seen you lectured before. I know you’re super passionate about digital dentistry. For those people who haven’t listened to that episode yet, just introduce yourself again and why you are so involved with digital dentistry why you are so passionate about digital dentistry. [Gulshan]So, my name’s Gulshan Murgai. I’m a practitioner, general practitioner practice in Watford, Northamptonshire. So, I’m basically got exposed to digital dentistry as an undergraduate. So year 2000’s thanks to Professor Burke at University of Birmingham. He brought in the guys that were selling Cerec at the time. Sirona and I saw it as a final year undergraduate and I was blown away. I was like, oh my God, I need to have this. And he knew how it affected me so much so that in my finals, one of my finals case presentations, Prof Burke, was actually the one who was examining me, and he asked me a question, that the answer was digital dentistry. But I was so bloody nervous, I actually couldn’t get it out. And it was the difference between the highest mark and one down. But anyway, so having found that out, I thought, you know what? I’m going to carry on with this digital dentistry stuff. Imagine then I go through VT. During VT, I then see that Cerec has now become Cerec 3d. So, I was at a trade show at Excel or Birmingham, whatever, and I saw it and I was like, you know what? I need that, I want that. And that’s what I did. So, age 27, 2003. So 18, 19 months after graduatuion. I ordered my first Cerec system, and that’s what I talk about in some of my lectures. [Jaz]And what generation of Cerec do you have now? Before I ask you the big question, tell us about your kit. What kind of kit do you have in your practice at the moment? [Gulshan]Lots because what people need to know is that I am biased. Okay. I’m one of the few that actually highlights the fact that I’m biased because loads of us are, okay. Don’t forget, I’m a practitioner, so I have my clinical biases, but I’m a lab owner, so you know, I see a lot of work from a lot of people. All around the country that comes to our lab. And thirdly, I own a supply company, right? So, I sell stuff, yeah. And the difference between our supply company and others is that every single thing that we sell, we use in our other businesses, right? So as a result, so we are not what’s called a box mover. We don’t just sell something for the sake of things. We’re a specialist kind of niche company. It’s called Implant Solutions Direct. And the solutions part, that’s the important. Is that we found holes in the digital market years ago as we were kind of going through it, and I wanted to find solutions for implant dentists and solutions for restorative dentist to make things easy. So, the answer to your question’s not easy, but what I do use now is open systems that all talk nicely to each other. I n order to allow me to do my chosen workflow efficiently and profitably. [Jaz]Well, I guess when I get come to ask you which is your favorite system? You know, it’s the one that you’ll be using anyway, so it makes sense. And so, just to give those listening, watching a little bit about my background. I first got exposed to digital dentistry about four or five years ago. It was a TRIOS 3. I really enjoyed using it. Then when I was working in Richmond, I had the iTero and then we had the new iTero so I’ve used iTero and TRIOS. I have seen Cerec In Action, great bit of kit, the blue cam, which is the older one. Ah, I tried it. I found it really complicated to do, but again, I didn’t go any courses, so I should have you know, actually done the due diligence to learn, but I didn’t. But where I am now is we use iTero in the practice because we use Invisalign. So, when someone asks me, Gulshan, ‘Jaz, which scanner should I get?’ I’m like, I don’t know. Ask someone who knows what they’re doing, like Gulshan. But then I say, but for me, we use iTero because we use in invisalign and you can’t use other systems unless you’ve got a TRIOS 3 in the US I don’t know if you can or not, but in the UK, you may still be able to. So, we use iTero for that reason. But if you want to ask you that question now, which is the scanner, so imagine someone’s entering the world of digital dentistry because people speak very highly about the prime scan and how precise it is. People who got TRIOS very speak very fondly of that. There’s many iTero lovers. Which ones should we get? Now, by the way, I’ve seen the Medit being demoed by Neil as well and that’s a lovely bit of kit, lots of different softwares, so it’s too much choice out there. Which one should people opt for? [Gulshan]Yeah, so like I said, I’m biased. Okay, so big bias, I sell Medit, I’m global key opinion leader for them. So obviously I’m going to promote it. However, I’m a practitioner first and foremost, right? I make the larger majority of my income is doing clinical dentistry every week, right? So, despite what people may think, you know, that’s where my income comes from. So, my history, as I said, started with Cerec because we gotta pay tribute to the fact that they’re the guys that kicked it all off. You know, massive innovators at Sirona came up with this technology many years ago in 1985, right? So they started off, that’s where I started my history. But what have I used over the years? I’ve owned and used Carestream scanners. I had a iTero here up until recently. Obviously, I’ve got all of the range of medic scanners now, but we’ll come back to that. But apart from that, I’ve used TRIOS I’ve used some of the Chinese scanners because I’m involved in exhibitions and trade and things like that. People hand me scanners and say, here, try this. But also, at trade shows I get asked to compare. So, I’ve lost count of how many different scanners I’ve tried over probably the last three or four years, because now things are really growing. But given that exposure that I’ve had, I still choose Medit every time. It doesn’t matter tomorrow if I no longer work for them and no longer sell their products, I would still choose to purchase- [Jaz]But that’s why you’ve chose to work with Medit, but that’s why you’ve chose to stop Medit and work with it because, you know, you’ve done your research and whatnot and you liked that one, and that’s why you went with that. But, you know, I want firstly, extract from you what makes the Medit so stand out and what are the features of it. But then also, I mean, the other question we need to respect is, it’s a bit like buying a car. If you say, which car should I get? It depends, well, depends what you want from your car, right? And then it depends on the needs of the practitioner. So please tell us about the Medit, why you feel that is the best scanner on the market today. And then also what kind of practitioner should be getting the Medit and perhaps, someone like me who’s has an interest in Invisalign and therefore would I have to get iTero, therefore, and then give a miss on it? How does that work as well? So you can come until later please. [Gulshan]So, let’s deal with the Invisalign thing first, right? I am originally an Invisalign provider from 2005, so I wasn’t just in the early adopting digital implant dentistry, 2005. Okay. That’s a long time ago. Back when it was just all impressions, right. And I’m actually still pretty good at taking impressions, right? But scanners are the way forward. So I’ve got nothing against Invisalign. I’ve got a bunch of patients who still see me all of these years along who’ve got great long-lasting Invisalign results. But like people say on tv, there’s other products out there that do the same. Likewise with scanners, right? Whilst I’m promoting Medit scanners and I know it is all that anyone needs unless, they’re wanting to do Invisalign, and we’ll come back to that. You know, prime scan’s a great scanner. So is TRIOS. So is Carestream, right? At a certain level, Jaz, they all work really well. But here’s the big caveat. You already highlighted it when you said that you had trouble using the blue cap, right? That’s where I came in. So where I bought Cerec 2003. From 2006 to 2010, I was one of the primary UK trainers for all new users for Cerec, right? It was my responsibility to go around the country on behalf of Sirona, right? There were other researchers where I was working for Sirona, and I would go out there and I wouldn’t leave that practice or that practitioner until I felt that they were competent and confident in using it. Right? And they were paying for that service. And that’s what I do now as well, is that I don’t just sell products, but I don’t leave people alone until I know that they’re competent in its use. And that’s what’s different about us as a company, but also like with anything else in a practical vocation. Right. At uni, we were all tested in non-clinical, like phantom head situations before we were let lose on patients. The sad thing is that nowadays, if you’ve got the money, you can go out and buy whatever you like, but no one tests whether or not you’re competent at using that. You then say lots of negative things about it, but you don’t put in the caveat that, oh, by the way, I didn’t purchase any training and I didn’t go for any support because my ego is this big. Then you won’t have much positive things to say. [Jaz]It’s like buying a laser. You can buy a laser, but if no one’s ever shown you how to lose, use it, then you might think this is rubbish. And- [Gulshan]That’s exactly what happened to me when I bought my first laser. Actually, I didn’t use it for the first 14 months. Because the people that I bought it from didn’t have anyone to train you on it. Quite happily to take your money though. Right. And you’ll see this on social media as well, when I go up against a few other people out there and say, well actually we do things a bit differently in that I’ve been responsible for training people that are bought their hardware from other people and they’ve hadn’t had adequate training support. So that’s where I come in. That’s why Medit choose to work with me. That’s why exocad and other digital companies choose to work with me because I’ve got the clinical experience. I work in my own lab as well. So I’ve got the technical experience and that’s why they came to me and said, ‘We want you to sell our product.’ Right? And I said, ‘Uh-uh, not until I’ve tried it.’ So I tried the Medit alongside the Carestream and the Cerec for a period of time before I thought, you know what? This just does everything I need. I don’t need the others now. So that’s the first answer to your question. It does everything I need – [Jaz]In case anyone missed it, cuz you mentioned it there, there are other aligner systems available, so I know that spark are becoming very popular. We know SureSmile, et cetera. And those other ones I’ve mentioned, they are open source, so they will accept Medit scans and Carestream. So there’s a huge shift happening now. I think finally we have some competitors for Invisalign, it’s fair to say. [Gulshan]Well, exactly, you’ve hit the nail on the head. So what’s happening in the clear aligner market right now? The big boys Invisalign are starting to lose market share in the same way that, as we’ve mentioned now several times, Cerec used to have massive market share in digital dentistry as a whole. Right? And now you know their product on the market is Prime Scan. Right? And Primemill. So it is just the new name for what was Cerec. Right? And so yeah, there’s loads of systems are out there that work and really, you’ve gotta decide what works for you. Some people in this profession and others like to have their handheld, okay? They want closed systems where they know that there’s few mistakes to make, so they go down that route. Okay? Other people and I deal with a lot of dentists nationwide, worldwide. They like to be open and they like to basically do what works for them. They like to take things apart. You know how many dentists that are super nerds that’ll buy some technology, expensive technology, and when no one’s looking, they’ll try and take it apart. Right? They do that. They’ll throw that with software, they’ll do it with hardware, and I’m one of those, right. That’s why I became a Cerec trainer because I worked out how to break Cerec, right? And only you see, I had no UK based training either. I was on my own. That’s why we run this company in our education the way we do, cuz I don’t want anyone to feel the way I did at age 27, 28. I spent 62 grand on this system, right? My dad went crazy, right? Because I just bought the practice. I just bought a car, just bought a house, and then I bought Cerec, right? Imagine that’s why I was working six days a week, right? But I wouldn’t change it for the world, right? The point is, I had no one to rely on. I didn’t have someone I could pick up the phone and say, I’ve got a patient in the check. Can you help me with this? And if I could, there was a language barrier, German English, right? So I had a once a month call with them and basically it turned out after a few weeks, me telling them how I worked out how to break the system and I was teaching them about their hardware and software that’s why three years later, I was their train. So going back to Medit and new scan as a modern scanners. Now, don’t get me wrong, they all work. Like I said, first you’ve gotta choose closed system open system. Invisalign, iTero, kind of let’s say closed system, you’ve gotta follow their pathway. Other clear aligner systems are more open. You know, you don’t even need to use a branded system. What I say as a lab owner, please support your UK-based labs, right? Who can do the same thing for you. Build relationships with people in your country where you are working. And deliver that to your patients. That’s what I try to do. Right. So likewise with the scanners, I’ve chosen to work with a scanner company that’s massively innovative. The Koreans are like me in my company, Implant Solutions. They basically go to clinicians and technicians cuz they’re big in the lab site as well, and they say, feed us your problems. Tell us what you would like. And look at the support groups. Look at the medic support groups. You asked for something six, well, not even six months, three, four months later, it’s in the new software, right? So they really do listen and respond to their users. That’s one really massive thing. Openly, right? They take criticism on the chin. We’ve just spent an hour talking about risk management and saying sorry, and putting your hands up when things go wrong. Likewise, when, you know, Medit has been criticized in the past for various things in their hardware and software, you know what? They put their hands up publicly and say, ‘Sorry, our bad, let’s talk about this. Let’s work it out.’ You know, and that’s a big deal for a multinational, multi-billion dollar company to put their hands up and do that. The others don’t. Their egos are just too big. They don’t do it. So I like that because I thought that works for me cuz that’s more like me. [Jaz]It’s an example of a big company thinking like a small company. [Gulshan]Absolutely. [Jaz]All right. And that’s what makes it very endearing. And that’s what makes it the support network that it is. [Gulshan]Yeah, well, I’ve met all of the senior management, they all know me. I’ve met the CEO, and when you spend time with these people and you realize that it’s not about the bottom line all of the time, it’s actually a lot of it’s about how they make people feel and the solutions they’re providing, and that just works for me. Previously, I worked with, like I said, Sirona with Carestream. I’ve worked with the guys at iTero because of my connections through exocad and things like that. So, you know, they’re all good people. But you asked me why I chose this because emotionally, they’re brilliant support wise. There’s no one that can touch them. The hardware, they’ve got innovative technology in the hardware that nobody else has got. And then on top of that, look at what they do in terms of software, apps that are free to use, free to download. [Jaz]I’ve seen the software, they’ve got the Medit splint one that’s recently released and they’ve got so many others too, so what I’ve used before Gulshan is that one of my delegates on my, I teach splints and stuff and they had a patient who suggested that their bite had changed due to over eruption from wearing an NTI, SCi, et cetera. So I was able to overlay the two previous scan before the over eruption and after, and found that actually the teeth are matching up perfectly is the joint level change that’s happened. You see, so I use that actually on the software. So the crazy thing is you don’t even need to have a Medit to use that software. [Gulshan]Exactly. [Jaz]Which I thought, like, why are they giving this away for free? [Gulshan]Exactly. [Jaz]So I respect that a lot which is pretty cool. Now I’m sure a common question you get is about money, about costs. So in terms of a hierarchy I’m fairly sure that Prime Scan is like number one in terms of the most costly is that fair to say? [Gulshan]No, there’s some pretty expensive criteria models out there as well. [Jaz]Okay. [Gulshan]You gotta remember Jaz, that the Prime scan system right, is the replacement for Cerec. So really that system is designed to be a closed system where you have their acquisition unit and their mill, right? What they realized some years ago was, we are losing market share here. Right? So then they thought, okay, we better separate these and give people the option to just buy the scanner. Right? Which is where there’s Prime scan, right? And that’s why the name has changed. That’s why it’s no longer Cerec, right? Cerec gives you that thought that it’s a whole system. So yeah, prime scans are not exactly cheap, but remember they’re innovators. You know? There’s always gonna be people out there who think that if it’s expensive, it must be good. And that’s why, you know, Bentley Rolls Royce still sell their products, but yeah, you know, there’s some expensive criterias. If you want, I can sell you an expensive Medit, you know? [Jaz]And with iTero, just so, because we’re very straight talking. I think you might give a good answer here, is the whole caries detection bs or something pretty cool? [Gulshan]Okay, you’ve gotta understand my position here, guys. I work for exocad as well. Exocad’s parent company is a line tech, and Line Tech owns Invisalign, exocad iTero, and you know, they might even own Medit soon. So I’m not gonna publicly say anything against these. It works. I had it here. Right. [Jaz]Yeah. [Gulshan]What I can say, and I’ll say, and I’ve said it to everyone openly, is that, right there behind me on my dental chair, I’ve got a caries detection device in my camera, right? It’s this big, it’s very light. It’s on my chair. I can use it in a second. I can switch it on, right? I don’t have to have this big trolley or anything next to me, and I certainly didn’t pay a massive premium for it. Okay? What they’ve done is they’ve bundled a lot of technology into there, and that costs money, right? Because that’s, you know, they’ve created convenience. In the same way that Medit have done the same in some of their higher end scanners, there are more features in there that you’ve gotta pay for compared to some of the more budget scanners, right? It’s one of those things, Jaz, that you pay your money, take your choice. Not just in scanners, but also software. We talked about cars. It’s all so the same between Android and iPhone, right? It’s BMW and Mercedes. But just with scanners, there’s quite a few out there, just like there are with phones and cars. . So I think there’s more to it than that. You have to first beat to people and say, what do I want to achieve out of this? Right? So there’s some people in their particular point in their career where this is what they do and this is all they’re gonna do until they finish. There’s other people who say, well, like for instance, you touched on implants. If you are gonna do more implant dentistry later on, you wanna keep that channel open, right? If you are not doing clear aligners, but you want to, you know, go down there in the future, that’s an option. If you are an associate that works in four different practices and you need a system that’s mobile, right? So I need to, as a reseller, I need to listen to what you need, and then I can say, is this, or this option? And here’s the pros and cons on all of them, right? And you decide. Right. [Jaz]So it’s a fair summary Gulshan, if you don’t mind paraphrasing whatnot, is that all these systems are good, they’ll get you from A to B. A closed system. An example of closed system is iTero and therefore that has some limitations, but it’s a good scanner still. Nonetheless, if you want something that’s a open system and something that from you who’s tried all these softwares and scanners, you’ve really enjoyed using the Medit and that’s something that you speak very fondly of, but ultimately have that conversation with someone to find out what your needs and wants are to really match up, which is the best ideals scanner for you as an individual practitioner. [Gulshan]You’ve got it. Absolutely. What I will say is, this is, I mentioned the term earlier, which is called box movers. Right? Box movers are suppliers who, they don’t care what they sell as long as they sell something. I think you’ve understood me a little bit more since we’ve been talking today. I’m passionate about what I do and also what I sell. So I’m far from a box mover. I sell a particular software, particular hardware, because I’ve tried and tested it, right? I can show people how to get the best out of all of those things. Now, there are some great reps out there from great companies who might also say, but I can show you this, and this. So just be careful of people’s biases. You don’t have to buy for me or the next guy. You pay your money, you take your choice. For me, it’s about building relationships and for me, I easily build relationships with other dentists because I can relate. I’m still practicing it pretty much every day. Right? So that’s where our company’s different from others in literally I put it into practice every day. I have used iTero. It’s a good system, right? We shouldn’t say it’s closed. It’s partly closed, right? It’s a little bit- [Jaz]Because you can export STLs and stuff, but it’s just that- [Gulshan]Exactly. Okay. So, you know, there’s other systems that are more closed. So if you listen to my colleague, David Claridge, he had a word that he created some years ago is called Tropen, T-R-O-P-E-N. Truly open. And this is a thing. So, there’s tropen and then there’s fully closed, which is flosed. Okay. Which is something I came up with just to go against him. But, you know, find someone who’s passionate as you are about the kind of work that you want to do, and then sit down and talk about it. And if you do that, you’ll make the right decisions. [Jaz]That’s a great way to end it. And I think I just wanna add in there that from being involved as an associate, in practices where the principal was at that time, you know, making that, buying the first scanner. So I’ve been involved that, you know, two, three times where the principal was about to buy the first scanner actually three times, four times that’s happened to me. Oh my goodness! You know, whilst I haven’t been the key decision maker, they asked for my opinion, and I’ve seen what happens in the first few weeks after they buy a scanner. A lot of hand holding and support is needed. So if anything, my 2 cents is find someone who will support you. That could be a big company, that could be a small company, could be whoever. But as long as that support is guaranteed and someone who can ideally, I mean, I like the fact they’re a clinician and then, you know, if you support and then having that extra sort of nuances of you know, you did a whole lecture, on capturing sub ging ival margin and stuff. You talk about that. So yeah, so the, we should probably do another episode on that. By the way so, Gulshan, I really appreciate and now please tell us about your company cuz you’re obviously, you’re doing great things in Digital Dentistry now we can tell about your groups as well. You know, you run the exocad and stuff. So those who are interested in Digital Dentistry and learning and getting supported would love to know about that. [Gulshan]So our company, our supply company is called Implant Solutions Direct. Our other name is ISD Digital. Obviously, implant solutions are digital because actually our biggest customers globally, because we actually export globally are labs. Okay. Around the UK I supply around about 105, 106labs. So we’ve got a big relationship with them. We are going more and more into the clinical side with our scanners and our software, hence ISD Digital. We have our sister company, which is a full production crown and bridge lab that’s called 4D Ceramics. I’m intricately involved with that. I have staff, but also we do a lot of implant-based staff, guides, things like that. As far as where you can find information, follow me on Facebook and then you’ll get access to my pages. So I’ve got Medit worldwide, I’ve got Exocad Worldwide, and the group called Intraoral Scanners iOS, that’s also my management. I manage that group as well. So, about 10,000, 12,000 people all in across those groups. [Jaz]And different levels. Welcome beginners experience, that kind of stuff. [Gulshan]Oh, absolutely. And what I try to do Jaz, is try and get my users and other people to share their cases, right? Because of various politics involved. I don’t get to share all of my cases everywhere that I want to because people just believe that all I’m trying to do is sell something. So that’s why I said in the last podcast that we just recorded about the case, that I was pleased that it was allowed to go out on various groups because it wasn’t about me, it was about the system and how I kind of beat the system, right? It was nothing to do with me. And likewise, when I’m sharing clinical cases, I don’t just share the good ones, I share some of the bad ones too. [Jaz]Super important. And we should always appreciate that in education, to learn from other failures and those who are open enough to share the failures. So, amazing. It doesn’t surprise me at all, Gulshan. Thanks so much for giving your time and for both those episodes. So guys, if you know, hopefully it’s giving you a bit more ideas about scanners, what your individual requirements are and the importance of planning for support once you get it. Cuz the first few weeks are very frantic and it’s a bit like the laser. You know, sometimes what happens, You know what, I’ll just take an impression today and the scanner just sits there and I know it’s happened to my colleagues before. So, go all in. Commit and make sure you are well supported. Gulshan, thanks so much my friend. [Gulshan]Thank you. Great for the opportunity. Thanks Jaz! Jaz’s Outro:Thank you. Well, there we have it guys. Thanks for listening all the way to the end. It’s not just about the piece of machinery, it’s about the support that comes afterwards. It depends on how it sits in your practice. In terms of what will you be using it for? Personally, I have really come to embrace digital dentistry. I first started out with the TRIOS, then now iTero just cuz the circumstances of practice and my vertical preparations are scanned 99%. I very rarely use impressions just for some denture work. I’m using impressions. Otherwise, I’m pretty much digital and I think it’s great. I think this is the future. The future is here. And so, if you’re not embracing digital yet, does it really matter to me which scanner you get? No. I think for me it’s important that you actually start thinking about how to take the first steps into digital. And so, there’s lots of great people out there like Gulshan who can guide you, but it’s something that once you get into digital, you look back and you think, how did I ever not do scanning? How did I stay in analog so long? Now we know that analog has its advantage and it’s great, but now might be the time if you’re not already digital, to consider making that move. And I hope this episode gave you some information in terms of what are the different scanners out there and what are their strengths. Thank you so much for listening, and I’ll catch you same time, same place next week.

Biomimetic Dentistry is the use of Restorative techniques and materials to mimic (and preserve) the structure and function of natural teeth. Dr. Taylor Paton will discuss his journey in Biomimetic Dentistry: how it differs from Adhesive dentistry and how it can be used to develop innovative treatment strategies for patients. In this episode we also discussed philosophies and guidelines following the literature for optimal bond strengths, so that your clinical protocols may benefit from Biomimetic principles. https://youtu.be/UFTwT86Urs8 Check out the full Video The Protrusive Dental Pearl: How to block out a metal post. Use something like ‘Ivoclar Direct Opaque flowable resin’, a masking agent that is highly opaque. Paint it on the dark tooth substrate or cover metal (eg a cast post) with it. Other brands include Pink Opaque by Cosmedent Inc Premium users on the App can download Premium Notes by PDF and PDF Transcript. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 2:52 The Protrusive Dental Pearl 7:15 Biomimetic Dentistry  13:17 Dr. Taylor’s journey to Biomimetic Dentistry 21:48 The Hybrid Layer  24:11 Improving Bond Strengths  26:58 How Decoupling with time works  31:41 Immediate dentin sealing concept  36:19 Caries Detector dye  42:58 Biomimetic Philosophy regarding crack management  Check out Dr. Pav Khaira’s Academy of Implant Excellence which would give you a comprehensive course encompassing A-Z of implantology If you like this episode, you’ll also like Composite Veneers vs Edge Bonding – Biomimetic Dentistry with George The Dentist  Click below for full episode transcript: Jaz's Introduction: What actually is Biomimetic dentistry? I think in the last few years it's become like a buzzword in clinical dentistry. Is it the same as adhesive dentistry? What is this decoupling time or decoupling with time? And how can we follow simple steps to improve our bond strengths? Jaz’s Introduction:Because essentially, from my understanding of BIOMIMETIC DENTISTRY, it is like EXTREME BONDING. Basically, it’s extreme adhesive bonding and using a set of philosophies and guidelines following the literature to get the best bond strengths possible. Today I’ve got on Dr. Taylor Paton, and I love him because he’s a young dentist, like he’s super young, and I respect that a lot because he’s got something to share. He’s got fantastic online resource, all about his passion and his learning and his journey with Biomimetic dentistry. And sometimes what happens in education is that the grand master, the king of any discipline within dentistry, they are so far removed from the plight and the struggles of that learner that sometimes they may not be the best person anymore to introduce someone to that topic. So, I think Taylor, what he presents today is a young Scottish dentist and I just love his energy and his knowledge. You know how much I love geeky dentists, and so therefore I’ve got him to talk about Biomimetic dentistry, answering my questions from the lens of a young dentist who’s just very well read up and very keen in this field, and that way he’s also learning and therefore, as us, we are all learning together with him. I think this episode is more impactful as an introduction to Biomimetic Dentistry than if I got on an established superstar that’s already well known. So, Taylor, keep up the good work, my friend. Hello, Protruserati. I’m Jaz Gulati and welcome back to the Protrusive Dental Podcast. If you’re listening to this, I love you. Thank you so much. If you’re watching this, then you can see the hoodie that I’m wearing. Oh, my goodness! Dr. Nekky Jamal, the dentist who made the Third Molars Online course. The course I always rave on about as the course to learn wisdom tooth surgery wherever you are around the world, because it’s online. It really helped me start tackling cases. He has this fantastic merchandise. This hoodie has got a photo of Drake wearing a mask and wearing loops. It just looks brilliant. So, thank you Nekky, for sending it all the way from Canada I absolutely love it. In fact, I’m lecturing tonight at local BDA Kingston branch. I’m talking about HOW TO STOP YOUR COMPOSITE VENEERS FROM CHIPPING, and I’m gonna be wearing this hoodie tonight, so I’m doing something quite brave. A borderline unprofessional. Is it? I don’t know, maybe it’s just a new thing now, and we can be a little bit, I don’t know if it’s unprofessional. I think my heart’s in the right place here, but this is representing the future of education. So, if you are listening, watching, and you are wanting to learn more about WISDOM TOOTH EXTRACTIONS and see videos of surgeries to guide you in your own practice, there’s only one course in the world to checkout. That’s Nekky Jamal’s Third Molars Online. It’s on thirdmolarsonline.com, and if you use Protrusive at checkout, you guessed it, you get a 15% off. So, that’s once again that’s third molars online.com. Use Protrusive for 15% off. And trust me, you will not regret it. It is a fantastic resource for anyone who wants to do third molars in practice. [Protrusive Dental Pearl]The Protrusive Dental Pearl I have for you is HOW TO BLOCK OUT A METAL POST. So, imagine you take off an old crown and you find an ugly metal post inside, and now you want to place your future crown. And maybe you don’t want to use PFM, maybe you don’t want to use porcelain fused to metal maybe you want to use a ceramic for whatever reason. And therefore, sometimes to mask that metal sub-structure can be very difficult. It can have shine through. It can look very ugly. So, what you can do is you can use something like Ivoclar Direct Opaque. It’s like this flowable resin, which is a masking agent. It’s there, it’s extremely opaque. It’s like Tipp-Ex for teeth. And essentially you put your air abrasion adhesive and you paint this on. And like for those of you watching, you paint it on the tooth, you cover the post with it, or you cover the metal with it. And it can also be used for really dark cavities. Like sometimes you remove an old amalgam and it leaves a really dark base. And if you go ahead and restore with your usual body shade composite, it’ll look really gray, it’ll look really ugly. So, if you put a base of opaque resin, it doesn’t have to be Ivoclar could be any brand, and a Cosmedent do a very popular one, pink opaque, anything too opaque to block it out, whether that’s the metal post or that’s the base of a dark cavity. Using an opaque like this can really bring your restoration to life, or it can prevent that shine through. So top tip for today is to consider, it’s one of those things that it’s good to have in your armamentarium. A syringe of a masking resin. This episode is sponsored by the Academy of Implant Excellence, and they have a flagship course by that man himself, Dr. Pav Khaira, let’s hear a few words from him. [Pav]There’s no secret to success. There’s a system to success, and I’ve developed a three-step training program. If you want to start your implant career or if you’ve already started and you want to accelerate it. Knowledge clarity, knowledge depth and building muscle memory so it becomes second nature to you. I’ve taken all of my years of experience everything that I’ve learned from my MClinDent and all of the courses that I’ve attended and condensed it into the Academy of Implant Excellence course. If you want to know more, head to the website page. And you can learn everything that I’m going to be including in that course. I am so excited! It is going to be absolutely phenomenal, and I am ready to give you guys my knowledge. [Jaz]That was indeed Dr. Pav Khaira from the Dental Implant Podcast. Do check it out if you haven’t already, and if that interests you, do check out his website, academyofimplantexcellence.com. That’s academyofimplantexcellence.com and of course, you can check it out in the show notes. That’s all for me and I’ll catch you in the outro. Let’s listen to Dr. Taylor Paton now. [Main Episode]Taylor Paton, welcome to the Protrusive Dental Podcast. How are you, my friend? [Taylor]Oh, very good. Thanks Jaz, and thanks so much for having me. I’m saying that, it’s very, very, very surreal. So, I think you’ve been the soundtrack to my very long commute to VT this year. So it’s been, yeah, I feel like I’ve been listening to you in my ear every car journey, so it’s crazy to be actually talking to, so thanks very much for having me. [Jaz]Absolutely. An honor to have you on, you are a Protruserati as we connected on Instagram. And then I remember, do you remember when we first like, we’re messaging on Instagram and I was really liking your page, the hybrid layer. And so I’ll be sure to put everything in the show notes for everyone to click on and find you. But then you had this like, and it’s very normal. It’s good to have this, you had this little imposter syndrome, he said, ‘Ah, but I’m only in like a DF1.’ So, guys, Taylor’s in Glasgow. He’s at the end of his DF1 but I’ve haven’t seen such beautiful commitment from someone such a young dentist before. And I said, ‘Look, you need to come to the show. We’ll talk about your journey. I also want to learn from you about Biomimetic dentistry.’ And then you probably had some imposter syndrome. And did you have that firstly? [Taylor]Oh, definitely. Yeah. And I think you were, I was actually listening to that the other day actually. I think you were talking to that about one of your other case the other day. And I think it’s definitely, I would agree with yourself that one, it is a good thing as well. Definitely in terms of Biomimetic dentistry, because it’s definitely not the sort of thing that I know we’re obviously doing this podcast, but not the sort of thing that you listen to one podcast then you’re suddenly an expert and know what you’re doing. Even at my stage, I still feel there’s so many parts of it. I’m using some of the basic principles and that sort of thing, but there’s so much of it that I’m still not completely comfortable with, even though I’ve kind of made the website and that sort of thing. I think it is good to have a bit of that. [Jaz]I think the main reason I wanted to do one, like to tell I could have had someone who’s got 25 years experience. But I think the beauty of now and again, having different levels of experience, so you’ve only had like one year experience in clinical practice, but from your website, from your Instagram page, your dedication, your hunger is so evident, and I want to extract that and share that. And sometimes, when you speak to someone who’s really super experienced, they forget the struggles that they had earlier on. So, you are very much in the midst of the struggles of a very young dentist. And I feel as though some of the audience will be able to connect so well with you and you’ll be able to break it down in a way that, you know, I might have forgot what it was like eight years ago to explain a certain concept. So, I think, I’m really excited to actually speak to you, say about an area of dentistry, which is very much like modal. Like in the last 10 years, Biomimetic dentistry has become like a buzzword. It’s also come under scrutiny by some experienced lecturers. They call it bio-pathetic dentistry. They say that ‘Oh, it’s just a fad name for just a brand of restorative dentistry. So, let’s just start with that, Taylor. Okay. Before we then also, talk about your journey and how you got into it. But essentially, what is Biomimetic Dentistry? [Taylor]Yeah, so I would agree with you that in terms of the label Biomimetic dentistry, it’s quite a vague one, and it can be quite fluffy at times when you see it. So, a lot of people, if you kind of start talking to them about it and they maybe haven’t looked into it too much, the first thing you usually tend to hear is, ‘Oh yeah, that’s just the, is that thing where you do the tabletop prep with the big smooth surface and only trying your best to stick on with your adhesive.’ And I personally think it’s quite about more than that and there’s so many of these kind of Biomimetic type dentists that there’s so much to learn from them. Just in terms of the fundamentals and the basics of just general dentistry as well, I would say, so I would kind of asking about defining it. I would say it’s obviously along the lines of a tease of dentistry, but a tease of dentistry and itself. I think you could see that as; say we’ve got Zirconia Crowns bonding that onto a tooth with a really heavy crown prep. That could be a tease of dentistry. I think Biomimetic dentistry would then be beyond that. Also, then just kind of respecting how the natural tooths build up and how the kind of natural tooth functions. So, it’s made of enamel and dentin, which are, you know, they’ve got very specific properties. And I think it can be quite- [Jaz]Would you say Biomimetic dentistry is a philosophy? [Taylor]I would say it would probably be just respecting that. We’re trying to build a tooth up the way that kind of nature intended. So, I suppose the word Biomimetic would be to mimic life. So, I think especially early in your career, like myself, I think it could be quite easy to maybe looking at like how to do crown preps and that sort of stuff. You’re looking at materials, what materials should I use, whether it’s eMax Zirconia, quite easy to think or which material then’s the hardest for this crown. So if you get a really hard zirconia, that’s good. That thing’s, it’s likely never going to break. But I think Biomimetic dentistry as well as probably using materials that if there is some sort of failure, then you would probably rather that your restoration were to fail rather than the likes of a really hard non-Biomimetic restoration that the patient might come in and you’re a hero because their crown’s completely intact and there’s no chips or anything on it, but the rest of their tooth’s fractured off at the gingival level. And it’s extracted and implant, that sort of thing.Whereas Biomimetic dentistry, I would think it would be accepting that you’re not necessarily wanting to just go for the hardest materials. You’re wanting to try and actually first kind of understand the way the tooth works and function and while I was listening to someone and thought recently, actually they kind of comparing it. I think it was, Graeme Milicich, have you heard? [Jaz]Nope. But please tell me. [Taylor]So, I think he does a lot of research about the compression dome concept of enamel. So that’s basically where the enamel basically works. So, the compressor forces on the tooth and it’s kind of redirecting those vertical forces in the kind of cervical area of the tooth, and it’s kind of disrupting those to the dentine. And he’s kind of saying, and a lot of Biomimetic dentists are kind of saying that by doing these kinds of aggressive, heavy crown preps that we’re used to doing and taking away that kind of cervical area of the tooth, you basically don’t want to do that because it’s the strongest part of the tooth and it’s the area that’s receiving all that tension under function. So, by taking that away, you’re not really doing the tooth any favors. And that little area, the cervical kind of two to three millimeters, if you go and then read about Biomimetic dentistry, you hear a lot of people calling that the bioderm. So, you hear a lot about kind of preserving that bioderm. And with doing that, you’re then taking a more kind of minimally invasive to an extent, but not going too far with that either. So, if there’s like a really thin cusp or that type of thing, it’s not like an extreme minimally invasive or you’re relying on, you know, ridiculous bone strengths and that sort of stuff. I think it’s more of an approach where you’re removing your carries, removing track. Trying to preserve the vitality of the pulp. [Jaz]I think the word approach is a good one though, Taylor because from my perception, from what I’ve seen, from my speaking and also, I actually did have David Alleman on the podcast, but we had such massive connection issues. They never actually got posted. But from what I’ve seen and from speaking to lots of my colleagues, you know, Germàn. He’s very active on social media. I’ll have to put his, Germàn Tekilla is his Instagram handle, so I speak to a lot with him about Biomimetic dentistry and what I like, and why I’m open to it and why I don’t think it is a fad, as some colleagues will say it is, is because it’s an approach, it’s a set of protocols and no one else is talking about cariology, but Biomimetic dentists are. No one else is talking about how to maximize bond strengths and actually those three words is how Dr. David Alleman described it when he had his brief little stint in my podcast, he said, Biomimetic DENTISTRY is really MAXIMIZING BOND STRENGTH. So, is it adhesive dentistry? What could he do to the tooth with your restoration to get the best outcome through the best adhesion possible? And also, it’s a way of preserving the longevity of teeth. So, all these philosophies and the protocols that Biomimetics has in place all lends itself to a favorable restorative outcome. So, for me, I see it as a philosophy and a branch of restorative density best practices. It’s another way to think about it. How did you get drawn to this? Because most couple people qualified one year maybe haven’t even heard of Biomimetic dentistry. Are you finding that you’re having to explain a lot to someone who you’ve met? Who’s like maybe at your level in terms of one year qualified or a dental student and you’re having to explain every time what Biomimetic dentistry is? [Taylor]Yeah, so I think how I kind of fell into it was, so I graduated, so it was 2020. So, it was Glasgow I graduated from, so we were the year that kind of stopped a bit earlier because of Covid as well. So, we had that really abrupt stop. It was about March time where we were in the clinic one day, the next day. That’s it. You’re done.So, there was a few weeks on, maybe a couple of months of waiting about to see. ‘Oh, do we still need to do this last OSCE exam?’ That sort of stuff. And then after that it just kind of fizzled out and that was it. So, at that point, lockdown was happening. I had a lot of time on my hands at that point as well. There was the big influx of all the webinars every day. Like you couldn’t keep up with so many webinars and stuff. There was one every morning, afternoon, night, you were kind of spoiled for choice really. And I think at that point, I was kind of then realizing like, wait a minute here. There’s just so much that I don’t know from dental school really, and I think we’ll come onto that a bit as well, but- [Jaz]I still feel like that every time my friend. Don’t worry. It’s very normal to feel that way. And it’s good to recognize it. It’s the most important thing is to recognize that, whoa. Yeah. It’s so much that you don’t know that you haven’t exposed to. And then the more you learn about things, then the more you realize that actually I thought I knew crown lengthening. But then when you start learning about crown lengthening, when you do your first crown lengthening case and then you’re like, holy crap, I need to learn more about crown lengthening. So it’s never ending my friend. Embrace it. Embrace it. [Taylor]Yeah. So, I think they started off with all the webinars, that sort of stuff. I think a similar point I probably found your podcast as well, and it’s genuinely being so helpful for like that stage in my career as well, I don’t know how much feedback you get from people at my stage and stuff, but it’s genuinely, completely changed my outlook on everything, and I’m not just saying that because you’re there. [Jaz]Much appreciated. You can stay. We’ll keep this in running. Very good. No, thank you so much. It’s nice to get feedback. It keeps me going, you know, sometimes where, yeah, like today, I’m behind on my episode and I’ve got so much to do behind the scenes and you may not, have not seen actually, and I’ll take it for everyone’s benefit. You might have not seen this, but on YouTube now for the last couple of episodes, not only is the interview on the right side, but there’s notes now coming up on the left side, so that’s double our production time. But, so, you know, let me know what you think of that. And guys, if you’re listening, watching this, let me know, should we continue working OT and maybe delaying the episodes a little bit to have the notes on the left, as we’re speaking, or is this a function that you really don’t need? So yeah, something to get some feedback for. So, feedback, always welcome. Thank you. [Taylor]Sounds good. No. Yeah. So, I’m one of the audio listeners who have then kind of started listening to your podcast, quite a long commute this year, like I was saying, it was about an hour later and an hour back. So, I’ve listened to all the podcasts from that, I was then just reading a lot more and following a lot of other dentists. And I think from that, it was kind of about on Instagram that I then fell into the little group of- [Jaz]Huge community on Instagram or Biomimetic dentist are sharing lovely things, great lessons, very educational posts, I, which need to be respected, you know, whether you agree with Biomimetic approaches or not. I think there’s a beauty in sharing and presenting information on Instagram that is disseminating information and research. So, I think we have to re respect that. [Taylor]Yeah. And at the start it was, I found there was so much information on these pages, and it was all, it wasn’t just a case of, I think it’s quite easy to think, oh, you’re reading that stuff on Instagram. Like that can’t be the way of doing it, but it’s all linked back to research articles and you know, reviewers and that sort of stuff. So, you can go away yourself and start reading through all those papers and kind of a lot of the time, I would then also form my own opinions as well. There’d be some things that people would post about, and I would think. Oh, I’m not, not too sure about that, but I think the more you kind of read about it at the start, it’s quite overwhelming. I was reading it at the start thinking, I have no clue what any of them are talking about. And I think maybe after about five, six months or so of just continuing to read and I then kind of then went to, there was a online conference. It was quite big, roundabout Christmas time. It was a karma dentistry. Biomimetic conference. I don’t know if you’ve heard of that. That’s been on a couple of years now. So that had about, it must have been about 15 or 16 speakers and learned so much from that. It kind of got to the point, I just- [Jaz]Just quickly, who’s your favorite speaker in Biomimetic dentistry? [Taylor]Who? Favorite speakers? I think- [Jaz]You had to pick one. [Taylor]I always enjoy listening to the duo of David and Davey Alleman.  They’re very, very, very entertaining. It was actually just in March this year, I actually got to meet them. It was a HandsOn course. That was- [Jaz]Of course, Tariq Bashir probably organized that, right? [Taylor]Yeah, that’s it. [Jaz]That’s right. The famous Scottish dentist. Yeah. [Taylor]That’s right. Yeah. So. Well, Tariq’s great. So, I think he’s done the Mastership program with David and Davey, so he obviously knows his stuff. And I think if someone like that’s, you know, following protocols like this, then you know, he’s sensible and you can tell he just really knows what he is talking about and I think, like you were saying as well, I don’t think it does. Even if you don’t agree with all of it, it doesn’t do any harm to have some of these concepts and approaches like in your toolkit really as well. So, I know that like, say yourself, you’re, you talk about bit like the verti preps and that sort of thing, and that wouldn’t be then saying that you don’t do things like that. It’s just another, you know, approach to how you can do things. So, it’s- [Jaz]I’m very much against like, dogmatic approaches. So, if anyone’s like two on one side, I think there are cases where I don’t think you can solve it. And I mean this, you know, with humility, I don’t think you can solve every single case with just one approach. So, I can show you some wear cases where like, you can’t stick anything on this. You need to do crowning; you need to do vertical preparations. You may need to use zirconia in certain cases to be able to fix it. Okay. On this 75-year-old man, for example, whereas other cases, Biomimetic dentistry all the way, I mean all the onlays that I do, I very much try and follow all that I’ve consumed so far when it comes to maximizing adhesive strength. So, I think there’s a beauty in learning from all the philosophies. [Taylor]Yeah. Completely agree with that as well. And yeah, I think sometimes people are quite quick when you’re talking about the Biomimetic type things, to think that, oh, that’s all that you then, then do. I know in my case, just now anyway, it, if anyone’s listened to it, it certainly isn’t. I sometimes feel like I’m going to work and I’m going to doing a completely different thing. So, I’m practice, I, I just. Like kind of heavily NHS type practice. So, to be fair, I’m spending most of my time going and doing extractions, dentures, that sort of stuff. When I get the chance with composites, whether that be in every anterior composite or a posterior composite or the odd chance to get a little chance to do onlay, or that type of thing, I can then go into some of these concepts and use these things. But I would only do that if I’m absolutely sure that I’d definitely know what I’m doing because you do hear a lot with the very experienced Biomimetic dentist as well, who are really keen on it. They would rather have a traditional dentistry done very well to them than someone who’s maybe on the fence about the Biomimetic dentistry and doesn’t maybe completely know what they’re doing. So, I would think if maybe anyone’s listening and think they want to jump straight into it, I would really just, read up a lot about it. I think your best bets probably to find a mentor as well, which I’ll- [Jaz]Well, tell us because tell you, you’ve been through this journey. You found Tariq, obviously in Glasgow. You went to the course when Davey and David came along. So, if you are speaking, if you’ve got your microphone to young dentist all over the world and they wanted to take the next step to learning about Biomimetic industry, maybe one or two of the key lessons. Do they have to fly to the states? Do they have to buy a book? What’s the good first step? [Taylor]So, I would say, if I can be cheeky and pluck the website for a second as well- [Jaz]Do because I loved it. [Taylor]Yeah, I’ve started up the little website and the website is in, it’s called the hybridlayer.com. Also, on Instagram as well @thehybridlayer where the share cases and that sort of thing. And the website, the main kind of goal of that. I got to the stage where maybe after about a year or so of reading things, I felt like I would then see people asking things and that sort of thing, and it would get to the point where I thought, yeah, I can start. And I know the answers to some of these questions. I can see that people are pretty confused as I was at the start, and the kind of goal of the website was basically just to get some of that basic info down so that it could maybe even give people the chance to have a read data, it saves you read, scrolling through thousands of Instagram posts that aren’t in any order trying to figure out what’s happening. And that can give you just a little kind of basic insight into what it is. The rough concepts, not necessarily read the website and then you’re a Biomimetic dentist, but it can give you an insight into saying, is this the sort of thing you’re may be interested? And if you are, there’s, I know I had the two-day hands-on course with David and David Allman. I would say even that sort of thing. I knew quite a bit. I don’t even know if the two days would be enough to then start doing it, but I know they also offer the kind of online mentorship programs as well.So, I know there’s the Alum Center for Biomimetic Dentistry and some of the people they’ve trained, they’ve also got similar kind of centers throughout the world as well. So, a lot of it’s going to, looks like it’s been done online, which I think makes sense as well. So, I would definitely recommend if you are going to be kind of serious about it and trying to use it on a day-to-day basis, definitely try and find someone who knows – [Jaz]Well, so much of our dentistry nowadays, adhesive dentistry, so if anything, we can do to improve our adhesive dentistry. So, what I’m going to do actually Taylor is I’m going to ask you the last question, straight up. And then we’ll go to some of the other ones. Because on this note, from what you’ve learned so far in your journey so far with Biomimetic dentistry and a year down dental school and because some of the knowledge that you have from dental school is more fresh, you’ll remember some more of the dental learnings than I do certainly. So, I like that you have that recent background plus all the courses that done in Biomimetic dentistry and how passionate you are about it. Give us your top tips on improving bond strengths. So, this could be with either direct composite resin or bonding onlays. What are the key lessons that you can pass on in just a few months? [Taylor]Yeah, so I would say one of the main concepts that I didn’t come across at all, maybe I missed it, but in dental school was the fact that when you are forming that initial bond to the test. So, if I imagine you’ve got your caries free tooth, or if you’re using the partial caries removal, you’ve got your peripheral seal and everything, maybe come onto that with the caries dye and everything. But if you’ve got your tooth that you’re happy to then say, bond a direct composite on tooth, so, an MO that you’ve prepared and your you’re happy with when you do etch the dentine, prime the dentin and use your first layer of adhesive, I didn’t realize that, that a tease of it takes time to mature, basically. So, it takes time for that bond to form. And I’m not sure if that’s something that I just missed, but I feel like it’s a really quite important point because- [Jaz]Is that the decoupling time? [Taylor]Yeah, that’s right. So, it’s basically the concept where obviously there’s a different types of bonding system, so the total etched, self-fetch, that type of thing. So obviously important, first of all to understand what you’re using, but if we assume you know what you’re doing, you’ve etched appropriately, primed appropriately, and you’ve got your first layer of adhesive on there. Once you’ve got- [Jaz]Now, what if you’re using something like a universal, so you’ve etched the enamel and now using a self-adhesive universal, and then that’s got the prime and bond mixed into it. Can you still apply? Can you still apply this philosophy of decoupling time, or does it lend itself more to a separate primer and separate adhesive stage? [Taylor]So, I would say just based on whatever, I think if you’re using a universal bonding system, which I’d imagine a lot of people will be using, you’re naturally maybe not going to quite reach the, the absolute best bond strengths that you possibly can. But I would say that- [Jaz]I think we know; I think everyone who uses universal bonding agents, I think we know that. I think we know that. You know, from the papers in the past anyway, the OptiBond™ FL was so high and then everything else is always a bit lower. I don’t know, which is the king of adhesives. Now maybe could fill me in, in terms of what you’ve read, but yeah, certainly. I think when we use Universal, we know that for convenience we accept a little bit of a compromise, but we’re hoping that it’s not a massive compromise and still good enough to get a long-lasting restoration. But I think let’s go with that fourth generation or fifth generation. So, we’re gonna do etch rinse and make it really tangible now. So, we’re gonna prime, and then sometimes we need a couple of coats of primer. That’s why I was taught, so you please tell me if- Get a nice shiny surface, get that dry, and then you’re gonna be using your adhesive. And then is that when you are waiting time? But just tell us more about how this decoupling works. [Taylor]Yeah. As soon as the adhesive goes on and you’ve cured it, you’re basically at that point, the hybrid layer is starting to mature. So, the hybrid layer obviously being that kind of interface between the hydroxy appetite, a little bit of the collagen and your resin monomer particles, but that bond, once you’ve cured that, that’s when the clock kind of start. So, you tend to think that a lot of the studies that they’ve done, if you were to just inject a big bit of composite right on top of that kind of bulk fill type technique, all of the shrinkage of the composite, if you do it straight away, the bond hasn’t fully formed at that point. So, you tend to find all of that shrinkage and the flow of the composite has basically shrinking towards like the kind of greatest center of mass of the composite. And by doing that, because you’ve got that shrinkage, it basically then just pulls the adhesive layer off the tooth or weakens that bond as well. So, the concept is basically that after about a minute, you’ll have about 70% roughly of your total bond strength, whatever that total bond strength happens to be. And after about five minutes, you’ll roughly have about 80, 90%. So that’s kind of what you’re aiming to give it just a. little bit of time, but it’s not a case of- I think when I first heard that, I thought, okay, so it’s a case of you do your etch, prime, bond and then you’re just kinda sitting there waiting, not doing anything. But there are things that you can do in that five minutes as well. The thing that they would usually suggest in a lot of the lessons and stuff would be to put just a little layer of what they call resin coating. So that would be basically your little kinda 0.5 millimeters probably of some flowable composite. And because it is such a low volume, you basically find that flow of the composite, it goes towards that hybrid layer. So, it’s kind of maintaining that bond strength. It’s not pulling it away, and that clock at that point is still ticking. So that’s increasing your bond strength there. You then tend to find as well that the rule is that from what they’ve read, that if you go more than about two millimeters in your first increment, in that five minutes, you’re a chance of losing about 50% of the bond strength in a lot of the studies. So, they recommend basically the simple rule of not getting any deeper than 1.5 millimeters within the first five minutes. And at that point as well, you could easily be doing that first 1.5 millimeters, you could be building up your little proximal wall as well, which isn’t then connected to that composite, that’s forming the hybrid layer. So, it is not like you’re sitting there doing nothing. I think that’s a simple kind of thing to understand and something that you could easily kind of incorporate. And if you just kind of understand that that bond takes time to develop, I feel like it really changes the way. Look at things all lot the time when you’re doing composites and that sort of thing. And I think- [Jaz]Listen, Taylor, I’m just gonna go have a coffee for like five minutes and then that’s still decoupling. And I can justify that to my patient. So that’s the other way to do it. But no, I prefer your way, you made it really tangible there too, to add a little bit of flowable. That’s great. And then you could be curing that flowable? And that’s still, the clock is still ticking. [Taylor]Yeah, that’s right. You would cure your flowable, and as long as, so there’s shrinkage of the kind of polymerization shrinkage tends to be to do with like the volume of the layer and also the kind of modules of elasticity as well. So, because it’s such a low volume, you tend to find it’s, it doesn’t have that strength to kind of pull away from the first layer anyway, so, that’s why. [Jaz]So, you could be curing that flowable, you could doing the contact area, but on the matrix and then like you said, so you’re not connecting it to the body of the composite elsewhere, obviously. And then you can be just getting that. So yeah, I think fill in five minutes and I would like to encourage everyone to practice TAKING QUADRANT PHOTOGRAPHY PHOTOS. So, get your buccal mirror and make sure it’s nice and warm. Or if you’re using rubber dam, it’s not an issue because it’s not gonna warm up, it’s not gonna steam up. And then you can start taking some photos, improve your photography. That’s easily a minute that you can do there. So, I would encourage everyone through that. So that’s a top tip. So, great. You mentioned about the decoupling time. Give us one more top tip because this is such a big, huge topic. If anyone gains something from this episode, I want to remember, okay, I’ve improved my bond strength in some way. So give us one more tip. [Taylor]: So, I think another one of the big main Biomimetic concepts, which I think you’ve heard of yourself as well from, I know you’re a Pascal Magne fan, aren’t you Jaz? [Jaz]Of course. Who isn’t? [Taylor]Yeah. So, the kind of immediate dentin sealing concept. So that’s basically the concept where you’ve got your freshly cut dentin and if we say, for example, this time we’re going for an indirect onlay type of restoration. I know from when I was at dental school, I would’ve thought just do the preparing. First of all, probably wouldn’t have thought to do an onlay, it would be a tune I was probably thinking of. But if I had thought onlay at dental school, it would probably be do the preparation, taking the impression that sort of stuff. And then at the time, just cementing it with your etch bond, resin cement, that sort of stuff. The concept of the immediate dentin sealing was basically with your freshly cut dentin. When you’re finished your prep, your then, just as we were saying, whichever system you’re using, the etch prime bond, obviously, your layer of adhesive and then again possibly that little resin coating over the top as well. And by doing that, I don’t know if you’ve read some of the papers by Pascal Magne as well. He basically found that by doing the immediate dentin sealing, professionalizing that, and then cementing it the next visit because you’ve been allowing similar to what we’re sending in that first point because you’ve given it so you potentially, if you’re sending your love work away and it’s coming back in 10 days, two weeks, that’s potentially two weeks of decoupling with time that you’re doing. So, he’s finding you’re getting four times in times the bond strengths with using that kind of method. Things like that, though. There are still some areas that can kind of trip you up as well. So that’s what I’m gonna seem to be careful that you can’t just start thinking, right, okay, I’ll start doing this tomorrow. So, things like the, so because it’s such a thin layer that you’re using there, you’ve got the little oxygen inhibited layer as well. So, if you have this little thin layer of resin coat, there’s potentially say, I’m not sure exactly, but maybe 20, 30 microns at the top of that, that just isn’t polymerized. So that can also react a bit with the impression material. So, it would usually recommend a little bit of the kind of glycerine- [Jaz]With the temporary material like bisacryl? [Taylor]Yeah. So that, and also the actual, if you were using a kind of impression material to actually take impression, it can interfere with that as well. I think it’s more the kind of polyether type materials that can interact with it. So, you basically want to make sure that you are curing through a little layer of glycerine, similar to when you’re doing a composite and you cure that last layer through the Vaseline or that type of thing. And so, it’s definitely do that. And then also just making sure, I think some people do the immediate dentine sealing and maybe think you can just use your etch bond etch prime, and a little layer of the adhesive. But you tend to find at times that layer of adhesive, you have to know the thickness of it as well because if it’s about as thick as the level of the oxygen inhibited layer could potentially be, you could potentially just have pretty much nothing there. So that little layer of the resin coating over the top, it provides, I think the concept is it kind of provides more of the free radicals for it to all polymerize and I’ll just make sure you have that good thickness and that’s, I think it’s definitely something to go away and read about and see if it’s something you can maybe incorporate in your practice as well. [Jaz]I encourage everyone to read about IDS, immediate dentin sealing, but as a practical dentist, I think there are some other advantages, ie if the temporary comes away, then there’s less sensitivity. Okay. That’s a real good advantage there. The other one is at the same time as doing my immediate dentin sealing, I’m blocking out any undercuts with my G-aenial™ Flo whatever. So, you know, if you just do it for those two reasons alone, and then now, if you get some added improved bond strengths, which we think we will, then it’s a great thing to do. I think it’s very- Some dentist, young dentists might get scared away from it because it sounds very complex. It really isn’t. It’s just your standard adhesive procedure, bit of a flowable resin coating on top. And then when you come to fit it, you have the whole air abrasion. I would suggest everyone checks out the episode I did with David Gerdolle, the episode with the David Gerdolle, Extreme Bonding. David is a very well-known Biomimetic as well. And he talked all about the main things we can do to improve our bond strengths and, and yes, one was talking about how we can use those concepts. So that’s great. We’ve covered two top tips there for improving your bond strength. Number one was decoupling time, and number two was immediate dentine sealing. Let’s switch gears to caries detector dye, because the biometric community is the community online that I see using as part of their protocol, caries detection dyes the most. And then, Germàn influenced me to start using it, and I love it. I think it’s great. I love that objectivity that it gives. So if, no one’s ever used carrie’s detected dye before, can you just explain the steps in using it? And then B, how do you interpret that information? That tooth you’re looking at now that’s pink or green depending on which one you got. I got the pink one. And then based on what you see, how do you act upon it? So, it’s three levels of questions. Okay. So why should we use it? How do you interpret it? And then how do you act on it? [Taylor]Yeah, so I would say like you’re saying the caries detector, that it’s probably another one of those ones that is seen as a bit controversial maybe with people that don’t know exactly the method you could consider using it in. So, it’s definitely not just a case of you’re using this dye and it’s helping you see, you know, all the occlusal cases and you’re just drilling away all the red stuff. I would say, I would probably break it down a bit back to how you’re actually wanting to deal with your caries removal, Biomimetically, possibly. So, I would personally, I think the kind of caries removal concepts make sense to me. And the main things that I would usually associate that with would be forming that peripheral seal zone and getting your caries removal endpoint. If I was able just to say what both of those are. It’s the peripheral seal zone would be basically- [Jaz]Which is exactly what we are taught at Dental School. You know, get the ADJ super clean and it’s just an extension of that and really linking it back to your bond strengths because- But you know, we said there, teach me at dental school that, oh, because that’s where your seals are most important. But that’s where also we want to maximize our bond strengths as well, so it makes sense. [Taylor]Yep, definitely. And then your caries removal endpoint, similar to the concepts you would learn at dental school as well, but maybe just making it a little bit more tangible would be once you’re approaching the pulp, basically, and it’s something that you’re probably doing at dental school and without really realizing it, but you’re getting towards the pulp, you’re starting to get a bit cautious. Should I keep taking away anymore? So, the caries removal endpoint concept was basically, it was giving you like a tangible set of numbers to follow changes a little bit depending on tooth to tooth and the age of the patient and stuff. But it was generally looking usually about five millimeters vertically. So that would be from if you were coming from occlusally removing caries. Once you get five millimeters deep, roughly you would consider, even if there is still caries, you would be stopping there and horizontally coming from the marginal ridge of the adjacent tooth. So that’s kind of your little three-millimeter peripheral seal zone. You’re basically then stopping there to avoid pulpal exposure. So, you’ve got your clean peripheral seal zone, and then you’re possibly a little bit of affected dentine, that type of thing with a little bit of caries life behind that, you’re willing to accept the slightly lower bond strengths and instead of basically exposing the pulp, and I think it’s at that point that the caries detector dye, I feel could be really useful. So, to use the caries detector dye, so, if I talk a bit about what it is first, so the benefits of it, I would see, it’s basically like, I think you mentioned as well, Jaz, it’s kind of given you an objective way of looking at caries removal rather than being subjective. And I heard- [Jaz]And that subjectivity has been studied and every dentist is different in terms of where they stop. So, I was attracted to it because, you always question, should I remove some more, should I not? And it surprised me enough for a couple times. You know, I use it many times. And I was like, okay, I’m doing good. I’m doing good. And then I got surprised. I was like, WHOA had I not used this, I would’ve missed it. And I like what Germàn said on a Facebook post recently. Like, yes, there are those people who argue that, yeah, well, you know, I just use my probe. And I can feel it with my probe, but are you gonna really be able to probe every square millimeter of your cavity? Probably not. And that’s got me thinking is like, yes, he’s right. [Taylor]That’s right. And then another thing with the probe as well that I’ve heard David Alleman as well talk about quite a lot in a lot of his lectures. He talks about, was from like a Japanese researcher that came up with it all. And I think he would be at his dental school clinic and talking to the students and a lot of the time they would be removing caries and he would tell them, you know, just keep removing it until it’s hard with your probe. And they would then ask him, well how hard, and that’s a good question as well, because like how hard is hard? So, I think caries detector dye, it’s a good way of, basically the way it works. Not sure if they know exactly how it works, but it extends denatured collagen, so it’s basically a solvent type of solution. It’s got some acid red, the carious dentin, so the likes of the affected and infected dentin. The collagen fibers are a bit looser in their denature, so it’s able to penetrate a bit more. And by doing that, it then stains the kinda red or pink type color. So, I mean the studies that you read about it, they’re all pretty, I feel like they seem all pretty conclusive, to be honest, that it does seem to work. And as long as you’re kind of accepting, there maybe are some limitations to it as well in that really deep dentin that you get really close to the pulp could potentially stain a little bit red, but at that point you’ve stopped your caries removal because of the end points anyway. So, it doesn’t really matter at that point. And I find from using it, A lot of the time if I think I’ve taken away the caries from that peripheral seal zone and I’ll put the caries detector dye on. And a lot of the time, like you’re saying, you do get a bit of a surprise at times and even if there’s little patches that you think you kind of look at and feel what the problem thinks. Oh yeah, fair enough. I’ve left that bit there, so and it is good then you can see the area over the pulp that you’re kind of leaving as well and you know, roughly depending on, I think you can kind of tell a little bit that the redness in terms of how red it is or how pink it is, roughly what you’ve got to work with in terms of your bond strengths and that type of thing as well. [Jaz]So, guys, everyone listening, all those watching, there’s an episode coming up with Germàn actually, we’re gonna talk all about with whole 45 minutes. All on caries, what you’ve done is you’ve given us a nice introduction. You got dentist thinking now maybe about it. So, we wet your appetite for the one with Germàn coming soon. I was actually gonna record with him straight after you, but we’ve had to reschedule that, but we will cover that in a good depth. So brilliant. We’ve covered some Biomimetic principles. We defined Biomimetic dentistry. We talk about caries detector die just now; you gave your top tips for improving bond strengths. So as an introduction, as a final introduction, as a final part of this podcast, I see a lot about crack management and now this crack managing cracks is very polarized. Like a lot of things in dentistry, I guess. And many schools of thoughts will manage cracks in a different way. So, I’ve been taught before chase cracks. I’ve been taught for never chase cracks. And what I do hand on heart will vary in every single case, it’s different to me. If it’s a nasty crack I might chase, but, if it’s not so mad, I won’t chase it so much. So, can you introduce us to the Biomimetic philosophy or thinking or protocols when it comes to crack? And I imagine this, I dunno, crack removal endpoints. What names have you got for that? [Taylor]Yeah. So, I feel like the crack element of it, I think that’s one of the parts of it that’s probably especially tough for me without having the years of experience at things. Because I am kind of going purely just based on like, Theoretical lesson to what other people have to say and just kinda- [Jaz]And that’s fine. Share, because this is new for me. The Biomimetic approaches. Absolutely cool. Just share what you’ve picked up so far and maybe in five years we’ll record again and see what your thinking’s changed anyway but share what you’ve learned so far. [Taylor]Yeah, so what I’ve kind of learned so far would be, I’ve learned from David and David Allen, and they had quite a good way of assessing. So, cracks were kind of forming a part of. They were quite good at teaching us ways of kinda assessing the tooth for structural compromise. So, there were basically four red flags that they told us to watch out for. So, the first one was obviously cracks into dentin. The second one was any kind restoration, say an amalgam that’s got an isthmus width of greater than two millimeters. The reason- [Jaz]Which is most amalgam! [Taylor]Yeah, that’s right. I know most of them. Yeah. And the reason for that was basically, I think more studies by Pascal Magne and several other people that basically show that when you do have an amalgam like that and it’s got say an MOD cavity that’s more than two millimeters, instead of the usual, the tooth can flex about two or three microns. With even an amalgam in there, it’s flexing about 180 microns, which is, you know, a really big difference. So that’s one of the reasons why these big amalgam teeth, you know, do tend to crack as well. The third one was any cusps that are less than three millimeters in width, which quite common as well. And the fourth one was- [Jaz]Let’s make that one really tangible. Where do you measure that three millimeters from? Do you measure it at the top of the cusp or the base where the cusp then joins onto the floor? [Taylor]Yeah, so I’ve seen some different answers for that one as well. I would tend to; I’ve mostly seen from the bottom of the cusp, and you can use the like in a caliper. That’s the way I’ve tended to do it and I think that kind of makes the most sense because that’s shown you how much connection that cusp actually has. [Jaz]It’s the base, the main strength of that cusp comes from what’s below it. So, absolutely. That’s fine. Yeah. Yeah. I just thought I mentioned that so that, you know, people listening can think where do you know, how do you begin to measure it? So that’s fine. Please tell us more. [Taylor]Oh, that’s good. And then, the fourth, last one, there was any kind of box there, so an interproximal box that was less more than four millimeters. So that’s another reason that a tooth will be structurally compromised because like we were saying at the start, you’re then into that kind of bio area as well. So then if you go back to the first one, which was the cracks into dentine, if I even just talk a little bit about, you know, it was Davey Alleman at the course, it was kind of a, a little talk about cracks and that type of thing, and his concept was basically he’s, I think he’s spent a lot of time in, obviously David Alleman. A lot of time they’ve spent a lot kinda looking into the engineering aspect of it and seeing how engineers deal with cracks and other industries and things like that as well. And they’ve kind of come to the conclusion that if you are to just leave a crack as it is, then it has the chance that can always propagate no matter what you do. If you’re putting force in that tooth, if that crack can continue to propagate, it might take a while. So, their concept is that similar to the caries removal endpoint, you’ve called it crack removal endpoint. So basically, that inside that peripheral seal zone. The likes of Davey Alleman, he would tend to try and chase that crack as much as he can. Basically being, wanting to try and avoid any pulp exposure or perforation or anything like that. But he’ll feel that if you can either remove that crack or at least remove a bit of it, then you’re kind of reducing the length of the crack. And by reducing the length of the crack, you’re kind of reducing the lever arm of it. By doing that, it then needs a lot more force for them for that crack to then propagate. So, he kinda sees that as the best way of doing it. It tends to be the only thing that I see with it as well, it’s kind of challenges it is that you’ve then got these areas that you’ve cracked really high, like C factor situations to try and then restore back and you’re kind of wonder if is that any better? What you’ve gonna made there? So, I’m kind of above the main that, I’ve personally not really decided. I’m probably like yourself. I’m so, so- [Jaz]I still don’t know. Look, I’ve been in nine years. I still don’t know what is the best way, and I think it will vary in every single scenario. I just hate cracks, man. I had like, I think episode 0.7 wasn’t my title. I just hate cracks with a passion. No one likes cracks. And there’s so many different opinions I mean, one of my friends, colleagues, Pasquale Venuti, which I know he’s like the anti-Biomimetic dentist, and that’s cool. It’s okay. And he’s very much like, don’t chase cracks, because if you’re chasing cracks, you never know where the endpoint really is. You can’t see the endpoint. But you mentioned briefly in case anyone missed it, is that actually, if you’re removing, you know, some of the crack, you are improving the mechanics of the situation. So at least we have the four themes that you touched on when it comes to crack considerations. So, if you have a crack and it fulfills all the other four factors, so, and you think the crack is into dentin and it is got a isthmus large in two millimeters and more than four millimeters, was the four millimeters in terms of the depth of the restoration? [Taylor]Yeah, just the depth in general- [Jaz]Occlusal gingiva? [Taylor]Of the restoration. Otherwise just from the marginal ridge to the deepest point. And then you’re into the Biomimetic at that point. So, they tend to say then if you are kind of beyond that, trying to bond, you know, a tough bit of ceramic into that really deep box, it creates a lot of stress in that area. So that’s when you’d maybe be considering the likes of the. The deep margin elevation with a material like composite which might have a wee bit more flex in it as well, which is another benefit of that sort of technique as well. [Jaz]Brilliant. I think we’ve covered a lot of breadth and I think we, you know, if wherever you are listening and watching this give Taylor around applause because it’s not easy to talk about these kinds of concepts. And I’m so happy to see what you’re doing with how proactive you’ve been, how you’ve been open to the universe in terms of a learner and a sharer. I think good things happen to those who share. Please continue to share your journey. I love it. It’s wonderful, Taylor. So, thanks for making time to share your learning with all the Protruserati, and I hope you guys gained a few lessons. If anything, it may have wet your appetite to learn some more, which is a beautiful thing and maybe you disagree with some of the concepts. That’s okay as well. I can always say, guys, it’s okay to disagree with your management of cracks, which may be different in a Biomimetic way. It’s completely cool as long as you have your own philosophy. If you have a philosophy rather than winging it the whole time, which it kind of sounded like I did with cracks. I promise you; I do have a bit more philosophy to it. But yeah, no, thanks so much. Any last words, Taylor? [Taylor]No, just thanks very much again, Jaz and yeah, today, I mean, you’ve covered it enough, but I’m very, very early doors in my career. I’m just kind of exploring all of these concepts, not necessarily then taking all of it into work. So, if anyone’s kind of listening, thinking, what is he doing at this stage to do all that sort of stuff, then I feel like I’m doing it kind of safely. And you know, I think I’m being sensible about it. And if anyone’s getting any kind of questions or wants to ask anything about anything at all, then feel free. I’m more than happy to talk to anyone. If there’s anything you think would help at all, then feel free to get in touch. [Jaz]Reach out to Taylor, guys @thehybridlayer. Again, I always, always encourage young dentists who are keen to learn, who are proactive and who go on courses like you have and you’re doing things that ultimately is gonna improve your dentistry, improve your outcome. And you are on the journey, right? Every master was once a disaster. Right. So, we’ve gotta be on our journey and the reason I got you on, it’s because you’ve spent time to think you’ve really, you know, read the books. You’ve been on some courses, you still early, you still need to drill some more teeth. You still need to remove some more cracks. But I feel as though your journey is valid and you are learning, and your sharing is valid. So, keep going. Don’t think that, ah, you know, I can’t talk about this because I’m not experienced enough. Sharing is absolutely a good thing to do. So, keep it up, my friend. [Taylor]Sounds great. Thanks very much, Jaz. Thanks very much. Jaz’s Outro:Thank you so much. There we have it guys, thank you so much for listening all the way to the end. Hopefully now we’re a little bit more clued up about Biomimetic DENTISTRY. Do check out Taylor’s website. I’m gonna put everything in the show notes for you, and if you’ve listened this far, you might as well claim CPD, like it’s just four or five questions away from getting a simple certificate that you can use for your end of year quota but also to validate your learning and its of space. For those of you who like to reflect and like to make notes. You can do that. Of course. Speaking of notes, all those premium notes that you see on this side. Or if you don’t see if you’re listening, you can download them as a pdf. So, every episode within about 48 hours we publish on the app. That’s a Protrusive app on Android or iOS. Do download it, do get stuck in, join the community, and gain CPD, but also watch the exclusive monthly content that Protrusive Dental Pearl at the beginning of masking a post that was actually taken from December’s premium content of actually showing you how I fit three emax Crowns and an emax veneer under Rubber dam. A full clinical walkthrough as you’ve seen perhaps on some videos on YouTube. So, if you like that kind of stuff, do check out the Protrusive app just for you, the Protruserati. Thank you so much and I’ll catch you next week.