Protrusive Dental Podcast

One of the most common questions I get from colleagues is ‘Which Intra-Oral Scanner should I buy?’ – I don’t have the breadth of experience of testing all the scanners out there, but Dr. Gulshan Murgai does! We discussed which scanner is best for your practice and how to choose the correct one for your needs. I hope you gain insight into the differences between the different scanners and help you move forwards a decision. For me, one of the biggest takeaways was that it may not be so much about which scanner, but more about ‘what is the customer support and guidance like after I invest in one?’ https://youtu.be/ERvzjlQaBRc Check out this full episode on YouTube Highlights of this episode: 2:00 Dr Gulshan Murgai Introduction 5:43 Which intraoral scanner should I purchase? 8:03 The best scanner on the market today and why? 12:37 Aligner system available for different scanners 15:17 Customer support on scanner companies 18:11 Scanner Prices 19:12 Caries detection within scanner 20:27 Importance of scanner and what’s the best for your practice Check out Dr. Gulshan Murgai supply company Implant Solutions Direct and also 4D Ceramix, which is a full-production crown and bridge lab Connect with Dr Gulshan Murgai If you liked this episode, you might enjoy the Story Of Digital Occlusion This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD waiting for you on the Protrusive App!

Ever considered moving to Dubai to practice Dentistry? Dr. Mark Georgy practiced in Abu Dhabi for 5 years, and Dr. Fraaz Ahmed moved to Dubai 5 days ago – on today’s episode we are lucky to get BOTH perspectives of life and Dentistry in the United Arab Emirates. Fancy tax deductible Skiing + CPD next month? Check out Destination CPD by Mark Georgy From qualifications to registration process and income potential, we covered it all in this episode. https://youtu.be/KGCk3YcK-e0 Check out this full episode on YouTube “You have to have your license already sorted out, a lot of people just won’t reply unless you have your license, which you can do remotely, you DON’T have to come in to the country (UAE)” Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE by answering a few questions on hundreds of episodes + You can get EARLY ACCESS to the episode + EXCLUSIVE content Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 2:32 Dr. Mark and Dr. Fraaz introduction 6:46 Considering Dubai as the place for practice 10:34 Dental Health Authority (DHA) License 12:19 Taking risks of moving to other countries 13:54 Requirements for foreign dentists to work in the UAE 17:06 Dental Protection in UAE 19:22 Family-run clinic 22:05 Contractual issues abroad  30:00 Things to consider before moving abroad 33:34 Quality of life and schooling in UAE 37:26 Income tax and income levels in UAE 44:42 Daily life in the UAE 48:38 Language Issues 49:48 Advice in considering moving to the UAE Enlighten Smiles sponsored this episode with their great whitening products and also their course flagship composite bonding course called Mini Smile Makeover, which is really heavy duty full sequence from peg laterals to composite veneers by the famous Dipesh Parmar. If you enjoyed this, you might also like this episode The American Dental Dream with Dr. Kristina Gauchan Click below for full episode transcript: Jaz's Introduction: Did you know that the very first episode of Protrusive Podcast was about my experiences and Surinder's experiences when we were in Singapore? And that was kind of the reason why I started PROTRUSIVE DENTAL PODCAST. Jaz’s Introduction: Well, so many hundreds of episodes later, another opportunity has come to talk about moving to the UAE, from wherever you are in the world, be at US, Australia, UK, New Zealand, wherever you are, and starting a new life, a new career in the United Arab Emirates, think Abu Dhabi, think Dubai kind of thing. And those are where my two guests have got experiences from. And I’m really excited to share this episode, because we’ve got Mark, who was practicing in Abu Dhabi for five years. And we’ve got Fraaz, who literally arrived in Dubai, two days ago from the UK, and is living the entire sort of initiation process right now. And he’s hoping to get started working there next month in January. So, a lot of takeaway points for anyone who’s even thought about moving to the UAE? What is it take? Are there other exams? What’s the income, like? What’s the tax situation like? All the things that you’d want to know, before you move out to the UAE to practice dentistry, funny enough, one of the the hygienist, Bev who I work with is also there now. I haven’t caught up with in a while. So I’m actually reached out to her. But there’s lots of people I know over the years, who’ve experienced dentistry in the UAE. And it’s a place that I’ve been to a fair bit, my wife actually grew up in UAE, and we’re going there again, on vacation. So it really piqued my interest, you know, my wife is actually expecting number two in summer. So looking forward to a summer of sleepless nights. And one of the things that we are looking for in the future and a couple of years is a bigger place, because we’re in a cozy to bed, and we’re gonna need a bigger space. So before we decide on that, my wife was like, ‘But you know, Jaz you’re recording that episode with those two guys from Dubai, let’s just hear what they have to say before making a decision.’ So I guess it’s it’s on my wife’s mind. And I know for a fact that many of you listen to this podcast, young dentists around the world, the world is changing. And now we want to experience this lifestyle where wherever village or whichever city we grew up in, we have to reflect on whether that’s the place you want to practice your dentistry, and that’s the place we have to raise your children. And that’s a place that you want to retire. So the world is now your oyster. And you can call anywhere you like your home. So let’s listen to what Mark and Fraaz have to say about moving to the UAE and I’ll catch you in the outro. Main Episode:Mark and Fraaz, welcome to this very special edition of Protrusive Dental Podcast. Great to have you. Mark I’ve known you since Dawson Academy days has been many years since I first met you. Mark just introduce yourself, if you don’t mind. [Mark]Thanks, Jaz. It’s great to be honest and honor. I’m a big fan and since we met in Dawson all those years ago. Yeah, so I’m a dentists, officially based in London. I’m a GDP I’ve got a special interest in endo, and went to Uni and King’s in London and graduated around 2009. And I’ve bounced around a little bit from working in Cornwall to London, then Abu Dhabi in the UAE for five years. [Jaz]And what about New Zealand? You mentioned New Zealand in our prior to that as well. [Mark]I did! Yeah. [Jaz]How do you skip on that? How do you miss that one? How do you forget? [Mark]A little bit of a nomadic lifestyle? Yeah, so I did six, it was more of a working holiday. So I didn’t count it as a proper place. But I did six months of kind of bouncing around New Zealand working enough just to have some more beer money, you know, to keep going. But yeah, that was fun, too. [Jaz]Amazing. And now obviously you’re based in Switzerland? [Mark]That’s right. Yeah. So I’m winding down my sort of practicing time in London to focus on being here. My wife works for the UN and so you know, so we decided to make Geneva, Switzerland our base It’s beautiful out here. So you know I had a camp in both foot for about a year and a half, two years. And I was commuting between London and Geneva which had its challenges but now I decided to really focus on being. [Jaz]Amazing and Mark for the for those of you who are who don’t know yet, Mark’s the one who’s behind this amazing ski trip in Morzine The Dental CPD destination, CPDs website, so please do check out the links below and also we’ll talk a bit more towards the end but anyone who’s up for a tax deductible ski trip there’s a few places left so come and join us if you can, but now I’ve also got Fraaz. And Fraaz you talk about yourself man it was just the timing was just beautiful man. I saw your Instagram post and it was like one of those like bye UK, Hello Dubai kind of thing. Literally you at the airport I appreciate you so much for giving your time and you must be jet lagged and stuff to talk about your very recent now move you’re literally must or you probably jet lagged in the Dubai Mall right now. [Fraaz]No, to be fair, because I don’t have my three children here yet. So my children are about five o’clock which is what Dubai time nine at 9am. Anyway, so I’ve been enjoying the lions. [Jaz]Very good. I bet you are, Fraaz. Tell us a little bit about yourself or where do you qualify from and do a little background before I started picking up both of you in terms of finding out what is going through your minds. [Fraaz]So, I’m really your typical humble to GDP, so graduated from Liverpool 2012. When I’m working Southwest Wales for a bit, so back to the values that was good. I completed my masters in 2015, with Manchester University, restorative and aesthetic dentistry. Steven Davis was the guy who really got into TMD. So I love TMD now because of him, then there are lots of small courses during that time afterwards. But that’s not my formal sort of education, been bouncing around from Southwest Wales to then Manchester and Oldham. Went to Wigan for a good period of seven or eight years. And then before I’ve moved here, I finished a spell back home, home from his Cheadle, South Manchester of the year. Now I’m here. And I feel like I’m back right to the beginning. [Jaz]Yeah, well, you’ve been bouncing from Wales to Manchester, Cheadle. Whereas Mark’s been going from like, UK, New Zealand. Abu Dhabi. So you had different experiences. But let’s start right the beginning guys, right? So dentists listen to this, who maybe is now thinking about it, and I guess I would be lying if I said, I’m not interested. I am definitely interested. I’ll tell you why. I said to so my wife’s pregnant, we’re expecting number two. And I keep sending these links to my wife. Thank you. I keep saying these links. My wife say ‘Okay, check out this house. Check out this house.’ Because we live in a cozy, too bad and we need the space. I’m thinking, you know, projecting two years forward, like we need the extra bedroom. And my wife has been really hesitant because she said, ‘Oh, Jaz, you told me that you’re recording this podcast episode. Maybe just hear what they have to say.’ So here we are. To any dentist who’s thinking about moving to UAE to be able to practice dentistry where do you begin? So let’s talk mindset. Mark let’s start with you. When you were moving to UAE you told me a little bit already but share it with the producer it you were it wasn’t just UAE you were considering few places you also considering Singapore and stuff. Why did you end up going to the UAE? [Mark]Right? Okay, so the backstory I guess for prompting the move was, you know, like I said to you earlier Jaz, I was in predominantly NHS practice in East London, which was great. As you know, and probably all of your listeners are familiar with that kind of Treadmill. Dentistry, it gets tiring physically, mentally, you’re kind of so I kind of drew a line in the sand. I was like, this is not going to work for me. So we took the plunge, my wife and I were decided to take a kind of extended holiday slash sabbatical. We were bouncing around Southeast Asia for a few months. So while we were away I was we were both applied to jobs all over the place. And I was applying to jobs globally. I was applying to jobs in the UAE, to Singapore to see you know, where we wanted to end up. And while I was in Thailand, I’m one of the recruiters that I’d sent out my CV to has said, right, we’ve got an interview for a practice in Abu Dhabi. And I did the interview, you know, while I was on holiday over- [Jaz]Skype zoom kind of thing, yeah? [Mark]Yeah, exactly. That was kind of like the first preliminary one. I know. You know, they were happy with me. They wanted to see if we could take it forward. And then you know, it was helped by the fact that my wife has, has family there. So her parents were living there. So that was that kind of obviously made the decision. [Jaz]Parents okay, we said you family, I didn’t appreciate parents. That’s a big deal. That’s pretty cool. [Mark]Absolutely. Yeah. So we made the move much easier. You know, we had a base there, we’d already been a bunch of times to visit and things like that. So that was that was- [Jaz]And is that why Abu Dhabi and not Dubai, for you, personally, because parents were in Abu Dhabi? [Mark]Yeah, so the parents were in Abu Dhabi, which definitely helped. Dubai, and I’m sure Fraaz will probably already echo this. Dubai and Abu Dhabi are kind of two different animals. One is kind of the older, more sensible parrot. One’s the wild child. But, you know, they’re both super fun places to be with, you know, I’ve always liked and preferred Abu Dhabi. It just kind of, we were drawn into it, the green space and the seas, like kind of is the backdrop for everything really in the city. So yeah, that’s why we’re drawn that. But yeah, a couple of interviews later and you know, kept going and we ended up there. Yeah. [Jaz]Great. And Fraaz, ou’re obviously in Dubai right now. So you tell me did you go through a process of thinking about different places to move to and again, I guess my question is, why did you move from UK to now in Dubai and you’re obviously taking your family there as well? And did you consider any other places or was it always gonna be Dubai for you? [Fraaz]Dubai was actually my wife’s dream. And then this fully because the dream then changed as she got happy. Just live in the UK life. We will Welcome to UK when she got happy there, I was sort of like I want to do something else. Dubai really came along similar to Mark in the sense of we actually have family here. So that’s why it was the other location that’s easy to move to. My inlaws, I have a lot of in laws in Dubai. That’s the main reason for here. And then literally, it was over a phone call. So last weekend of June, my brother-in-law calls then goes, ‘We’re opening up this polyclinic. Do you want to join in?’ I’ve had my DHA license for a good, I think five or six years? Like, ‘Yep, let’s just do it.’ We just made the decision on the phone. [Jaz]What’s the DHA license? Is that something that you had, yeah? [Fraaz]Yeah. So, the Dental Health Authority, so the equivalent of sort of the GDC for Dubai. [Jaz]And how did you have one six years ago? [Fraaz]So they’ve got like a fairly simple website as he goes through like Cherian portal. You just follow the flowchart, submit your documents, certificates, things like that. You do have to do Prometric exam. So I just went to a like a center in Salford, did set of exam on there fairly straightforward. Yeah, that was it, then you just get your license. You have to get a job though, to make it active. So I actually still don’t have an active license yet until we get the practice up and running. Yes, it’s fairly straightforward. As long as you don’t mind the- [Jaz]It was always in the back of your mind, then? Because if you had this license, you must have at one stage had the intention or the desire in the back of your mind? Right? [Fraaz]Yeah, so it’s actually quite funny, because when I got the job in Cheadle, I did my NHS to private transition completely. And I’d given up on the sort of the Dubai dream because I just had a bit of an issue with applying for jobs I just didn’t quite get a sense of, let’s say professionalism was a bit different to how it was in the UK when it came to contracts. I’m not sure what Mark’s experience has been like over there. But I just thought this is how much hustle we’re having with jobs now, remotely. I totally want to, I was too scared to take the plunge, I would say, to move my whole family over, and then have contractual issues. That’s how it felt. And then it was just that June, that phone call where just the opportunity came up. And I was like, ‘Yeah, we’re going to regret it if we don’t try it out.’ So, I’m here- [Jaz]And one thing I want to see is on your Instagram, I see you know, you have some beautiful dentistry and looks like there’s no shortage of patients and stuff. And so did you feel as though you’re taking a big risk? Like imagine someone who’s got like, a steady income as a dentist, maybe a mortgage, I don’t know if you had one or not etc. and then to sell up and give up everything to move. That’s a big risk, in a way. I guess it’s helped by the fact that you’re moving to a family sort of venture, I guess. But tell me about your thoughts in that regard? [Fraaz]Yeah, so I think financially, yeah, there’s a financial risk, but I think over, although I know I think to a lot of my older colleagues, I would still be see it as like a fresh new dentist. I feel like after what, just over 10 years experience? I feel like you build that confidence in yourself, you know what you can do. I’m quite confident in the level of customer service and Dubai, a lot of it is about service. So I know that I can bring that service to here. It’s just about you got people through the door. I think we’ve got the location right. And then we’ll see. I think another person that helped me was I don’t know if you’ve had James on one of your podcasts already. James Martin, so- [Jaz]Yes. [Fraaz]He was somebody as well, I was speaking to a lot. And he changed a lot of my mindset with the whole thought of money. So you realize it’s quite, it’s something which you don’t really have to have much of an attachment to? There’s always ways to make money. So you do what you love. And you’ll always find a way. [Jaz]Well done for chasing your dream or as a wise man, you chased your wife’s dream. So even more brownie points and whatnot, so well done. And both of you, I did right by your significant otherss sounds like. So before we- [Fraaz]I hope so. [Jaz]So before we come on to the spicy contractual things, which definitely piqued my interest. Mark, what are the requirements, like if dentists in the UK is thinking, ‘Okay, I want to go like, for example, when I had to go to Singapore, I had to like, agree to a position, I had to get some paperwork with the SCC, but there wasn’t the exams to do.’ I guess Fraaz already touched on it. But do you want to summarize in a paragraph? So what are the requirements that you need tickbox as a UK and maybe international dentists to work in the UAE? [Mark]Sure. So kind of, for us, that there’s quite a simple process in terms being and I can talk about the HAAD, the Health Authority Abu Dhabi, which has now transformed into the DOH, Department of Health. So they operate kind of independently. So between Dubai and Abu Dhabi, there’s two separate governing bodies. The first step in terms of is your accreditation. So you have to go through something called the data flow, which is like where you submit your papers, work through, you know, it’s an outsourced company that will validate everything, all of your degrees and your references and things like that. In terms of exams, there’s for Abu Dhabi. There is nothing that you have to do if you’re graduate from the UK, Australia, New Zealand and a couple of other countries, I think the US as well. So from that side, it’s fairly straightforward. The requirements are just that you have all of your paperwork is in order. So I actually applied without having had the job, you know, in my hand, and you can get through all of the paperwork, it’s kind of get somewhat accredited. And then finally, the last step is once you have the job, you kind of attach that on to your license. And then you license and gets attached to a facility, which is kind of obviously the practice that you’re going to be working. If I missed anything out, I think that’s, that’s pretty much it. It’s a straightforward process, it is timely, it took a good like three or four months minimum to kind of get through all of that, because they will send back things for more rubber stamps. [Jaz]That’s an important point, because that’s three to four months of loss of earnings and something that a dentist should keep in mind and then plan for and accommodate for. Fraaz, anything want to add to that, because it’s all very fresh in what you’re living through right now? [Fraaz]Yeah, the only thing I would say to add, well, I wish I knew there was a Prometric exam for the DOH license, because I think it’s quite easy to then switch them across, I believe. So I would have maybe done it that way around. But anyway, it is done now. And regards to, if anybody’s thinking of it, because of the amount of months it takes later, they do come back and forth with small tweaks you need to make. My advice if you’re thinking get your license done now. Iit’s not. It’s not too costly. I can’t remember the exact cost, it’s on the top my head but I think it was less than 1000 pound when you equate it for the license. So if someone’s thinking of it, just go and do them get your two or three licenses sorted- [Jaz]And that’s a one off rather than an annual release renewal. Right? So one off, [Fraaz]There is an annual renewal fee but it’s fairly inexpensive. I think it was a few 100 dirham, which is- [Jaz]Oh it’s like GDC money, it’s like- [Fraaz]No. [Mark]No. [Jaz]That’s a lot of benefit. [Fraaz]You have three UDAs. All three UDAs pays for your renewal. [Jaz]You know what, on this topic, and this might be complete rumor, this might be false, right? And this might be, I might be talking complete garbage. But one of my old principals told me that some of these Arab countries, that there is no such thing as dental protection and stuff because if something bad happens, something wrong happens. It’s Inshallah, that they say that it’s what it was meant to be. Is that correct? [Fraaz]Mark, I think you’re probably in a better position than I am since I’m at the beginning of the journey. [Mark]Okay, well, yeah. So, I mean, there is indemnity, but I think it’s related to the facility rather than the clinician. I know, certainly, that I didn’t have indemnity that was directly associated to me. And my practice owner was kind of deducting a small fee, but it was nothing like what we’re used to paying in, in the UK. I mean, I have also heard stories of you know, you know, surgeons that, you know, if something goes wrong, they’ve got the passport, and then they leave the country. I don’t think, I think those are all urban legends. I don’t think they’re actual reality. But yeah, I think that certainly that the level of litigation that clinicians face in the UK is not not there, in the same way. [Jaz]Like in Singapore, they had dental protection stuff, but my fee was like, a quarter of what we would be paying here, basically. And that’s how it was and even then, it was like, a must, it must have been compulsory, I guess. But it was very rare for litigation to be at the top of someone’s mind as a dentist and I imagine it’s the same there. [Mark]Yeah, I mean, I think in the same way that you practice defensively or you practice carefully and you always try to do the best for your patients. It goes without saying right? That’s how you get to operate in anywhere. [Jaz]Just because you don’t have it doesn’t mean you end up being reckless. Of course you’re supposed to stay true to your ethics and whatnot, but it’s just a requirement wise it’s good to know that okay, maybe a medical legal, just wanted to get the medical legal landscape, I guess. [Mark]Yeah, absolutely. Yeah. It’s different in the sense that you know, I didn’t pay any dental indemnity protection while I was there are that was significant. It was only coming out of, it was not even noticeable. So yeah, it’s definitely not the same figures that we were looking at in the UK. [Jaz]Sure. And for us, what’s next for you now? So you got your license years ago, in a way and now you’re waiting for it to become active. Now tell me about this polyclinic, this sounds like a family kind of, are they doctors? Are they creating a clinic with different specialities? [Fraaz]So my wife and her sister or two sister they’re all chiropractors. So two of them obviously my wife comes over. They will be having the chiropractic side in the polyclinic. This is where I think if Steven Davis just does listen to this, he might be cringing a bit because I incorporate them into my TMD wear. As to do a podcast on that, I think chiropractors of TMD. So they’re there. [Jaz]Let’s make that happen for us. And we’ll get your wife on, we’ll have chat again about that, you know, you definitely piqued my interest. And we need to geek out on TMD stuff for sure. Yes, carry on. [Fraaz]Sounds brilliant. We’ve got like a medical GP, obviously very different to the UK, because all insurance based here, or just pay as you go, then we’ve got some aesthetic sites like laser hair removal, like the HydraFacial stuff. That side of everything I’m not really getting involved in, that’s my sister in law’s husband. So I just called him, he’s just a very good businessman. So he’s got a couple of yachts here and car hire. And this is his next venture. And then I’m basically essentially similar to a typical UK setup where I’m almost renting the space and doing my own thing within the polyclinic. So with those, we have a license on the six specialities on the clinical already. And we need to now get the radiology license and then the dental license will be something we’re doing afterwards. So we’re doing that now. We’re currently in the process of it. Once that’s granted, then I can attach myself while I’m attached with the license on the practice, and that I can attach myself my personal license to be able to work as the dentist inside the clinic, if that makes sense. So I have like a flow diagram of how everything’s attached. [Jaz]Sure, sure. I mean, your situation is very unique. If you want to go down, the more Mark way of applying to a cold practice, someone you don’t know, principal who’s looking kind of thing, essentially, is they probably have to do a bit of paperwork, you have to do a bit of paperwork, and they sort of need to sync together to activate the license. Is that a good gross summary? [Fraaz]Yeah, to my knowledge, yeah. So as I got that far with a few job offers, where we got to the contract stage, and that’s where everything sort of fell through. However, it was just that they just need to activate my license attached to the clinic as Mark pointed out before. [Jaz]Fine. Now, before I ask you about the contractual issues, I have a very good friend of mine, who practices I’m not gonna say in which country, but country we all know very well. And then he also considered going to Dubai. And now I’m thinking very carefully. Should I continue or not? I’m going to continue. So he was Indian background. But he had a very good Queen’s English. He had the Queen’s English, okay. And so he felt really betrayed when he went to Dubai and having some interviews by principals and stuff. Because this is what the principal said to him. He gave him a contract, which was he actually no, he didn’t give him a contract. He considered it but it didn’t, because this is what he said to our our brown skinned Indian dentist. He said to him, ‘If I shut my eyes, and I give you the contract’, basically, he’s trying to come say that he can’t decide where he’s is an Indian dentist, who is your British dentist, basically. So it’s racism there basically incident that will either contract or give you either offending the Indian or offending the Brit. Because, you know, I can’t believe that when I open my eyes, you’re a brown guy, but you speak such good English, that’s kind of direction was going and I’m not saying that all principals like this. But that was one N equals one experience that with that I heard of him, and then he end up going to different country, he’s thriving, he’s doing very well. So that’s one thing that I had heard, obviously, might be very different to the kind of contractual issues that you’d come across. And the professionalism, you mentioned, that word professionalism was a bit different. And that’s, you know, funny enough the experience I had heard, so tell me Fraaz and Mark, any stories that you have anything like be careful with this or any lessons? [Mark]Fraaz, I’ll let you take this one first. [Fraaz]So my experience is fairly limited. Of course, I know, racial issues, I understand where you’re coming from, but there’s no issues of prejudice from that. My contractual issues were more when I was looking for a job or how to be quite plain about it, I pretty much told the two jobs that I was going for, that I needed to come on a similar salary to what I was earning in the UK, in order to be able to fund and keep my family lifestyle, the same it was at that time. So we’ll try to figure a way where we could see if I did actually earn that amount every year- [Jaz]Of retainer? On your first few months that we had that thing, we had six months retainer that, okay, if you grossed above it, you get more, but as a minimum, just to help you settle in you have that. So it’s a good thing to have, I think when you’re moving abroad, and I think it’s very fair that you asked for that. [Fraaz]Yeah. So I think they were trying to work out how they’re going to put that in the contract. And then the two clinics I applied for, there were then I’ll speak like a general dentist from the UK. He was like the manager you could call it and they were owed by saver, the businessman that one was there from different countries. We’ll try keep it as anonymous as possible. And I think it was the communication between there that they had issues. So it just came to where there was just delays and delays. I think so do you have a contract and other contract? And then it’s just mutually we’re like this is just not going to work out. So let’s just leave it so that was with those two jobs. It turns out the racial prejudice though. I’ve not felt it personally. Obviously, this is my own clinic. So are we from a social media marketing and so on? I’ve not had any, I’m gonna have a feeling of that either. So for me personally, you know, I don’t have any stories, but I feel like especially where Dubai is now is even different to where I used to visit 10 years ago. But this way, I think Mark can probably give a lot more insight and knowledge on two things. [Jaz]Yeah, Mark, tell us about actually be not only any contractual issues better than actually being a wet thing, a dentist in the UAE in Abu Dhabi. [Mark]Okay, so well, I mean, so in terms of the my working environment, and you know, the practice, just to give you a bit of background of where I was working, because my situation was a little bit unique as well. And the practice I was working for was owned, and, you know, by just two brothers that were working in the practice, so we had an orthodontist who was working in the practice, and, you know, prosthodontist, that was working in the practice, and they were brothers, one was like, CEO, and the other guy was like, in it. So they cared a lot about their patients, they cared a lot about, you know, the equipment, the materials, everything, and how the practice was operated. So, I think a lot of the problems where people may encounter issues with these contracts and things like that is potentially where there’s kind of, I guess, a separate business entity that has got no relation to the dentistry and- [Jaz]Like a corporate, right? Like- [Mark]Yeah! Corporate. [Jaz]You’re kind of describing a family run clinic versus a corporate really? [Mark]Absolutely. Yeah. So and, you know, the corporate jobs, you know, exist in clinics, and they exist in hospitals in the UAE. So you know, you can find fine, every permutation of that. And I think the family run business in the UAE is probably getting smaller as a proportion of clinics. So, you know, I was lucky to, you know, effectively by chance, stumbled upon that opportunity. And not only that, you know, we had a polyclinic in the sense of dental polyclinic, we had an endodontist, periodontist, you know, pediatric specialists. So, everything- [Jaz]Were they all trained within UAE or did these dentists qualified from around the world? [Mark]Yeah. So they’re all from all around the world. Our endodontist was from Turkey, my pediatric specialist was raised to do sedation clinics with was trained in the US, but he was originally Libyan heritage. We had prosthodontists from Syria, the orthodontist and the other owner were both Palestinian. We have Lebanese Periodontist, so it was great. I mean, they’re all from I guess, you could say the Middle East and Middle Eastern heritage. But yeah, we had a very intimate- [Jaz]I love that about Dubai, man. I mean, guys, you guys might know this, but maybe I’m saying it wrong. But I think one in five of the people in UAE are actually Emirati, like maybe that’s the wrong stat, but something like that, right, like, so people are from all around the world. And I remember being on holiday in Dubai, and being in this lovely restaurant and the South African couple were eating next to us. And the man who has been there for like 20, 30 years described Dubai as Disneyland for adults. And I’ll never forget that. [Mark]Yeah, you’re absolutely right. It is a little bit like that. Yeah, you did. The Emirati population is only 20% of the full of the whole country. So yeah, they’re a minority. But, you know, it’s an amazing place in that sense. And, you know, I have never experienced that kind of racial prejudice, it’s sad that the people do, I’m sure it exists it probably in the way that it does everywhere. But you know, luckily, it was an issue and I think it’s not something that’s common, but I’m sure it does exist. [Jaz]Hey guys, just interfering here with this message from Enlightened Smiles to good people with Payman Langroudi et al, who do such great whitening products but of course, their course, their flagship composite bonding course, MSM, Mini Smile Makeover, which is really heavy duty full sequence from peg laterals to compensate veneers caused by the famous Dipesh Parmar. And the wonderful thing about that course is that once you go in at once, you can go again and again for free, which is one of the best highlights I think any course has to offer. So if you’re looking for a composite course do consider Dipesh and Mini Smile Makeover. And thanks again to enlightened for supporting Protrusive, back to the episode. Yeah, but I’m kind of glad I didn’t get it out there in terms of like a Just be careful kind of thing in case you come across this but yeah, hopefully it is just a one off kind of thing. And it’s not going to affect anyone, we kind of covered already in terms of processes and how long it takes, make sure financial advice, make sure you have four to five months worth of supply to feed yourself and your family before you go out there. If you were to do something like that, before you get your affairs in order. And anything I just want to add so far before we now talk about quality of life, which is what life is about right? It’s not about yes, it’s about the dentistry, is so important. But you know, how can you nurture and raise children in a country like that the school system, the income, all these things, but before we get on to the fun bits, anything you guys want to add in terms of contractual getting to work there, the systems or anything like that? [Fraaz]I think in terms of jobs themselves, I just speak to a lot of dentists who are already here, I think it’s very limited with applying for jobs when you’re not in the country, for a couple of reasons. So number one, I think you almost now. So given you have to have your license already sorted out, a lot of people just want you to reply to unless you have your license, which can also remotely, you don’t have to come into the country, which is great or- [Jaz]That is golden advice right there, the thing that you told me. [Fraaz]And then number two would be if you are really serious, and you can’t take the financial hits to come over, maybe some of the busier times or busier periods, unless you physically present yourself to this sort of clinics after do some research. Because a lot of people in Dubai will just go jobs like that they literally walk in with a portfolio and be like, I want a job, let’s negotiate type of thing is from people I’ve heard secondhand, but I’ll show Mark, if that’s similar to what you would say or something a bit different for your experience. [Mark]My weigh in was a little bit different. But you know, I think as you said, for us, I think no one will give you a look in without the license because it can be such a long, lengthy process that will filter out so many people. That’s something that you definitely have to have, you know, 80% done or pretty much done. And then I think it’s in the same way that you select any job I think, a little bit of reflection and time taken to choose a good fit is important, especially important when you’re moving abroad as it is in the UK. [Jaz]Guys, episode one of the podcast is all about my experiences moving to Singapore and came back and at the time I talked about the Singapore dental classifier on the SCC website, there was like this monthly PDF that would come out with all the sort of different vacancies. Where do you begin to look for a job in the UAE as a dentist? Is there a community forum? Is there something that’s like the BDA equivalent like a website? Is it indeed? Or I don’t know? You tell me. [Fraaz]I use them. Indeed. Just Google jobs with the main two. And then through some of the dentists in Dubai, they’ve got like a British dental Whatsapp group, which I still need to get myself into. There are people just post on there. People just post on the WhatsApp group like looking for a dentist and we know anyone. There’s not so much of how in the UK we’ve got like Facebook groups and what I tend different Facebook groups among dentists, so if you have an argument of one dentist, you can join another one. You don’t really have that over here. As such, there isn’t like a UK or British Dental Group or Facebook, to my knowledge that everyone sort of uses, dollar mark Wales you used? [Mark]I mean, the only other one that I can think of there’s a golf based site called bayt.com, which I think they post jobs on but and then actually, you know, I send my CV out to recruiters so the recruiters would have actually called me when the opportunities came up. And that was how I got in. [Fraaz]I think, just to be careful of, just last a tad is there are quite a few scams that go around as well. And some of them can be quite realistic because there’s just as you mentioned rubber stamps before then they love rubber stamps over in Dubai. So they’ll send you lots of official looking things. So you have to be careful as somebody who can be quite tricky scams. Yeah. [Jaz]That is really valuable, man. That is good to hear that. Well. It’s sad to hear but it’s good to have our wits about us and antennas. [Fraaz]See that Mark? Mark, I think enjoys a rubber stamping. Group of stamps. [Jaz]I think you both have been through enough rubber stamping. Right. Let’s talk about quality of life. You both got three children, right. So I know Mark, your youngest is two. Fraaz, how old your youngest, and your eldest? [Fraaz]So they’re five, three, and one. [Jaz]Wow. You’ve got such a young families. That’s amazing. So I mean, you bet. I mean, Mark, you’ve already experienced a schooling system there to some degree. Fraaz you already see at the very front of your mind, you’re thinking about where my kids going to school and stuff. So a lot of dentists when they’re moving, a lot of people in general in any career when they’re moving, they’re either at the very beginning of their career, or maybe towards the end of the career. So children come into the factor for to those young dentists maybe starting a family and stuff. So how does it work? Schooling, I’ve heard conflicting things I’ve said schools can be very expensive, but at the same time, I was saying to Mark to get domestic helpers is like, amazing. I get nannies and stuff very accessible. So Mark, let’s go with you. What advice do you have to a dentist who’s thinking about taking their family like you guys did to UAE? [Mark]Sure. So we had actually had both two first kids while we were living in Abu Dhabi, my eldest Jonah started school there. So we had him in the lease in Abu Dhabi, which is the French schooling system. And, you know, the quality of the schools is amazing. The teachers in our school certainly were all civil servants from France that were there working there. So you had and it’s the same for the British schools. So they’re all privately funded schools. So you have an American Academy, you’ll have B sack which is the British schools schooling system. So wherever you’re coming from, you can actually almost transplant your kids. And they can have the same sort of educational continuity that you had. That they were having while they were back home. So the schooling is good, it’s expensive. And there is competition. I think the competition is even tighter in Dubai to get places. So people you need to apply early to get spots, but you know, your kids can get in everywhere. In terms of fees. Yeah, the fees are not cheap, but you know, equivalent to, let’s say, private schooling in the UK, I think. [Jaz]Okay, they are similar, they’re not like astronomical out of reach kind of thing. Like, if someone’s already paying for private school in the UK, they could probably then also transfer that to Durham’s and afford a school in the UAE. Is that fair to say? [Mark]Absolutely. I mean, I can give you a rough ballpark, I think we were paying about 30,000 dirhams for our son’s school. So and that was like, for the French system. So I don’t know what the other schools in Dubai are like, probably the range is big. And I’m sure you can pay up to 100 per year if you want to- [Jaz]Of course, so Fraaz, what are you thinking for your children? Have you found a school ready for your eldest? [Fraaz]Yeah, so the eldest two will, because in January, there’ll be six and four. So they’re, they’re going into the January, we find a school for them. Echo what Mark said about the competitiveness. January seems to be a decent time because a lot of people leave the UAE and new people sort of join just seems to be the way the system is over there. So places do free up. So we’re quite lucky. So we’ve got our places in school we wanted and they’re with their cousins, because I’ve got cousins the same age. So yeah, so we’ve been quite lucky though. Most of our family helped my toast my sister in law did all of that. All I did was, have you found the school was good, but wife, a sister in law communicated all I did was to deposit by let’s transfer it that’s all. I was just transferring the money. That’s about it. I think in terms of cost, I think maybe a little bit higher than the average of the UK but not much more because my eldest two who are already in private schools at the moment this may be in great British pounds maybe two or 3000 pounds difference over the year per person so I suppose it’s not a crazy jump are a- [Jaz]Little bit dearer. But I guess the elephant in the room is, there’s no income tax. Let’s just get that out now. There is no income tax now. Have I got that wrong or right? There’s no income tax in UAE. Right? [Fraaz]No, there will be a 9% corporation tax on businesses come June. Next year. That’s coming into effect. But I suppose like the UK just find a good accountant. Miles away. No. So way the system. [Jaz]Amazing. Well, that’s one good thing. In terms of income levels, though, you know, when we talked about the first episode, when I called with Singapore, and when my guests are in there talked about what you can earn as a dentist in Singapore, it was really important that we reflected a range because if you ask how much you can earn the UK, you’re gonna have a range, right? Associated with a monthly take home will be in a wide range, it could be from 3000 to 40,000. In the UK, it could be, right? If you think about it, so maybe not as wide as that. But as a remuneration kind of concept. Do you think you can live the same lifestyle, if not better in the UAE during the same time dentistry that you’re doing here? Or is it going to be a bit more of a squeeze on your finances moving to UAE as far as you get the vibe and as far as you feel? God, Mark, you go first? Because you- [Mark]Okay, all right. Yeah. So I’ve done time there. Yeah. I mean, I think you can definitely match your salary in the UK. So I didn’t really take any hits in terms of what I was taking home. [Jaz]Like the net, right? Because the gross might be low in Income tax. Right? So we’re talking net? [Mark]Yeah, exactly. Exactly. Okay. So if we’re talking net, maybe it was effectively is about the same. I think the key thing here is also makes a big difference what the environment and the system that you’re working with. So for example, our practice was mainly treating Emirati patients. So we had an Emirati base and we were treating using one particular kind of insurance or mainly one kind of insurance. So one thing to this important to note is the patient base wherever you’re going, because if they change the insurance rates that they pay out to you that can impact your pay almost overnight. Right. And that happened while I was there. So but you know, as I arrived, and towards the end of where I left, yeah, it was matching matching what we earning in the UK. So that’s your same range that you could have in the UK exists. [Jaz]Thank you and Fraaz, what are you expecting because obviously you haven’t worked there yet. So what are you kind of expecting? It’s scary, I’m sure but what have you got in terms of financial planning? [Fraaz]So I think in terms of like, I think with like dentistry, going back a little bit, you’ve got different personalities. And I think of applying the same personalities. So going back to the big DF, so like, VT purse, I was type person, I said, I need to become good at extractions. So I don’t care what that radiograph says, I used to go for everything. And I got myself to a lot of problems. But that’s how I learned maybe dangerous in the UK climate, but I got through it. And I learned a lot, so very much sort of going in with that similar sort of approach. So I’m trying- [Jaz]You’re just focusing on the quality of dentistry and in a good advices, you’re gonna see, you’re gonna hopefully, see that reflected in income over time. [Fraaz]Yeah, yeah, exactly. I’ve made contingency, obviously, got my financial sort of plans in my mind of, you know, what your thresholds of how long you can sort of live for and so on. I mean, I sort of haven’t tried to too much look at the other markets. Obviously, you’ve done your normal, you’d almost have to compare yourself. But I almost feel as though like it with me. If you look at everyone else, sometimes you may confine and restrict your own ideas. Sometimes it’s good to let your mind just go, what do you think is right, and do what you think is best if you have the confidence. And then you’ll tweak it. So my first child wants is, I call it my tweaking 12 months, I’ll learn and then we’ll take it from there. So my assumption at the moment is I don’t know. [Jaz]That’s totally fair. I mean, I wouldn’t expect to know all the answers, but it’s good inspiration for someone who might be thinking of moving there in terms of okay, what to keep in their mind. So, I guess a summary of that is yeah, the earning potential is there. Would you say and here’s interesting when you say, based on you Fraaz, your perception and Mark your experience, in terms of the ceiling, in UAE? Do you think it’s higher for income in terms of if you look at the averages in the UK, from your colleagues and stuff from what you feel. And then perhaps a ceiling? And you are you do you feel as though the ceiling might be higher because of this whole you know, you see on Netflix, Dubai blinging stuff, and it’s a very affluent place, and maybe the top denture you’re doing, is that a fair perception? [Fraaz]HSC Mark, before you answer that, if I give you my perception, and we’ll see how that lands with your experience, sure. Because it might be different to all so because in my mind, generally what I’ve learned is, end of the day, even in the UK, you’re going to hit the ceiling. See, it’s it’s hard to put a finger on it, until you make it into a business which then you’re almost no longer a dentist, you become a businessman and your dentistry is a secondary, you either open a practice or whatever dental type of business you go into, or you hire associates, things like that. And I feel the same exact same thing with Dubai, just like Dubai is a place where Dubai is of our business. How would you meet it? You moved to Abu Dhabi, that’s how I understand it. [Jaz]Mark, what do you think about that? [Mark]Yeah, I mean, I think you first kind of knocked it right on the head, you know, that there is probably a ceiling that you are going to achieve with being an associate in the same way that you probably will in the UK. And that ceiling can be super high for some people that are putting in implants, you know, eight hours a day versus someone that’s, you know, doing our simple class twos, but, or not so simple class two. But you know, that’s in the nature of it. But yeah, you I think the word of caution, I would say is that it’s, you know, people have this perception, and it’s probably a well crafted perception of the UAE and Dubai that they sell an image of the streets being paved with gold. And as soon as you come here, it’s out of your pockets. And, you know, you start going to the vending machines to buy gold bars, and you have a cheater in your car, you know, some of these images do exist. That’s there. It’s not something that there is a real Dubai and a real life and there’s like people that are kind of living a normal life and that’s kind of the reality of moving anywhere, right like and Dubai or Abu Dhabi is no exception. There’s normal, normal life that’s going on. And I think by moving there, you’re not suddenly going to be erupting and cast. [Jaz]Yeah. And then when I remember when I moved to Singapore for work, and I had a great time there. But then I had to keep telling myself that whilst I’m here in Singapore on holiday, I need to appreciate the holiday is not real life, and that your real life experiences are going to be different to experience on holiday, you won’t be eating out lavish every single day. You gotta get you know, think about and visualize what daily life might be like. And I suppose that’s important to keep in mind when you go to visit a place I’m sure you guys would agree. The other thing I want to cover is final bits is like daily life in the UAE, like the heat in the summer is unbearable, they say and also in terms of the timings, is it right that a clinic would open maybe in the morning and then take like a four or five hour siesta kind of thing and then open the evenings, Mark what was your hours like? [Mark]So our hours were not like that. Actually, we worked. So when I first arrived to Abu Dhabi, we were working six days a week, which was at back then very normal. So we were working. And we only had Friday off. I was wanting to convince my boss that we have to close on clothes, what an extra day. So we’re going to have a two day weekend. And now I think officially, actually, so where it was a Friday, Saturday weekend, I think it’s shifted now in the UAE. So you’ve got to find it, you know, Saturday, Sunday weekend. So that makes things a little bit easier. The work hours are long, but no, we didn’t have, you know, the siesta time in the middle of the day. And it was a normal, sort of, I think we started at 10 and finished at six or seven, something like that. So that’s kind of how our clinic was run. [Jaz]Fraaz, what about you in terms of the jobs you apply for and also the polyclinic, in the future, have you decided on timings? [Fraaz]I’m actually still in the process of deciding. I have come to understand that if you don’t open a certain hours, which can be quite early morning and late afternoon, early evening, then you are really going to miss out on sorts of clientele so I’m still deciding at the moment. I like to my take on an associate and so on. So I’m not to set but I think we will be doing a similar pattern to what you said maybe not four or five hours, but a couple of hours close in the middle of the day. But everyone do the school runs and so on because Dubai is a bit early than some of the American timing. And they will probably reopen but I’m still yet to decide. But I’ve come here with the mentality of for the first few years it’s gonna be like, it’s gonna be hard work not used to my nice cushy associate four and a half day nine to five and 9 to 5 and 9 to 1 as it was in Manchester, with my clinic given me all my patients and yeah. [Jaz]Yeah, I’m excited to follow your journey, Fraaz. I have every faith in from what I’ve seen so far. So now, I wish you all the best and my friend honestly, we all we’re all rooting for you everyone listening right now. We’re all rooting for you. Exciting story. And again, so thankful that you gave up your time fresh in Dubai right now and how exciting that we had your sort of input from that as well. I guess the final bits to talk about now before we wrap up this podcast is any final bit of advice that now you’ve thought of now that we’ve discussed everything, to anyone who’s probably thinking of moving to the UAE for work from wherever they are in the world US, Australia or wherever, anything that we haven’t covered yet that you want to leave everyone with, because we’ve talked a little bit about lifestyle. I mean, one thing we didn’t discuss a lot about is having a nanny and a domestic helper, but from what I understand that’s quite a thing there. That’s quite common place to have that for childcare, and that really helps massively, but anything else on that vein, either work related, or culture or quality of life related that you want to leave the listeners and watchers with, Mark? [Mark]I mean, you know, I think we’ve covered most of it, I guess, you know, the UAE did give us a really great five years, we were privileged to enjoy a really great time there. I think the one of my motivating factors and was being able to be out in nature, and I think, you know, it isn’t necessarily the as I said before, the bling bling culture doesn’t have to be the basis of you moving there while it exists. You know, we did a lot of camping trips in Oman and diving trips and Oman and things in the beach and you know, hiking mountains and things like that. So we had great communities and in you know, in the gym and things like that. So there are still cheap beats and stuff. So there is every kind of lifestyle that you want to pursue there you can find. [Jaz]And Mark, is there any point have any language barriers or anything issues that thing’s worth checking on after five years, did you find the fact that I don’t know if you do know Arabic or not, but any issues like that? [Mark]Well, so yeah, so I’m Egyptian by heritage. So I speak Arabic. My Arabic was not great when I arrived. But it certainly got a lot better because as I said a lot of my patients were Emirati and it’s a tough, it’s a Scottish of Arabic, really, it’s a challenge to understand. But you know, they’re all really great. The patients are really nice and patient and the official work language is English, right? So you don’t need to speak Arabic to move there. So- [Jaz]Yeah, that was the same in Singapore, you didn’t need to know Chinese or Malay or anything like that. And it was workable in English. So it’s good to just know that’s the case. Fraaz, do you speak Arabic or any of your colleagues where they already have any language issues? [Fraaz]No, I’m the only one who unfortunately my family that’s not like bilingual so my wife speaks Arabic, which is more the classical Arabic. My kids, we’re trying to get them into that. So Dubai hopefully will help and then see my in laws. So like the odd one out in that respect. [Jaz]We’ll have to follow up and make sure you’re doing okay and Fraaz, anything that we haven’t covered yet. They want to leave as a final thought of this podcast. [Fraaz]Yeah, I think my similar intentions of living here have quite similar to Mark’s where I’m not trying to chase the Ferrari or the Rolls-Royce or the villa that’ll all be nice if it comes. But that’s not the intention, the intention is to, to enjoy life for what it is over here. A couple of things that pulled me in that some of you might be thinking of is like the safety aspect, a good example is just now. So as you know, we’ve had issues with be setting up for this podcast, I tried to run over to die. So to try and get like an adapter for the headphones, I’d left my laptop, iPad phone, everything, just on the Tim Hortons counter, just went over and I know what’s going to be there, when I come back. You know, I know it’s not gonna be taken or anything like that. So simple, small things. So safety, that’s a big factor and the lifestyle I think you can make about what you want, really. But again, as Mark alluded to sooner, you can lose a lot of money as well, if you decide to pursue the Dubai bling pathway. So you have to be quite careful and know your personality quite well. Keeping up with the Joneses, I think is quite easy to get into over here. Jaz’s Outro:Of course, in any way of life in any culture. Mark, Fraaz, thank you so much for making such an enjoyable fun podcast about moving to Dubai, I guess my wife will have to listen to it and make of it what she will. And I guess you’ll hear from me, for my principals who are listening, don’t worry, nothing’s gonna happen. I want to be one practice for a long time. But if you piss me off too much, I’ll be on the plane to Dubai. Thanks so much, guys. Well, there we have it, guys, thank you so much for listening all the way to the end, I hope there was lots of nuggets, lots of food for thought, maybe you are settled wherever you are working, maybe you’re happy where you’re working. But it’s sometimes good to know what dentistry might be like in another country. So hopefully, you’ve experienced that today. And if you’re someone who’s actually actively looking for a big shift, and maybe you’ve been thinking about UAE, I’m sure there was lots of nuggets in there for you as well. This episode is not suitable for CPD, there wasn’t enough meat in terms of CPD, but most episodes are suitable for CPD and CPD certificates. And obviously, that’s all on the app on Google and on Apple, and even the web. So you go to protrusive .app as a website, or download it on the Apple Store, or the Google Store, and I’m constantly adding exclusive content, some of the new content I’m working on now is a full clinical video of me prepping and bonding four units of ceramic under rubber dam. This is a case where also I had an interesting black triangle when I was trying in the ceramics and how I manage that by sending it back to the lab and how my technician was expertly able to fill in the black triangle and how good it looks now. So lots of learning points in that. And that’s all in the Protrusive Premium Section of the app. And you can also of course interact in the community section and be able to download the videos for offline listening. So in case you have choppy connection, you can just have it downloaded to your device. So that’s all of the Protrusive App. Thank you so much. Once again, I’ll catch you same time, same place next week.

I admit it. I have relied FAR too much on my lab technicians to help design my chrome partial dentures. This needs to change! I realised that I want to take control of the denture design process – who better than the King of Removable Prosthodontics education Dr Finlay Sutton to help us ‘Make Dentures Great Again’! In this episode, Dr. Finlay Sutton clarifies the philosophy behind Scandinavian Chrome Dentures. He also explains what each appointment entails to help those earlier in their career. https://youtu.be/3aS7kZZUM_0 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: DENTURE DESIGN CHEAT SHEET! Dr. Finlay came up with a Universal Design Sheet. It covers all aspects of missing teeth – all different combinations and patterns of tooth loss. It covers teeth with good prognosis and also teeth with dubious prognosis Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 2:15 Protrusive Dental Pearl 4:05 Dr. Finlay Sutton’s Introduction to Partial Denture 6:31 The Scandinavian Partial Dentures vs other designs 11:24 Scandinavian approach for Chromework 12:56 Acrylic-based Partial Dentures 18:04 Indications for Chrome Palate on Complete Denture 21:17 Acrylic dentures with a wire mesh inside? 22:49 Cast Partial Dentures Protocol – Appointment by Appointment 32:13 Patient Reviews  34:39 Average treatment fees Join us for The Scandinavian Approach to Partial Dentures with Dr. Finlay Sutton in Reading, UK on the 13th of January OR the 14th of January If you enjoyed this, you may also like another episode with Dr. Finlay about Chrome Dentures Made Easier Click below for full episode transcript: Jaz's Introduction: I love restorative dentistry. But the thing I always enjoyed the least I guess is DENTURES, complete dentures because I had a bit of experience. And I did a restorative post and I did loads of complete dentures I quite enjoyed. Jaz’s IntroductionBut chrome dentures, for whatever reason, demographics exposure, didn’t get enough chance to practice the art of chromed dentures. And to be honest with you, I never got on with surveyors and I never really understood denture design. Now fast forward many years, and I started to get a more elderly patient base and the demand for good quality denture work increased. So, I had to match that demand. And I’ve been relying too much on my technicians to help me with the denture design and touchwood, I’ve had some good results so far. And what that did, it inspired me to learn more, I want to take control of the denture design now, hence why I’ve got Finlay Sutton coming next month. So, now it’s December. In January 2023, he’s coming to Reading I’m bringing him down south because I’m allergic to the north. And I’m just so excited to start implementing everything he’s teaching, but this episode will go a long way in teaching you about the philosophy of SCANDINAVIAN CHROMED DENTURES as well as for the younger dentists, every single sequence of Chrome Denture Provision, what is done at each appointment and why you do it in that order. Hello Protruserati. I’m Jaz Gulati, and welcome back to the Protrusive Dental Podcast. It’s almost coming to the end of 2022. It’s been a crazy year for the podcast. We’ve had so many episodes, we launched the app this year. Like I am so proud of what our team put together. Thank you for hundreds of you who’ve been downloading on iOS and Android and sending the feedback and good vibes overall. So, really appreciate that. This episode like 98% of the episodes of Protrusive are eligible for CE or CPD certificates. All you have to do at the end is answer a few questions to validate your learning. And my team will email you a certificate, you also get early access to the episode. You get exclusive monthly content. So, last month it was the full mouth case discussion with Alan this month is through the loop view of fitting for ceramic units. This is not found anywhere. But on the app only. And the future, we’ve got Vertie prep for plonkers course exclusively on the app and loads more to look forward to. So if you’re a true Protruserati, download the app right now on iOS or Android. Or if you’d like to consume it all from the web, go to protrusive.app. The Protrusive Dental PearlToday’s Protrusive Dental Pearl is actually going to be read out and spoken by Fin himself first ever Protrusive Dental Pearl, which is spoken to by my guest. Fin, take it away. [Finlay]Okay, so I think one of the most difficult things with partial dentures are designing them. And so what I’ve come up with this a universal design sheet and sequence. So, it covers all aspects of missing teeth. So, all of the different combinations and patterns of tooth loss, I’ve got two sheets, which you can laminate, just print it off, laminate, put it in the surgery, and then you can apply that to any case that comes in. So, it covers both teeth with good prognosis, the good support teeth, and it also covers teeth with dubious prognosis that may need to be added on to. So, I think that’s the main Pearl here. And but the other thing I think is really important with top tips and things like this is, it really is attention to detail. So, getting really good at dentures does take training and practice and dedication and reading, you know, so it’s not going to happen overnight. But like anything that is hard to do. That’s worth doing. It’s hard to do, really. So really go for it. Thank you. [Jaz]So if you want to access to this PDF, there’s two ways to get it. One, is if you have the app already, you go to the Protrusive Vault, it’s been uploaded to the Protrusive Vault already. And number two, is if you go on www.protrusive.co.uk/denture-design, that’s denture-design. You’ll be able to download this very comprehensive design document that I heavily encourage laminating and using as an aide memoire when you’re designing your dentures, let’s join the main episode with Finlay Sutton. Main EpisodeFinlay Sutton, welcome again to the Protrusive Dental Podcast! How are you my friend? [Finlay]I’m really good. Thank you. It’s great to be here. [Jaz]It’s so nice to have you after that really epic episode. We did Episode 56, which you covered so much ground really like we talk everything from Chrome dentures for bruxists to ideal design to immediate dentures, and we had lots of questions from the community and that was just brilliant. And I am super excited Fin to be learning from you next month. It’s been one of my, in terms of courses, on my bucket list to make sure I get to see Fin and I want to learn partial dentures because I’ll be honest, a little confession I’m really bad at them. But, so that’s why I wanted to come to you to learn, but you’re too far away from you, Lanarkshire. So I’m bringing you down to Reading, it’s a sold out course. And we are just absolutely buzzing to host you. [Finlay]Absolutely. So, well thanks very much Jaz, I’m super excited about doing that. And it’s gonna be really, really practical. Because I think that’s the end of the day, that’s what we do is a subject. You know, we are dentists, and we treat people, patients. So and that’s what it’s all about. It’s just case, after case, after case, there’ll be shown was a little bit of work done by you and the delegates too because what I’ll be wanting you to do is to design the case before actually show it. And then I’ll then show the case and tweak the whole thing. Because at the end of the day, what I’m really wanting is for every delegate to go away, knowing how to design a partial denture, a really good partial denture, for any patient that comes in through the door. It’s as simple as that. That’s what I want to do. [Jaz]And that’s exactly what I need. Because although I’ve been doing a lot more chrome work and partial dentures over the last three years, just patient demographics has changed over my career the last 9, 10 years, I am relying far too much on my lab, to do the designing for me, and I’m going by their best judgment. And so I can’t wait for that all to change when I am a little bit more savvy on designing so that practical exercise that you’ve got inside that course that you plan, I think that’d be really key for learning. And I know you’ve been teaching all over the world for so many years. And you refine the art of education and personally from seeing your speak more didactic, like big, you know, 400 plus kind of sessions, by the way, we have me and Fin we’re just talking. Fin recently lectured an IMAX theater, which is mind blowing. But even then you are just so such a brilliant educator, your energy is wonderful. So, thanks again for coming on. Today, we’re talking about Scandinavian Partial Dentures. Now, I always having to think about this Fin and I was thinking, a dentist who scores across on Spotify or on the app or on YouTube and and comes across his term. What could that mean to them? And maybe some dentists might think like IKEA, let me think does the patient just build their own partial denture? Is this like the smile direct club for chrome dentures? What are Scandinavian Partial Dentures? What makes it Scandinavian? [Finlay]Okay, so I’ve thought about this. And it’s something that people ask me all the time. What I think is really important is that if we go right back to basics, and the way that I was educated in the UK, here that my textbook was this, which was the Davenports, and Heath. Basker, Davenport, and Heath, and this is very, very much like the British dental journal textbook on it. And if you notice here, in this design there, we’ve got a few of these little struts coming up. They’re little minor connectors. And these sorts of things are in the Scandinavian principle, crossing the gingival margin like that, in the interproximal area, these are areas that patients can’t actually clean. It really is a no, no, it’s breaking the rules completely. So, the overall concept about that it’s a hygienic approach to design. And the other thing is, the other Bible I used when I was doing my specialist training was McCrackens here. And this is the latest edition or it certainly may be a new edition, but look at this partial denture on here. And this partial denture there. [Jaz]And just describe it for our audio listeners, if you don’t mind just describing it. [Finlay]That has a plate on it. So, there’s a plate design. And if you imagine a plate, if you’ve got a free-end saddle, bilateral free-end saddle on a lower denture, if there’s a plate covering the gingival margins, what’s going to happen underneath that plates whilst it is worn. Just think about the plaque retention, the accumulation, the inflammation that causes and the Scandinavians have got 50 years of research to show that if things are covered like that, on the gingival margins like a plate, it really increases periodontal problems and also caries too. So, the whole concept about the Scandinavian approach is to keep it open. So, where the gingival margins of the teeth are, then we don’t want, I don’t want any component crossing the gingival margin, because any component sits there increases inflammation. So, I think the best way to try to visualize this is that if we’ve got any missing teeth there, we’ve got underneath that we’ve got the bass so we could call that the sublingual bar or the lingual bar or the palate, the plates at the top, the major connector at the top so that the basis and all the bits for the denture, come off that base. So, when we’ve got the base there, if we’ve got a missing teeth saddle, we just want the minor connector to come up into that saddle area, and then rest on the teeth either side of that saddle area. So, everything sweeps up into the saddles and onto the teeth. So with the Scandinavian concept, if the denture is made really well, we should be able to get TePe Interdental Brushes between all of the teeth with the denture in place with it in place. So- [Jaz]I think that’s brilliant. I think that the data that I used to come across as a DCT and restorative, when I wrote the paper on resin bonded bridges many years ago, it was that partial dentures in the literature are likely to increase your caries or incidence by three times. And it’s been shown that there’s conflicting studies, but some studies show that you’re more likely to get periodontal disease, or caries. But I guess it depends a lot on how you design it. And one lecture I remember going to was an implant based lecture even though I don’t do implants, I just remember very clearly a really good point, the educator made Fin, he said that, you have to be very careful with a patient who is edentulous, because what they have gone through in their life to get to that stage is like a lot of disease processes, a lot of neglect to some degree to be able to end up in that position. So, when you’re doing your implants, be mindful of that. And maybe that’s why we’re in a peri-implantitis happens. And if you apply that same concept to partial denture wearers, then maybe part of the reason why they lost the teeth is the reason they may lose the teeth again, so just make sense to make them as cleansable as possible. Do you also apply a Scandinavian approach to acrylic partial dentures? Or is this philosophy exclusive to chrome work? [Finlay]So, it is exclusive to chrome work, and I 100% agree with what you said previously about patients that have got multiple missing teeth, you know, they’ve suffered disease processes, but the beauty about the Scandinavian approaches, and you touched on it perfectly, then because they are removable, resin bonded bridges. That’s what they are. And this is the other difference between Scandinavian and the way that was taught in Britain, the rest seats in the Scandinavian approach, a much bigger and wider, smoother. And we have backings and support on the anterior teeth too. So, they are just like a resin bonded bridge wing, like the retainer parts. And the beauty about these and it’s very important for these patients that are going to be potentially losing teeth in the future. Because, you know, we don’t have a crystal ball, how long everyone’s teeth are gonna last. The prognosis is quite often dubious for these cases, I don’t like taking teeth out. And I know you love teeth as well, natural teeth are fantastic. Let’s keep them even if they are not great teeth, we can put a backing on them, we can add to it in the future. So, these things are totally future proof. Now, if we then move on to acrylic based dentures and my personal opinion about acrylic based dentures are they are temporary appliances, I totally get that. If we’re working in healthcare system like say the NHS, we may not be able to provide a metal based denture for a patient. So, I think it’s important to retain good prosthodontic principles. So, for instance, if we’ve got a free end saddle, and we’re going to be providing an acrylic base denture, then extend it fully, right up the retromolar pad, so you’ve got a good support on the lower. Same for the upper use the palate, it’s brilliant for support, and use the tuberosity for support too. That’s really important. Essentially, though, acrylic dentures are temporary appliances, they are gum strippers, unfortunately, because it’s hard to get to support. This is the important concept for the Scandinavian approach to support is king. If we can rest the denture on the teeth, and it’s not sinking into the soft tissues, stripping the gums, then that’s brilliant. Now, and this is really important having a great technician, sometimes a very, very occasionally have made a long term acrylic denture for a patient. Now- [Jaz]You mean like long term partial acrylic denture, right? [Finlay]Long term partial acrylic, and this chap had missing two to two. He had retained three, four and then missing posterior teeth. So, this nice sort of symmetrical situation. So, we made an acrylic based denture. But Rowan fashioned, little metal rests outs of 0.9 millimeter wire, which you’d use for normally for making clasps with. But if you bash the end, you can flatten it. And then, we had little rest seats on both sides. So, one on the four, one on the three on both sides, which meant that acrylic based denture had a rest. So, it stopped it from sinking in as much obviously the main- [Jaz]And in that scenario what made you then continue with that long term partial acrylic denture rather than either going for chrome in the outset? Was it periodontal reasons? Was it prognosis reasons? Or was it support reasons? [Finlay]No, it was actually because of finance for this particular patient. So, it is less expensive to do this. But I don’t normally have my arm twisted with that type of thing. It’s normally the acrylic is a temporary and generally they are immediate dentures, which are used for one, I’ve taken out, hopeless teeth. And then we’ve placed them and then that immediate denture then becomes a definitive, which is a metal based Scandinavian concept. So, that’s it’s a really important thing. And the reason that I don’t do there’s two big reasons I don’t do acrylics as long term partials is that number one, they break and snap and crack. And patients come in for repairs, if a patient and when they come to see me that. So, I would say if I was doing an acrylic based denture, then it would maybe be four to 5000 pounds to do that. So, a patient will be cross if that breaks. So, they are very much a temporary appliance for the patient. And secondly, they’re just really good as a diagnostic tool as well. The great you know, if we’re taking out a load of teeth, I can put this immediate mark one in. I call them mark one dentures. Mark one goes in. [Jaz]I love that. [Finlay]That’s a diagnostic appliance, and then we can move on to mark two later on. So when patients come to see me, that’s how I planned them, they’re always mark one and mark Two, if we need to extract teeth. [Jaz]Amazing. And when I come to your course next month, I’ve got a couple of cases on the go, who are wearing mark ones. And I’m going to design my mark twos the chromes when I come to see you and learn from you. And really interesting ones, an eight year old chap who I did an alveoloplasty because he had severe over eruption of his anteriors with too much bone, not enough space for the teeth aesthetically with the teeth. So, I did an alveoloplasty, bit of surgery, and now he’s wearing the mark one, he’s very happy with. But he needs a lot of general dentistry, crown work, restorative work. And so, I’m really looking forward to that fun case, and a few others, which I’ve had an honest conversation with him, I said, ‘Look, I’m gonna go to this guy called Fin, I’m gonna learn from him, give me a couple of months. When I come back from the course let me design you a denture.’ And they’ve been fine with it. They’ve understood that what they have in this acrylic partial denture is a mark one. And I show them an example of a chrome and discuss the benefits and patients are on board with that. I digress a little bit, but I just want to ask you, because this is a thought that I’ve had is upper complete acrylic dentures, which I know you lots of education on and it’s a beautiful art and your videos on suction from them. Your upper and lower is just amazing. When would you consider an upper complete denture with a CHROME BASE? What are the indications because I’ve seen a few those I’ve done one in the past. I couldn’t tell you what the reason rationale was behind at the time, but I’d like to hear from you. [Finlay]Okay, quite simply, the metal base strengthens the denture, it reduces the potential for it to fracture, and it reduces the potential for an unhappy patient. Because if the denture breaks, it’s quite easy to fix, but it’s quite difficult to repair the patient’s confidence in it. And, you know, so as a rule, this is how I go and I always break the rules because there are certain circumstances that we have to- But anyway, generally, as a rule, if I’m doing a complete denture opposing natural dentition, which is called the combination syndrome, I’ll use a metal reinforcing base in the denture. So, that’s number one. Number two, I do it for implant supported dentures. So if I’ve got an implant supported lower, you know, with two lovely locators, really secure bottom denture biting onto a complete upper, again, metal reinforced to the upper. And also, obviously the lower two, you know, the Implant Supported Denture, if there are any implants in the maxilla, as well, and I’m doing full upper overdenture on implants, metal reinforce always because of particular. And then the other. I think the fourth reason is history of breakage. If a patient comes in and they’ve got an old denture that has got this wire in, because they fractured it previously, and maybe they’re very warm the teeth, bruxists tendencies, because bruxism still occurs in patients that have got no teeth. So, it’s really just to add that extra strength, just as a little caveat just at the end. Why don’t I do it for everybody? Well, getting retention on an upper denture with a metal base is slightly more difficult because it is marginally heavier. It’s just only few grams, we’re talking like a metal reinforced upper complete dentures 25 grams, whereas the acrylic base is usually around about 19-20 grams-ish. So, that can just slightly offset retention, if we’ve got a very flat maxilla. And also, if we’ve got a patient who’s got high frenal attachments, that means when they smile and talk, that frenum exposes the edge of the denture and the seal, the peripheral seal breaks. So, it’s those two cases where I’d say to them, ‘Look, I’d prefer to do an acrylic based denture for you is more likely to break. Would you like a spare as well?’ So, I then offer a spare. So, then they can wear one on a Monday, different on a Tuesday and swap it and then wearing them together. [Jaz]I think that was an emphatic answer for that question. That was absolutely brilliant. I really love that. So, when you have a metal base, how does that compare to an acrylic upper complete denture with a WIRE MESH inside? Is that just a waste of time? Or it does not have some benefit in terms of giving it rigidity? [Finlay]The only benefit of a wire mesh is that if the denture snaps or cracks the acrylic, then the two edges are still held together. So, it’s not a catastrophic failure for the patient, they’ll still be very uncomfortable and not great. But let’s say they’re on holiday. And it happens they can probably limp along until they get it sorted. But they don’t offer anything other than that. And sometimes we, Rowan, I think they actually weaken it. And then the other aspects of a metal base in the opera is what’s really important is to have an acrylic post down. That’s crucial. So the denture has a better peripheral seal. And also we can realign the denture should it need it as well, which just makes it future proof, much better suction. [Jaz]Lovely little gem there. The next question I have, as we get towards the end the questions is quite a big high level question. And I think to to make it tangible. This is aimed more at the young dentists who are starting to make their first few dentures or slightly more experienced dentists like me who just doesn’t get to make enough volume of chrome dentures, and it’s nice to revise. We can make like a little handout for this is what are the STAGES in general? Obviously, there are nuances and we have to deviate away from the rules, but a very standard patient for a partial denture, what are the titles or sequences of the appointments? And how many appointments would you typically take? [Finlay]So, I think if we look at it, really, I’m looking at a list here, and on average, to fit a chrome, it’s seven visits for a metal base denture, talking about metal base dentures. So, let’s go visit one. So, we’ve got our consultation with a patient and we have a look in the mouth, we make a diagnosis, I’d take a photo. And from that I then do my first design because that goes into the patient’s letter. And that’s my first thing, I get my first design done, number one, the first active treatment is a visit two and that is primary impressions. ‘So, I do my primary impressions to record the whole thing. And from that, I then Rowan post those models, we cast them up and then we can have a look at it and we can finalize that design. So, I say to Rowan this is what I want to do. This is my aim and design. This is the model here. And then we put it on the surveyor and we have a look at it. And Rowan says to me, ‘Yes, we can do that.’ Or, ‘No, we need to make minor changes.’ He’ll say, ‘Look, sometimes it’s just not possible.’ I’ll say something that he can’t actually do, he might not have enough space to put a tooth in place. Anyway, it’s just a good discussion. So we do the definitive design then, and they will tell me, ‘Right Fin, I want you to take a little bit off the teeth here for the guiding surfaces, or make some space for rest seats in these areas. Because just like with resin bonded bridges, they have to fit in an hour.’ So, sometimes we’ll have an undercut, you know, the lingual surfaces of the lower teeth go inside like that, I might just have to shave a little bit off to make your level [Jaz]I just want to make a point there, Fin. Sorry to interrupt but that’s such a huge point. Because a path of insertion often dentists thing that path of insertion is applicable to removable dentures, we think of denture as part of insertion, path of removal, but resin bonded bridges and indirect work also needs a path of insertion. And it becomes extra important with rigid materials like chrome denture work to visualize that path of insertion, and it doesn’t often need much prep, it just needs a little bit. I like red flame diamond burs, soflex discs, just to get those planes, is that what you use as well? [Finlay]Absolutely all the time. Just little tickles. I call it a dusting of the teeth, more than grind to shaving a touch off to fit. So, absolutely. So, visit one is design prelim exam. Visit two is primary impressions, definitive design. Visit three is then definitive impressions. So, my working impressions and I always say to the patient, this is the most important, this is the most important visit of the whole thing. Because I’m wanting this thing to fit and I need to record your mouth exactly as it is. So, I’ll do my adjustments. And I’ll then do my working impressions. And then visit four will be jaw registration. So, that’ll be you know, wax rims, or a gothic arch tracing. If I want to find CR, I’m either making the dentures in intercuspal position, or I’m making them in centric relation. So that’s my jaw. Number four- [Jaz]At that stage, do you take a face bow record? Do you personally? [Finlay]Yes, I do. [Jaz]Do you take a face bow record? [Finlay]Yeah, I do face bow as well. So now, just going back to intercuspal position. And this is really important. This is why there’s not a set rule of thumb in terms of visits, sometimes I can actually skip a stage, if I’m doing my working impressions, and the patient’s got a really stable intercuspal position. And those models can be mounted really easily, then I don’t need to do a jaw reg, at that. I don’t need an extra jaw reg visit. I can put a bite in. And just do that if need be or quite often they just fit together beautifully just by wrist articulating you know so and a – It was really good. It all everything fits together beautifully like that. So normally though, I will do a bite, a jaw registration at visit four isn’t it? I think we’re at now I’ve gotten the list, and then visit five- [Jaz]I’ve lost track as well. [Finlay]So, let’s do so primary says one, definitives in, two. Bite at three. Number four, will be try-in. Tooth try in at this point. [Jaz]This is with the chrome and the wax attached together? [Finlay]No. Definitely. And this is a common sort of misconception the chrome is made after the trial is done. [Jaz]Got it. [Finlay]And the reason being just like we wouldn’t put implants in randomly in the mouth without having knowing where we’re going to put the teeth to start off with. I want to engineer the chrome to be in a perfect position to where the teeth are going to be placed. So, the chrome try-in comes after just purely the chrome try-in comes after the tooth try-in. So it’s tooth try-in and then it’s chrome try-in and then it’s finish after that. [Jaz]Now, with the chrome is tooth try-in to check the aesthetics and make sure the chrome will be in the right place. I guess there is a place for the chrome you might modify the design based on the tooth try-in but then when you go to the stage after the tooth try-in and just to clarify, the tooth try-in is wax and acrylic teeth. That’s it right? [Finlay]Yes, it is. [Jaz]And then the visit after it chrome, wax and teeth together? [Finlay]No, no, it isn’t. It’s purely bare chrome try-in without teeth. [Jaz]Got it. [Finlay]And with these Scandinavian dentures, there’s lot of tooth to contact. So, you got multiple contacts. So, I don’t want to have wax teeth getting in the way of me just checking that this chrome framework, the metal bases fits in beautifully. [Jaz]Your visualization is improved? [Finlay]Yeah, it is. It’s visualizations improved, everything. So, so once I know the chrome fits, I’ve already done the to try in, I can just go late to finish. [Jaz]Would you recommend for a less experienced colleague, a younger dentist to at that stage, if they’re following your principles, and they’re learning from this? And they want to apply, what they’re learning. The tooth try-in make sense, the chromework try-in a lot of dentists would do that earlier on in the chain, perhaps off the definitive straightaway. Would you recommend that the less experienced dentists or for a tricky patient maybe to do a chrome and tooth trying together? Everything’s in wax still? Or do you truly feel that has no benefit, and rather, is better to go to the fit if you’ve already done a separate tooth trying and a separate chrome trying? [Finlay]Yeah, so the only circumstance that I would do, add in an extra stage of doing the chrome and teeth would be if Rowan one is setting the teeth up and arranging them feels that there may be a little change in the tooth positions from the first try in to the finished denture. If he feels that, there may be some very important retentive elements on front teeth along a bit of front, is the aesthetic zone stuff, if there may be some changes that he has to make, or we have to thin the teeth down so much, that the color may change as well. Because when we, you know, when the ground out of the back, the chord changes. It’s really, if there’s going to be an aesthetic change. That’s when we do metal try with teeth on trying. So- [Jaz]Got it. Got it. [Finlay]Yeah, that’s just purely. So, essentially, if we go back, we just need to recap this, this is quite an important concept. So, normally, and I’m just doing it on my computer here, because I’ve got it here. So, we’ve got number one, primary impressions, number two working impressions. Number three is the jaw registration to prescription. Number four is tooth try-in. Number five is metal base try-in, bare metal base try-in. And then number six is fit. And then it’s reviewed after that. That’s the my general rule of thumb approach. [Jaz]I take, since all everything I picked up from you, from Episode 56, about trying in dentures and using occlude spray, you taught us so much. And I took a lot away from that. And even just from that, the last four chrome’s I fitted, the patients come back at review. And there’s no ulcer. There’s no adjustments, the occlusion’s spot on, everything’s been really good. So, either it’s got lucky, or I really implemented everything you told me from that short podcast episode. And I’ve gained a lot from that. So tell me, what do you usually see? Because you take so much care and time to get these right in various stages. And for those who need it a gothic arch tracing, if you’re repositioning the the bite, do you often have to do much adjustments at the reviews? And how many appointments are included? When you when you quote a patient for a fee, in terms of quoting correctly, how many review points do you build into that fee? [Finlay]So, I’ve built in two, because on average, and I’ve reviewed my cases since introducing the Scandinavian concept. And on average, I’ve 1.7 reviews for patients with metal based dentures. So quite often, it’s just like one review, and then we’re off we go. So, it really worked beautifully. And interestingly, the way that I was taught the British standard approach, the reason that I changed to the Scandinavian approach was that I wasn’t getting good consistent results. And it wasn’t predictable, and not on average, in my specialist practice. And I was a specialist at this stage. I was reviewing my patients four times, I had to see them four times with the sort of RPI system and that sort of system that I used to learn approach so it’s much better. So, I just find it remarkable that virtually it’s between one and two review visits. It’s amazing like- [Jaz]Well, I think I definitely need to buy my technician a bottle of wine because I think kudos to my tech because he’s been doing a great job and he’s helped me a lot with my design, Fin. I’m hoping to change that so I can I can lead the design held by. [Finlay]You know what, it makes me really happy that you have that success from this. It’s really wonderful that you know, your patients are benefiting from this. It’s lovely. So, great. [Jaz]Oh, it’s great. I have so much more and more confidence in delivering partial dentures and it’s a really important thing to cover. I’m starting to get a reputation now, Fin to help drive the areas of dentistry which are not perceived as sexy, so treating TMD in general practice, occlusal appliances, or recently hosted an acupuncture course in Reading with David Johnson who came by did a wonderful thing. Now with occlusion, we were doing a lot work with occlusion, so things that aren’t considered sexy. And now obviously, one of the reasons I bring you on is because some people, a lot of dentists, they’ll go on the composite course, they’re gone the Botox at facial aesthetics, but partial denture education, I feel it’s something that’s so necessary of dental school. And I think guys like you, and my good friend, Rupert are really and Mark Bishop, you guys are making removable prosth, sexy. So, I have so much respect for all of you, and keep doing what you’re doing. But I think young dentists need to appreciate that we need to charge appropriately for these amazing devices that are just a miracle. We look at it as a work of art, it surely is art. How much if you don’t mind disclosing do your cases typically cost into it for patients in terms of your fee for an average, but like you describe the average sequence. And I think this will help people realize that we’re under charging, just like I teach we under charge for clothes appliances, grossly. I think we undercharged for partial dentures, but you probably have a stronger opinion on that than me. [Finlay]Absolutely. So, I think that my average fee for a metal base denture for one single is it’s about 10,000 pounds. And I think that it’s really, first of all, they are worth it. And you’ve touched on this beautifully, just then when you were talking about they are works of art. Now, I strongly believe and I’d love to stand up and with these implants, people that just really are extremely dismissive of partial dentures. And I’d like to have a battle with them. And say that I’m actually right. Okay, which looks better, you know, a really good partial denture, what is aesthetically superior, when someone’s got a high smile line, and missing teeth. So, the best way to replace the missing tissues is with a partial denture, if we have a really, really skilled technician, and there’s a great clinician, they’re working together as a team, I think we can beat hands down, fixed prosthodontics, you know, with with this, I think the detracting factor of a partial is we’ve got other clasps, and, you know, those clasps have to be hidden some way, you know, we use gold and we put them back as far as possible. That’s the main detracting factor. And, and also, the thing is removable, so the patients do have, you know, within the dental profession, we have negative connotations about dentures, and also within the general, too, so, but, you know, like, we’re both both of us are pushing these non sexy areas of dentistry because I think they are sexy. I do, I think, you know, we, I restore patients lives, I totally changed their life with these lumps of plastic and metal. And I probably changed them better with these sorts of things than with, you know, with fixed restoration, where it’s extremely hard to engineer gum work to look like natural gums, the white is not too bad to deal with, you know, the teeth themselves, but the gum work is. And I do believe that we should charge for these sorts of things, too. And I think, the ultimate testbed, and I used to work in the hospital system, I was a consultant at Manchester dental hospital, and I was, will be treating patients with cleft lip and palate and with missing, you know, big defects and that type of thing. And also normal patients who would be referred in as in patients without these problems, but were difficult denture cases, I’d get to the end of the road with them. And some of them may be weren’t totally happy with the outcome. But I could say to them, ‘Look, we’ve tried everything here.’ And the patient would buy that because they’re not paying directly for the, you know, actually say, okay, consultant, you know, professional, I know you tried your best, and they’d accept that. Now, it totally changed when I went into practice and worked as a high street specialist making referrals that patients would come in, and then I’d be charging, you know, between five and 10,000 pounds for a denture. If the denture wasn’t totally right, and the patient wasn’t totally happy with it. I couldn’t say to them, ‘Oh, we’ve tried everything. I’m really sorry now’, and then off they go. And they’re a happy camper. Not at all. So, this is why I had to change from what I was previously taught to something more predictable. And this is where meeting John, he’s a very old dentist now, you know, he’s in his 80s. But he’s probably one of the best British removal prosthodontist ever, who learns off Charlotte Stilwell, who’s the Danish prosthodontist that brought it to Britain. She brought this concept here. She’s a specialist, Charlotte works in London. And I went on a course. And it completely changed the way I did things, you know, so, and that’s why I learned Scandinavian concept. So, my reviews went from four, and not very happy patient to two, and happy patients. [Jaz]Amazing. [Finlay]And it was amazing. And also like yourself Jaz, you’ll be understanding that you sort of engineer of practice to the type of work you want to do and the type of patients that you want to treat. And that happens over time, as well. So, there’s something really important as well about this is I only do two clinical days or week treating patients now, I’m 51. I do another day, which will be is today actually, I’m actually doing online, Zoom consults with new patients and phone calls, just to filter them out and make sure they’re okay for coming in. Now, I find that two clinical days is enough for me, because my patients are referred to me so they’re quite difficult, there may be technically challenging and most attentive, potentially challenging. But also, they do have personality issues, potential personality disorders, were the densest, that’s referred to men, it’s just found them hard to manage. So, they’re quite tricky to cope with. So now, I personally can only really handle two days of working with these types of patients. So each day, I’ll be seeing maybe six patients a day, four of them will be lovely, absolutely great. But two will be really hard to manage, and will really test my metal and my patients. So, I find that two days is absolutely enough to keep my sorts of mental health good. Now, in order to do that, though, I have to charge a lot of money to sustain, it’s like two days of intense work to keep me in a living. So therefore, my hourly rate is currently 750 pounds per hour of clinical work in order to you know, fund that, that process. So, hopefully that just explains my situation Jaz. [Jaz]It does wonderfully. And I think we should appreciate the how much care intention experience that you have behind you also having a specialist status. But the reason for asking you that question, and Fin, thanks for answering this, honestly, and giving it all away. I really appreciate that. Because I think dentists need some inspiration that actually everything we do, when we put so much thought and care into it, and to adopt a mindset whereby A) you’re worth it, and B) not to undersell yourself, because these patients are tough. And sometimes the difference you can make, even from a single resin bonded bridge, but I speak to dentists all time, who are just way under charging for a single unit resin bonded bridge. I’m like, forget that it’s a resin bonded bridge, it’s not an implant, you are giving that patient a tooth, you’re restoring the patient’s smile. [Finlay]Yeah. [Jaz]And then once they think of it like that, but patients also kind of compare it to an implant and they shouldn’t be that much different today, you know, they shouldn’t be like one is like 300 pounds, or 3000? No, no, it should be a charge much more probably. Now, when you apply that to denture work. I mean, it’s very obvious that you’re restoring someone’s function and aesthetics in a huge way. And you just have to subscribe to Fin’s newsletter to see the amazing work. So, I’ll put a link at the bottom for that. But anyone who would like to join the waiting list for the course in Reading on the 13th and 14th of January, please email me DM me, we’ll get you on that. So, we’re looking forward to learning from you Fin. And actually one of the reasons I asked you to selfishly. Well, the reason I asked you to come on both Friday and Saturday, and I was really keen to fill those spots is that we can have you to ourselves on Friday night, we go out for a nice dinner with everyone a Christmas themed dinner. No, not Christmas theme, it’s next month. We’ll think of a new visions New Beginnings kind of dinner. And I think everyone’s really looking forward to. Just getting to know the man behind the dentures. So, Fin thanks so much for discussing Scandinavian Dentures. The philosophy, just makes so much sense. And telling us all every little detail, you’re so giving with your information that other episode we did 56. I learned so much from that personally. And then I love the style of education that you developed. So, thanks for making dentures sexy again, once again, and appreciate your time always. [Finlay]Thank you. It’s a pleasure. Absolutely. Jaz’s Outro:Well, there we have it guys, Finlay Sutton. Thank you so much as always for listening all the way to the end. If you’re listening or watching on the app, you can not only download the full transcript, you can also download the notes. The notes include a sequence by sequence cheat sheet and on the protrusive vault. You can also download the PDF of the Pearl he described which got every single design. So that’s all on the app for you if you want it. Alternatively, you can get the cheat sheet but not the notes on protrusive.co.uk/denture-design. And if you wanted to come and join us for Finlay Sutton live course in Reading UK on the 13th of January or the 14th of January. So, if you just drop me a DM @protrusivedental or email me jaz@protrusive.co.uk, and let me know, we’ll put you on the waiting list. Thank you, Protruserati and I’ll catch you same time, same place next week.

This podcast will change the way you think about pulpotomies and endodontics in general.  Georg Benjamin explains that severe throbbing pain (or classic signs of IRREVERSIBLE PULPITIS) does not necessarily mean a pulpectomy is needed. Instead, we can consider a pulpotomy for permanent teeth to preserve radicular pulp tissue and maintaining a vital tooth! Download Protrusive App on iOS and Android and Claim your Verifiable CPD/CE answering a few questions + EXCLUSIVE content: https://youtu.be/PoWDRz714uQ Check out this full episode on YouTube Protrusive Dental Pearl: Check if your anesthetic is successful by carrying out an objective test by placing EndoFrost (-50 C) on the tooth (about 10 secs) and checking for a cold response. If the patient is not fully numb yet, they will still feel something. If they are sufficiently numb, this test gives you (and some nervous patients!) confidence. I like this before placing rubber dam as I hate ever removing the dam to top up LA! Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 2:02 Protrusive Dental Pearl 4:47 Georg Benjamin’s Dental Podcast Journey 7:10 Georg’s Endodontic Journey 11:46 Case Discussion: Pulpal Diagnosis 16:17 Pulpotomy 19:37 Direct Pulp capping  22:26 Indirect Pulp Cap 23:58 Pulpotomy Protocol 26:59 Classifications of Pulpotomy  30:52 Bleeding Time Protocol 33:31  Patient Communication  35:34 Treatment Decision-Making 38:57 Success rate of pulpotomy 41:10 Early and Late failures 42:30 Long-term treatment 45:14 Unhealthy pulp 48:08 Materials and Products for Pulpotomy 50:54 Leaving carious dentine as base For our German Protruserati, check out Georg’s Dental Podcast If you enjoyed this, you might also like this episode with  Dr Ammar Al-Hourani ‘Is Single Point Obturation Acceptable?’ Click below for full episode transcript: Jaz's Introduction: Grab your onions Protruserati, because this podcast will change the way you think about a pulpectomy, you will probably do way LESS EXTIRPATIONS and committing to a root canal. Jaz’s Introduction:And this episode really challenges our beliefs that we hold in terms of what requires a root canal treatment, ie we were trained that irreversible pulpitis equals pulpectomy, which is a root canal right? Now, that’s what I was taught to. But what is happening now in endodontics, is brilliant. And Georg explains it really well, with his lovely German accent, we go over the fact that nowadays, whenever a patient comes to Georg, with irreversible pulpitis , that you know, severe throbbing ache, it does not mean root canal for him anymore, it means a PULPOTOMY OF THE PERMANENT TOOTH, it means a pulpotomy of a vital permanent tooth, which then hopefully, will preserve that radicular pulpal tissue, and therefore, the patient will not require a root canal treatment anymore. So, it’s pretty different. Now, maybe you’re already seasoned in this, maybe you’ve already using MTAs, and whatnot. And that’s amazing. Good for you. But for a lot of dentists, I imagine this is like, wait, what do you what do you mean, we don’t have to do I commit to a root canal anymore like we can, we can actually do a pulpotomy for an adult, let alone one that we have diagnosed as, quote unquote, ‘irreversible pulpitis’, which actually Georg argues, is a poor term. Welcome, Protruserati. I’m Jaz Gulati, I’m your host. And if you’re new to the podcast, welcome. It’s great to have you. If you’re a veteran, and you’ve been with me for many years, it’s always a pleasure to have you. This one’s a really cool episode, I didn’t think before I recorded it, that I’ll be having so many moments of laughter with our guests, Georg Benjamin, who was not a specialist in Germany, he is pretty much limited to endodontics. And he’s been following vital pulp therapy or pulpotomy of vital adult teeth for a long while now. And he’s got some great views on it. And if you listen to the end, we say some very controversial things about certain groups in dentistry. So, I apologize to my friends by offended you. It was all a little bit unjust but a little bit serious at the same time. The Protrusive Dental Pearl The Protrusive Dental Pearl I have for you today is and I’m really hoping I haven’t shared this one with you already before, but it is how do you test for OBJECTIVE ANESTHESIA? So, as you know, guys, I’m a big fan of buccal articaine infiltrations, for lower first molars and even lower second molars, if I’m doing a root canal, or a crown or a large restoration, I am no longer reaching for an ID block, I am doing a buccal infiltration with articaine. I’ve got a video on YouTube showing exactly how I do it. And I get about 90% success rate with this. And I say there’s easy patients and then there’s difficult patients, the difficult ones being the thick bone and whatnot. And yeah, probably successes 80% with those guys, but more normal anatomy than I’m probably getting 95%. So, if you balance it out, it’s about 80- 90% success rate. And so, one thing I started to do to really make sure my patient is super numb is instead of subjective, instead of asking the patient, are you feeling quite numb, is that is that really numb, it’s much better to be objective. So, I get some endo frost, so minus 50 degrees on a cotton pellet. And I put it on tweezers, and I press it onto the tooth. And I leave it there for about 10 seconds. And hopefully the patient will feel nothing at all. Now that for me, gives me so much more assurance that that tooth doesn’t require a supplemental anesthetic. It does not require an inferior alveolar nerve block. And that’s worked really well for me. So, in those times where I put the coal on, and after about six seconds, they say you know, I just feel a little bit, either give a little bit more articaine into the gingival tissues, subperiosteal region, or I might even in a tricky patient, give it an ID block at that stage. So, it really helps me in my decision making. So, next time you’re not sure, do a objective test by putting endo frost on the tooth and just seeing the response before you start your therapy. Now by this point, usually I already have rubberdam on as the last thing I do before I then continue my treatment because most of times, they won’t feel the end of frost anymore. This episode is brought to you by Enlighten Smiles, the good guys Payman Langroudi et al who support this podcast so dearly. Thanks so much. I love using Enlighten Whitening, I’m getting great results. My patients, they got some awesome trays, and their gel is always fresh. And of course, if you want some training, you have to check out the one-hour webinar that Payman does, as always is in the link section. It’s also on the YouTube for the freemium version. And if you’ve not already downloaded the app, the Protrusive app, oh my god, we’re getting so much traction. We’re getting so much good vibes on the community section and the exclusive content is just gonna blow your mind. The amount of things I’ve got planned for it. It’s gonna be amazing. So, if you haven’t downloaded Protrusive app yet, what are you waiting for? Download it. Let’s join Georg Benjamin to discuss vital pulp therapy aka pulpotomy for adult teeth, no more irreversible pulpitis. Georg Benjamin. Welcome to the Protrusive Dental Podcast. How are you, my friend? [Georg] Oh, I’m fine. Great to finally be on a different podcast as well. [Jaz] Well, it’s for those who don’t know, Georg is a host of his podcasts was mostly in German, I believe. Tell us, you’ve been podcasting way longer than I have. Tell us about your podcast and in Germany and what kind of topics do you cover? [Georg] Basically, I started podcasts in 2016, which is now basically ages ago, and actually, I remember in 2018, everybody in the podcast environment was talking about, oh, which podcast peak, it’s over now. It won’t rise anymore. And I was basically inspired by the dental hacks podcast, basically, the American podcast, which is now very dental podcast, they kind of split up, but I’ll admit they’re still doing it. And I was kind of surprised how Americans talk openly on their podcast, about certain things like, oh, well, I got everyone in my team, an iPad. I mean, they’re just a $1,000. So, I got 10. [Jaz] Sounds like a very American thing so. [Georg] Things you would never hear on a German podcast, it was like, Yeah, talk to my text advisor. And afterward, we found a way to make it work. Yeah. Well, at least my podcast is called SaureZähne Dental Podcast, actually, the name wasn’t very SEO, anything. We just started started enjoying the dental hex and started our own podcast. And actually, we were the first German dental podcast for our dentists. And it was really good networking too. I mean, who should I tell you that I saw how you grow with your podcast. You know, you even have an app, which is really great. And it’s the networking part is so good. I just can encourage everyone to start a podcast. Today, there are so many podcasts on how to start it and how to present yourself. I started just without anything. I just started about a name at first and started recording. It was so much fun, I can really recommend to everyone. [Jaz] Amazing for those who who want to listen to a German Dental Podcast, check out yours. I can’t even pronounce it. But it you know, it’s amazing that you are so dedicated and I’m sure every dentist in Germany probably knows your podcast today would do this in English guys. Don’t worry, be reassured. We’re gonna do an English podcast today on vital pulp therapy as you in our preamble, our pre chat you described as vital pulpotomy for adults, because dentists are more likely to be like, ‘Oh, okay, I can visualize what that means.’ So before we get into that, just tell us a bit more about yourself. Are you limited to endodontics? Are you an endodontist? Or do you just love endodontics? [Georg] It’s very interesting. Basically, in UK terms, I’m a general dentist. But I spent most of my time with endodontics. That means now I recently opened my office, I have scope CBTC. So, everything you need today, for endodontics. But actually, when I graduated in 2010, I basically didn’t have any or when I heard this term pulpotomy of teeth, I was only thinking about milk teeth, and never heard about anything else. It was really interesting. When I was a young dentist at my first dental job, I was in an office in a rural area close to Berlin. But they were like two dental offices in a town of 10,000 people, and very well, really bad. So many patients, it was crazy. I mean, after two weeks, all my afternoons are already fully booked. But it’s like the best start for young dentist. And we had an interesting approach to pain treatment, if someone came in refer a reversible pulpitis. And the pain treatment was basic, very simple, because we didn’t have a lot of time, it was a full pulpotomy. And we basically just placed a cotton pellet on it with a Ledermix, which is like an antibiotic steroid mix, which is very popular in Germany and covered at Cavit. And we call the patients on the next day just to see if they’re fine if we should need to root canal treatment, or if the whole thing bought us time. Actually, it surprised myself a lot, how much times it’s actually gave us and when we started to do the root canals later on. It was quite useful, but pulp was still vital and the root canals. And it was basically we had to do anesthesia, rubberdam, of course, and it was pretty much standard endo. And I was always chatting with my boss back then. It was Dennis. ‘Dennis, how come this pulp cells and they are still vital even it’s I know. How come we can’t place anything on it like MTA. So we don’t need to do the endodontic treatment. And you know back when it was like if it’s irreversible pulpitis it’s no way out completely. It’s a one-way street. [Jaz] Which you know that everyone who’s listening so far. I mean, not everyone but I’d say 98% of the colleagues, the Protruserati listening right now probably think the same as what I thought as well, which is when you diagnose irreversible pulpitis, that’s it. I mean, that’s the end of the line for the tooth. It needs a root canal if it’s even possible, right? [Georg] Yeah. And basically, maybe the terminology is wrong. Not saying but it’s not very easy terminology. If it’s irreversible, we don’t have to do it. If it’s a reversible, we have to do it. But if it would be have a different name and wouldn’t have the name I will suppose that it’s a one way street, we might think different. But let’s be honest, it’s very easy diagnostic tool to say. That’s the street we take here. That’s the street, we take there, and fine. And basically, I did some endodontic continuous education. And I met Martin Trope who basically showed us a really nice study from a guy called Mr. Bowden from the US an endodontist, who basically treated young molars of young children basically, with full removal of decay. But he called the direct pulp capping with MTA. But basically, when I look at the clinical picture, it was basically a partial pulpotomy because you really removed all the decay nichts apart a couple of times, just placed MTA on it. And it worked. And the thing is, you know, okay, it’s one study, let’s see, but this recall rate was 97%. Yeah, it’s like enormous. Martin Trope was joking, but private detective was hired to get this week away. Unfortunately, Georg couldn’t attend the last German endodontic Society Meeting due to some restrictions, because I wanted to ask him that. But with these results in mind, I kind of started in a different office where it’s getting more and more endodontic focus to treat these cases. And I remember one case, where basically everything went wrong, Jaz, seriously, everything. Yeah, it was a deep cavity assault on the x-ray before I basically knew that. Some partial pulpotomy is better than the direct pulp cap due to the literature, which is outwear on these topics. And I did a partial pulpotomy places- [Jaz] Before you progressed with this course, let’s paint a picture, how old was the patient? And what was your pulpal diagnosis before you started? [Georg] Yeah, basically, the patient was maybe in the mid-30s and adults. My diagnosis was basically in reversible pulpitis because the patient didn’t get any pain. And- [Jaz] I want clarity, reversible or irreversible. I couldn’t hear it. [Georg] It was reversible pulpitis . [Jaz] Reversible, okay. [Georg] Just imagine, you see deep caries close to the pulp, and you’d be like, okay, the tooth is vital. The patient doesn’t have a lot of pain, but we need to treat it, it’s pretty sure. And basically, entered the tooth, did a partial pulpotomy, placed my MTA. And back then I basically had a two-step approach for the first place the MTA, did a temporary filling, and we call the patient to see if the MTA has set. And when I was placing the temporary refilling, which was Cavit at this time, I basically suddenly saw how the blood from the pulp came out. And we’ll say okay, this will not gonna work at all, because I’m out of time, I can’t do anything anymore. It is how it is. And maybe she will be there as a pain patient the next day, but she didn’t come at all. And you know, if the patient doesn’t come up, you basically already know what happens. You went somewhere else in Berlin at least. But basically, the patient came back, I think a month later because the temporary filling fall off. And basically, the MTA and it was hard. And since this was a partial pulpotomy I could do my cold test and to correct normal. And I just placed my composite on it. And that’s it. And then, I kind of realized maybe I didn’t trust the pulp too much things. [Jaz] You didn’t have faith? [Georg] I didn’t have faith at all with a pulp. I mean, I kind of like- [Jaz] Like most of us, right? Especially if it’s caries, like, you know, you’re gonna think okay, ‘Mr. Smith, you need to have a root canal treatment for sure.’ So, I don’t think that’s surprising. I think most of us would, I think there’s a real paradigm shift for us. [Georg] Yeah, it’s a paradigm shift. And actually, now there’s new literature out of which it makes it easier back then, it was eight years ago. This is how we noticed that we are actually old, Jaz. But you know back then, whenever you had such a treatment, you should always say it was reversible pulpitis because still wasn’t really allowed in a irreversible way, kind of you know, but the interesting part is, actually there’s this term called Vital Pulp Therapy. And it’s actually sometimes a bit misleading because vital pulp to me could mean anything, it could be in an indirect pulp cap, a direct pulp cap, partial pulpotomy, full pulpotomy. In the last e-meeting. I even learned the term mini pulpotomy, which is interesting. But I like this term. It’s from a British guy I forgot to sorry. And basically, I’ll focus pretty much on the pulpotomy part because it’s the more interesting part. [Jaz] Okay, before we get to that, Georg I just wanted like back to that case that you mentioned that lady who had this positive experience where you thought that okay, she’s gonna come back in pain or it’s gonna go necrotic and it was fine. Eight years on now. Do you still see this lady? Have you seen her? Is everything still, okay? [Georg] Actually, with this woman I didn’t saw her again. I saw her husband. But she also had like a really bad root canal to the teeth, which needed treatment. And she didn’t like my fee behind it. So, she never came back. But I know that she was fine for quite some years. But I started recalling and documented these cases after that, actually, because it has gotten a bit more interesting. [Jaz] And with that case, for the younger dentists listening which everyone actually, when you had that deep caries, which you knew was close to the pulp, but your diagnosis was that you know, it was still reversible pulpitis at that stage. There wasn’t signs of deep throbbing pain, keeping awake at night, nothing like that. Why did you not consider just removing as much caries as possible, but leaving some caries over the pulp and just restoring like that? Do you not think that perhaps dentin could have been the best insulator, the best base, in that case, the best lining if you’d like. [Georg] Oh, you’re touching a really topic, which are feeling really strongly about it, I would like to put it in the end of the podcast, because- [Jaz] We’ll find out. Stay tuned until the end, we will find out why Georg prefers to actually go into the pulp in that case and do a pulpotomy which leads us nicely to what you were just going to explain. [Georg] So, let’s focus a bit on the pulpotomy part because it’s quite interesting. First of all, basically pulpotomy started more or less in traumatize tooth. And therefore, we have a lot of really good literature about pulpotomy and permanent tooth, you just say, chipped, central incisor, the pulp is exposed. And we basically know from literature, even if this young patient is running around with this open tooth for a week or so. But we just need to remove two millimeters of the vital pulp. And it still will work. Yeah. Which is surprising because the pulp has an immune system, and therefore it’s fine. Of course, we have probably cases where it doesn’t work. But spec showed that in his enamel studies, that it worked and even like later on with his patients, and which is interesting. And this pulpotomy has a high success rate. But let’s be honest, it’s all young patients on traumatize teeth, no caries, of course, it works very good. So, what’s with the teeth we see in our office and interesting there’s like study from Iran, actually. But they did a multi-central study with full pulpotomy in permanent teeth and compare that to a root canal treatment. And actually, the results were comparable. But we have to be careful when we’re this study. Because you can also always make studies and kind of get the same result if you don’t read them well. And I’ve never been to university and never, of course I’ve been to uni. I’ve never worked at university. I’m really not good to literature, Jaz. So it’s the first time I didn’t see it. But actually, in this study, which is was quite good. The RCT group just brings sterile water. And you know, in vital case it probably works, but not as good as maybe a stronger disinfectant like sodium hypochlorite. So- [Jaz] Okay. [Georg] So, the results are pretty much the same. [Jaz] So, for the actual root canal therapy prior to the obturation for this RCT group, they chose to use sterile water. And- [Georg] Yes, that’s it. [Jaz] But we know, let’s talk. That’s not even the gold standard, we know that we should be using sodium hypochlorite. So, why would you do that for a study? Surely, that’s negligent? [George] Yeah, you could do it. I wouldn’t go so far to and maybe they wanted to have the RCT group to be a bit less successful, but they both more or less get 80% success, and which is actually 80% percent success. If you just look at by the vital pulp therapy group, multicentric, a lot of different dentists is quite good actually. When you look at the molar, it’s much easier to do a full pulpotomy and a molar, play some MTA and restore the tooth right away than to do a root canal treatment, but I always have to advocate if people are now saying, ‘Well, it’s an alternative to an RCT. No, actually it’s a more predictable pulp cap. I would say pulpotomy is more predictive and a pulp cap. But let’s be honest, a lot of people out there and I have done the same, came from the university, done a pulp cap and it went horribly wrong. That’s a patient- [Jaz] For students, just for student listening young dentists, vital pulp cap just recap. Direct pulp cap, indirect pulp cap, what is the difference? Just describe what kind of materials you would use in each scenario. [Georg] Let’s say you just removed an old insufficient restoration, maybe an old GSE amalgam whatever, and you accidentally see that vessel open pulp. Yeah, or maybe you nicked it. And basically, in this case, I would just like use calcium silicate cement that could be an MTA could be biodentin, could be whatever and rinse it a bit with sodium hypochlorite usually I use 2%. Some people suggest 3%. Some say I always use 5% because it’s the only thing I have to offer, doesn’t matter in my eyes. And basically if it’s like, doesn’t have a lot of symptoms before, it probably is fine. Yeah, I probably best- [Jaz] And that’s a direct pulp cap, right? And then you know what it when I trained we were using dycal. [Georg] Yeah, dycal was actually quite bad idea, because it- [Jaz] Of course. [Georg] There’s literature that dycal, carelife, self-setting calcium hydroxide products work less successful when freshly mixed calcium hydroxide. It’s quite surprising. But I was taught that in university because already back then everybody should know it from literature. And basically, it’s better to use a freshly mixed calcium hydroxide and two places on the pulp. If you come up with it, I basically use MTA because due to my endodontic background or endodontic 70s. I think it’s cooler. But if you look at the literature, they are both are great. Maybe it’s a cotton product that resolves. Yeah, we see that sometimes old pulp caps, but the pulp is still vital. And sometimes in this scenario with the direct pulp cap, I tend to avoid it by doing something I would call now learn that term. It’s called mini pulpotomy. Because before I come to the mini pulpotomy, because I noticed I did some pulp caps with really cool materials. They’re called Bioceramics effing unfair still went wrong. And then noticed that sometimes even it’s just a small pulp exposure. And the bleeding stops by itself, which is basically by the book, the best indication sign. [Jaz] It’s a good sign. [Georg] Yeah, it’s a good sign. Actually, I now with my experience in vital pulpotomy or pulpotomy, I rather see the pulp bleeding, and look for it, I would just like freshen up it with the diamond burs at high speed. Just don’t remove anything, just touch it two, three times, see, okay, it’s really bleeding. Because I noticed sometimes that there’s some blood in the pulp chamber, which kind of finds its way but when it stopped when you open it, you really don’t see a lot of really nice vital pulp tissue. And remember that story when I come back to the decay part. So, but first, I hope I don’t jump around too much the indirect pulp cap. [Jaz] Yes. [Georg] I also already told you at this podcast, that I like to remove all the decay even if it’s an hour Cochrane Review, which basically states that I’m basically dentin Bavarian, who removes too much dentin. That’s fine. Yeah, in cases where I have deep caries. And I really thought I would expose the pulps but I don’t. Even if I removed everything, sandblasts everything. Then I will do following, still use sodium hypochlorine like to clean something. Yeah, because- [Jaz] So, you’re basically killing the cavity even though you don’t have exposure? [Georg] Yeah, you know, we cleaned the cavity, because we have one study from Michael Sander, who basically did vets and even in an indirect pulp cap, a successful rate was much better when without, which was interesting. In my logic, it’s quite logic. And then I will just pass again, calcium silicate cement, this can’t go pretty fast as the biodentin. Just cover the dentin, close to the pulp, not everything. And basically covered with self-etching flow. Because I’m really lazy. I don’t really like to wait for the biodentin to set. In my hands, it works very good. Some people like to wait 12 minutes until it sets, that’s fine. Some people even do the two visits, which is fine and do a cut back. For those indications, a metric is really a good choice. And that’s it for indirect pulp cap. [Georg] Yeah, let’s now go to the real pulpotomy part. And now’s the interesting part that you have someone coming to you could be an young patient or patient with a big decay. And of course he has pain, maybe even at night. And I always say, of course he has pain. I mean, if you have like Swiss cheese, very close to the pulp and you feel everything. Of course, the pulp is irritated. And so the question is always, how much is the pulp irritated? So, of course I do my pulp testing, I do an x-ray to kind of see if there’s no lesion on the x-ray. Although we have to kind of say if it’s a huge lesion, we probably say that’s a necrotic and our cold test was basically a false positive. But if it’s like really, really tiny one, I wouldn’t give it too much of a thought actually, yeah. [Jaz] CBCT maybe if you’re, in that would you consider that? [Georg] I have a CBCT. Actually in this case, I wouldn’t consider it because now I strongly believe it’s a vital pulp therapy now and then confident, but I handled the root canal treatment, I really like to consider it. But it’s a case by case decision. But the past, I went more and more for the pro CBCT. Because it gives me a lot of information I need. But for example, these cases, you see maybe something on one root, which is like an enlargement, not to be lesion. And when you kind of take out your measuring tool and measure, it’s more than one half millimeter. Because if it’s more one half millimeter, referred, it’s probably more likely to be lesion. If it’s less than half a millimeter, it’s probably not a lesion. Yeah. But so rule of thumb, I heard somewhere, I can’t credit anyone, but it was a great tip. I got but usually in this vital case, ideally, if I would do CBCT in this case, I probably would expect I don’t see a lot of it. So, since I wouldn’t probably not to wear root canal treatment since I don’t see anything, it doesn’t really bring anyone a benefit. But remember just in case, and everybody who’s a dentist knows that. This one will be a no for sure. Because it’s such a big caries. And I don’t have to point out if it’s molar or premolar or whatever. You just know that feeling. And in some cases, even you think about which posts I’m going to place or whatever. And it’s interesting when you enter these cases, these really deep caries we see in the dental practice, I considered my first choice of treatments always a full pulpotomy. If it’s really, even me if it’s pain, we don’t bother around with partial pulpotomy, due to pain management reasons, actually. Because, of course, if you would be a patient and you accidentally, it would have like hidden caries nobody saw with all the technique we have, I would probably consider in your case of partial pulpotomy, knowing that we have an full pulpotomy as the second option as well. Because your patient, which is a dentist and we both know what we’re doing. [Jaz] But you know, one thing before you then maybe continue is coming on to the difference between the mini, the partial, and the full pulpotomy. It seems like you know, for me, the pulp chamber and a molar sometimes is very, very small. So I mean, what is really in millimeters difference between and the protocol, I guess between a mini, a partial, and a full? For me, it’s just you’re tickling the pulp chamber, you’re going to make it bleed, and then you’re going to put your MTA on top. So, I’m surprised that there’s three classifications of nicking the pulp chamber. [Georg] Actually, there’s a really interesting German PhD thesis that she found more. But let’s say the mini pulpotomy is really easy. You just have a pulp, you just push the burs really gently on it. And you know, it’s- [Jaz] How big of a bur? Because this is important, you know how they used to say like, ‘Oh, if it’s like a half a millimeter exposure or etc.’ [Georg] Yeah, okay, I know what you mean. Basically, I have Komet bur, which is a ball, which will really long shaft. And basically, I think, a millimeter in diameter. And I have also a bear cut which one is always sterilized for this kind of process. Because I just don’t want to use a bur, just used for excavation, where efforts they will kit I take out you can argue that it probably doesn’t matter. But that’s a different discussion. And referred, I would do mini pulpotomy and the partial pulpotomy. And by partial, my ideas to take two millimeters away. But now it really depends on the molar, for example, from which angle do you look at, from the occlusal? Or from the lateral? And from the lateral, it’s quite hard to distinguish sometimes. And there’s interesting studies about pulp caps about pulp expose on the occlusal and pulp caps on the lateral. And of course, on occlusal I our work better. And I would say we probably can transfer this knowledge to the pulpotomy as well. But it’s harder to do partial pulpotomy if you just nick a pulp horn and kind of remove it. And so you don’t know, did I do a full pulpotomy on one root of smaller and the partial pulpotomy of the other one. And to make it short, if a doubt, go for full pulpotomy. What is full pulpotomy? You just go until the root canal entries. [Jaz] Like the orifice, a bit literally like the canal orifice? [Georg] Yeah, pretty much. That’s the full pulpotomy. You basically take the whole pulp chamber away. And actually it sometimes makes bleeding control quite easier than the partial pulpotomy because you just have some root canal orifice where it’s bleeding and you can kind of just use your sodium hypochlorite, which is my first choice. Sometimes I even use sterilized cotton, the foam pellets to put some gentle pressure. [Jaz] And one thing that maybe someone may not appreciate and I’m just thinking out loud here is if you’re trying to stay within the pulp chamber and not actually damage the pulp tissue in the canals, it’s fair to say that with you’re hypochlorite, you’re definitely making sure that you’re definitely staying within the pulpotomy. You’re not forcing any hypochlorite into the canals, is that an important part of protocol? [Georg] Actually, it’s important that we don’t put our syringe like an endodontic treatment and place it directly into canals. But actually, it’s a typical question you’re pointing out, Jaz. Because a lot of people are afraid, will sodium hypochloride destroys a pulp? And basically, just say, ‘Did you ever get a sodium hypochlorite on your skin?’ Yeah. And the question is some say yes, some are ‘What’s happened?’ Well, it burnt a bit. But did it went through your hand? No. And actually, it lower concentration that used to be in the First World War, instead of infection agent for open wounds. And so, of course, the sodium hypochlorite can disolve necrotic and vital tissues, but that’s good news. It’s basically doing parts of your pulpotomy for you, but in a chemical way. And that’s why it’s like the best thing you have here. [Georg] And now we have to talk about bleeding time, because that’s the most obvious question when it comes after it. And it’s really interesting when you look at the literature, and we have now recommendations from the German Endodontic Society from the ESE. And it’s great when we have, for example, Dominica, where we could wait two minutes, and then he goes on with this partial pulpotomy, wait two minutes again, until he reached the full pulpotomy. But Dominican Country is really great. And Mayan, but he has a lot of time and patience. [Jaz] Yeah, but what are you waiting for? Like if you enter the pulp chamber, and then you just wait two minutes to let it bleed out? [Georg] Yeah, basically, you place, your sodium hypocholride and wait for the bleeding to stop. Basically, actually, in the ESE paper, you are allowed to wait for five minutes, for example, first to a partial pulpotomy wait five minutes, bleeding is still there, when you do a full pulpotomy wait five minutes. And if it’s still bleeding too hard, you basically go for root canal treatment. And that’s actually a recommendation, which is for every general practitioner out their fight gods, but we have to think that it’s just a recommendation. It’s not a law, we have no science supporting this bleeding time. And, of course, there will be now someone on university under endodontic department who wants to kill me for that statement. But that’s fine. Actually, I love having discussion with my German endodontic department because I say and have some minor literature to prove it. But the bleeding time doesn’t really matter. But that’s just my science opinion. But it’s okay to have it. Because I noticed that sometimes there are also other bleeding control agents out there, which don’t have any signs of doing so I don’t mention that. But if we just look at milk teeth, they basically use ferric sulfate that works great. Yeah. Could you use ferric sulfate in a permanent molar? Yeah, probably you can. Is your science on it? No. Pretty easy. So, I basically come to guessing and some people are afraid that we are hiding some symptoms which are inside the pulp and which costs pain. But let’s be honest, if the patient has still has pain after full pulpotomy, you do a root canal treatment. And that’s it. Did you lose anything? No, you have a nice pre-endodontic build up? Probably? Is it hard to drill through MTA? No, it’s quite easy. Because MTA is like under filling out an amalgam. You really say ‘Yes, great. It’s so easy to remove. It’s not tooth colored composite, or GIC, which is template so easy to remove.’ So go for it. [Jaz] But a real-world issue here, Georg, is then is fee discussing, you know, setting your fees for the patient and extra time that’s going to take to then need that and then you need to have a patient on board that, okay, we’re trying this. If it doesn’t work, then you need to pay for the root canal treatment. And then he just needs additional procedure and having a patient on board that, you know, had you just had the root canal treatment, you’d be out of pain. Now, It’s a shame that you don’t have a pulp anymore. But we’ve been doing it for many years. [Georg] I know what you mean, actually, in the beginning it’s quite easy. You just present two plans. One is pulpotomy and one is root canal treatment. We don’t know yet what will happen. Probably if we have time to plan that, you say pulpotomy is one appointment where it’s just maybe half the price. And root canal treatment is two appointments. So, it’s double the price It’s logic.  And basically, the people are crazy, always on your side. If you say we try to avoid what kind of treatment or I don’t like it, I told you, but I don’t like it to point it out as an alternative to what kind of treatment but for example, it could be a false positive, so there’s no pulp inside. That’s just the necrotic, of course, you have to do a root canal, pretty much, pretty easy. And so for the beginning, it’s actually quite good to do it. Actually in Germany, we have the problem that our health insurance billing system doesn’t really have this pulpotomy position for permanent teeth. For milk teeth, they have. So it’s kind of, you have to be a bit creative. Unfortunately. [Jaz] We know what that likes in the UK we know how to be creative in our systems. [Georg] But basically how it works. Just because you’re from UK, Jaz. So, a guy from the UK said it also too easy meeting he waits for 10 minutes. [Jaz] Oh, my goodness. Okay. He must have been in private endodontist. Not a health board. Yeah, nothing insurance base there. So, that that makes sense. I mean, there’s so many questions going on my mind now. So, you’ve described the mini pulpotomy, your sink the bur through a little bit, let’s say a millimeter. Partial is up to two millimeters that you go into the pulp chamber and full is you reached the canal orifice. One thing I want to know now is still that decision making. So, what I’m hearing I’m guessing Georg for you is that irreversible pulpitis. I’ve been awake all night in pain, I need to put a cold bottle next to my tooth to get out of pain. That classic irreversible pulpitis. You’re suggesting to me that you will still try to assess the bleeding time and potentially go down the route of pulpotomy. In this day and age, 2022 Qatar World Cup coming up. And you’re saying that now you’ve shifted away from okay, there’s two things RCT to, actually, I’m going to go for pulpotomy. Am I hearing you right? [Georg] Yes. But there’s also a little but. For example- [Jaz] Let’s see the nuances. [Georg] So, for example, if you now have a businessman who will be at the World Cup in Qatar next week. It’s a different patient management in this case. I would say, look, I would strongly believes this will work. But it could be but emergency dentist in Qatar says that I’m the worst dentist of the planet, because I started the RCT and did not finish it. So, and it really depends on for example, now I’m more or less don’t have my own patients anymore. I have I get referrals. So it makes it a bit more complicated as well. So, let’s say the next 14 days he’s in town, and would be fine, if it were something I would probably go for pulpotomy. The younger they are, I tend to more say pulpotomy is my first and only choice, because it just makes sense in my eyes because I did a lot of the treatment of teeth, broken canals, broken instruments, and I know how many things can go wrong and I break even instruments of course, yeah. So, it’s for my logic, my first choice. And if you have your first patients where you’re doing it, always do a full pulpotomy. Dentist always wanted to do a partial pulpotomy in their first case, always do a full pulpotomy. Just trust me. I talked to really cool people like Ness retire from John who did research on it. And she even said, which is something scientific. The full pulpotomy tends to be a clinical better than the partial one. [Jaz] Then, why not always do a full pulpotomy? It’s only like a millimeter, two millimeter extra pulp tissue. Let’s just go for it. [Georg] Yeah, I mean, there is a partial pulpotomy which has some advantages. And one big advantage is that you can do a cold test later on to see if the tooth reacts to it. But full pulpotomy, you can’t do a cold test because- [Jaz] I didn’t know that. [Georg] Pulp chambers for and that’s really drawback, but it’s still safe for your first case, guys remember me saying that. Go for a full pulpotomy. I know where people sending me x-ray. I did a partial because I was afraid. Okay, do full pulpotomy before. Okay. Firstly, then get experience. And that’s fine. [Jaz] All I’m thinking Georg is the next time your uncle, your brother, your father, your mother, your nurse, your receptionist, your neighbor has signs of irreversible pulpitis or that very deep caries that you just know it’s going to be an issue, then perhaps your first full pulpotomy should be on this kind of patient. [Georg] Yeah. And actually, right now, I wouldn’t have any problems to do it on any family member on any staff member to do full pulpotomy. Because I now have the confidence. But we talk about failures as well. Because without talking about failures, it would be very misleading this podcast. Yes. Yes. Basically, you can basic distinction between early and late failures. Yeah. First of all, how high is the possibility that the patient will be better on the next day and still have pain? I can tell you, that’s a pulpotomy as a pain treatment works in 91%. Well, as a pulp ectomy will work at 99%, and from an emergency dentist point of view, and you had to do a podcast recently, I think. [Jaz] Yes, yes, we did. With Sanj Bhanderi. [Georg] Yeah. Was a great one. [Jaz] I’m sure you would have done. [Georg] Yeah. And for those 8% more success, how much time do you spend? So, I can tell you whether it’s pretty much less likely that the patient will show up the next day and have pain. [Jaz] So, the lesson there really is if your main occupation is an emergency dentist who does not have the privilege and the pleasure of following up your patients and you’re delivering a service and that services, get this patient out of pain and keep them out of pain, then perhaps in your setting, in your environment, you should stick to pulpectomy Is that a fair statement? [Georg] Depends from how many patients in a waiting room. Actually, it’s during the corona pandemic, yes. And Garrett even suggested from his time in Lebanon, to just place dexamethasone, just to injection with dexamethasone close to the pulp, just doing this filtration. That’s the best word. And it will resolve the pain. [Jaz] Like intrapulpal? [Georg] No, no, it’s just like an regular- [Jaz] Like a buccal infiltration. [Georg] Buccal infiltration. [Jaz] Okay. [Georg] Yeah. And he’s suggested with a braided wet back, when was Lebanon. And maybe now it’s beginning of the Corona, because everybody was afraid of aerosols, that should be a treatment option we got considered. So if you have really a lot of patients, you basically have to take the one with the past coming out, he’s your first choice, everyone can get injection. If you have a lot of patients more or less, no severe swellings, I would go to full pulpotomy with everyone and just play some temporary filling on it, and it will work quite good. And of course, if we have such cases where the bleeding is so extensive from the canals, no matter what you do, it won’t stop these cases, you do a pulpectomy. Of course, yeah. Because you can’t really tell them even in emergency but bleeding out of the tooth is normal. [Jaz] But well, it is true. But early failure, you said was the next day pulpectomy 99%, out of pain pulpotomy 91% out of pain. And then so if someone comes in with an early failure, does that mean they now advanced to stage two, which is the pulpectomy is that what happens? [Georg] Basically, after full pulpectomy. It’s pretty easy. Actually, interesting with my failures, it’s actually you have a gender part in it lots of more female patients have an early failure. Which is interesting. And usually, the early failures in the first seven days, yeah, even like now tennis to hot drinks are still cold after full pulpotomy if you feel something cold. That’s something wrong. You can basically say, okay, maybe that’s a real recession. It’s a palatal route, and where you can kind of get some signals. That could explain it. But after full pulpotomy, you don’t feel any cold. And so if I still feel something, it’s kind of odd. Really, I would say in the first seven days, it can happen. Yeah. Remember the 80% success from the Iran study? And I think we can relate for very good, very good, but it’s not like that every fifth patient will be visit you next week and have pain, because we have also late failures, but somehow to get necrotic. Or, yeah, basically, they get necrotic somehow. [Jaz] Well, the interesting thing here, and the dilemma we have is that if we start in the in the future, because look, Georg as much as we’d love for everyone to pulpotomy. And I think this episode is gonna go a long way, hopefully, to start making dentists think about this. And so that’s what I love about speaking to people like you generating new ideas, not even very new, like relatively new, because we know the lecture is now getting out there, which is amazing. And we’re sharing these new protocols and ideas. But the dilemmas it poses are also new, which is the whole thing about cuspal coverage, if the patient now needs to spend additional, I don’t know, 900,000 pounds, 1000 euros, because to be able to get to a point where the tooth potentially needs a pulpotomy, it’s the same thing as it potentially needs pulpectomy. It’s got a huge amalgam of fracture, it needs cuspal coverage. And then the extra dimension of doubt that you have now is should I put a crown on? What if two years later we had to then drill to the crown and do an RCT? Which is the same dilemma we have, and we have deep caries, right? So, this is another layer of complexity. [Georg] Yeah, but in my hands, actually, the full pulpotomy makes things simpler because we don’t have nose guessing. Spheres, deeper divorce leavings decay. Okay, how was the pulp studies anyway? We don’t know where it. And with the pulpotomy, we have one advantage we saw was it vital? Was it necrotic? Or didn’t look well? Actually, it’s really hard. There’s not really a good book about how the healthy pulp and a lot of picture of healthy and unhealthy pulps which it really comes down to experience and I even myself say something on it. Yeah. And for example, you just mentioned your staff member I just had a staff member opened up the pulp and there was a small moment where I said OKAY, it just exposes the pulps a bit. I just do a mini pulpy and we’ll be done it was great. But it was like no, she had pain. I go for pulpotomy, and they looked at the path and you don’t use could see the pulp but was not really bleeding very good. So, I did the full path to me it still was not being very how I saw some bleeding I was like, oh okay. I still went for the biodentin on top, placed my filling but said okay, let’s look. Next seven days and you know the seven days Oh, over she still have some symptoms on hot. So, I say no, we have to probably do adversities pretty sure after seven days if it’s a pain has not gone up seven days. It’s quite good sign. I mean, she has a short distance to the dentist’s differentiates at work and experience fame. So, when the next [Jaz] When the next patient cancels, she’s the one in the chair. [Georg] Usually, the last patient of the day or something like that. We always find a way. And therefore when you kind of have a look at the pulp and you kind of still don’t feel really comfortable, it’s probably not working. [Jaz] And what is the unhealthy pulp look like? Like a vital but unhealthy pulp that gives you that feeling in your stomach, that’s not going to work for them less experience. Because look, think about it, Georg, we are used to a living less way less experienced then we are used to opening up the pulp chamber with one motive; kill, kill, kill. We don’t even probably look at the we just go through the bleeding, we stick some hypochlorite right in the canal and we put the pressure inside. We don’t even look pause and see. What is the health status? What is this pulp looking like today? So you need to enlighten us. [Georg] Yeah, it’s very difficult to tell. But even when I look at Dominica, we could use studies where he did a lot of pictures of really nice pulp and say, and she says that’s unhealthy, but suffering like, oh, wow. And there are some things where you can say the color methods, if it’s really pinkish, and it’s probably it, if it’s more brownish or leathery, let’s say this one, it’s probably nothing. And sometimes I mean, you can just pop the pulp and if it feels like it’s one block of very liquid, it’s probably not working. And I even had one case where I did want it to do kind of some pulpotomy at the central incisor and just rinsed it a bit. And suddenly the whole pulp was in the vacuum sucked away. And I was like, okay, probably that was not unhealthy pulp. Pretty easy. But it also has a case with a young patient, where I had on the referral sheet, root canal treatment to ferrule, and I looked inside, it was a healthy pulp. Apparently, the pulp kind of went away, did put two people by the file, which was interesting. And so I don’t have the answer for you, unfortunately. Yeah, but my answer so I like bleeding pulp, if it’s bleeding, and it stops its- [Jaz] What if it’s that term, hyperemia? You know, we always see that the patient in pain comes in, and it’s just flooding in blood. Is that encouraging for you, as someone who’s not looking it as a pulpotomy? [Georg] Let’s say it’s this way, if it’s really hyperemic, you probably have no chance, because you would need a really strong leading control agent, or even something where you just close your eyes place MTA on a cupboard, or is probably not gonna work. I wouldn’t say never. But it’s not that- [Jaz] Okay, good to know that if it’s too much bleeding, it’s hyperemia, go with your gut, and then that is an unhealthy pulp. [Georg] That’s why I basically like the time of the five minutes, which is basically I don’t want to say it’s literally have to stick to it. Because some people are very dogmatic about what’s in the literature. It’s a recommendation without any proof. And but I like it and I would say if it’s still bleeding very hard after five minutes, you left sodium hypochlorite on it. It’s probably your restorative material will not work. Yeah, but I also found that some MTAs work better than the other. It’s just interesting. And since people are always asked me for products, biodentin has the best literature from Zepto don’t outwear so it’s my first choice when I have for example, a really young kids, which has a bleeding it’s a little bit itchy. Yeah, that’s the best way to describe it. But I still want to keep it. Sometimes tend to use material from CERKAMED, Polish company, BIO MTA+, because it’s bit better- [Jaz] That’s a cool name. Bio MTA plus a second every single good thing endodontics BIO MTA+, and just that’s the best product name there is in endodontic surely. [Georg] Second mate, is a nice company, they’re not good at research. [Jaz] The real wet fingers dentists of the world. [Georg] Basically, it’s for surrounded by wet finger dentists. And but it works good in situations where the pulp bleeding is a bit bitchy. The other materials which are also very interesting because ultradent and just released, MTAFlow White, and the material has like an agent in the liquid, which is less problematic when washing away and wash away fluid can longer- [Jaz] So, less water soluble? [Georg] We have, who knows. Actually, just that company told me that it’s something which is very, very common in the concrete industry but only to people in the dental industry habits and other products. Then there’s also products from Angelus MTA REPAIR HP. It’s also quite good. And I tell you why it’s important that we have some different materials because we didn’t talk about one thing which is tooth discoloration because some MTAs even the classic approved MTA have some radiopaque and acids, which when it’s combined with sodium heparin, discolors. And they have different concentration for example, second one has also this radiopaque and bear. So, I would rather use it at a molar and tell the patient that’s a tooth might discolor that won’t turn black, don’t worry, but it will appear more grayish. And if it’s a first premolar, you’ll see it. And then we also have to take in consideration that in every manual you take out and buried and in better say, as I only placed it on basically on the non-bleeding pulp. And the reason is when even like when materials come in contact with Bloods, which I suppose not discoloring. Of course, if there’s too much blood with iron inside, it will discolor Yeah, it’s very natural. So that’s also reason to spend a bit more time in controlling the pulp and that’s why it’s a pulpal bleeding. And that’s why I’m not a fan of this five minutes in vets situation. [Jaz] Well, we have to now wrap up and talk about okay, why is it that you’re so anti-leaving some caries weight where you can get a good bond? Because your peripheral seal will be good, you know, the seal is a deal and when a kid so why not leave caries dentin as your base? [Georg] Yeah, I mean, I tried to make it short. Basically, it’s the concept is very good. And I liked it at the beginning a lot and did it a lot, even with this deep caries one and I got failures, failures, well, I’d say I would have done a pulpotomy. versus refill so on, it’s a good idea. But let’s be honest, if you think about it, that the ceiling sounds better than it is even like a healthy tooth bacterias crossing, it’s the whole time it’s not sealed in the way because we don’t have sterile and violent at the mouth. And the basic is carriers model everyone is talking about as maybe a flower model, if you take aways in a tuition vans, and when nothing will happen. [Jaz]It’s a disease of the surface, as you said. [Georg]And it’s a simplified model. And it’s really easy to understand, and it’s far completely okay. But you have to always say it’s a simplified model, who says where we are not some backs in the decay, who don’t need sugar, they just live on pulpal fluids. So, this box is really simplified. Now, I, myself doing the same thing, but I have a friend from the University of Munster Germany, who can say at a much more convenient way. Actually, we have a German podcast on it. But- [Jaz]Very good. [Georg]But he basically says we are some bacterias who are irritating the pulp and you know, functioning and one of the advisors of the seal is a deal theory, which he stood on grade z is research says come on, it’s just of course the pulp is irritated. It’s what’s the deal about it. But I would say clinically speaking, I tried it. In some cases, I’d even still do it. For example, in cases where we have a lower molars. And really cervical dentin cariers widened the distal, where, you know, if I would do it directly, I would destroy a lot of tooth in these cases, I would just try to push some GIC inside and monitor it. And, of course, there are some patients where it makes sense to use this approach. But it really also depends on your personal setting where you work in. And for example, if I have the time, if I have rubber dam magnification, of course I can remove more. And look if there’s a pulp, and we have a success rate of a vital pulp treatment of the Pulpotomy, which is so good. I would even say- [Jaz]That’s 80%, right? We’re talking about 80%. Right? [Georg]80% Actually, if you look to literature, it’s the lowest [Jaz]And how many years are we talking? Five years? 10 years, what do we have? [Georg]We don’t have 10 years we have five year max, that’s a pretty basically. And that’s why now the Cochrane Reviews favors leaving of the decay. I say it on purpose leaving of the decay. And anyways, if you have have, like, a new rule area where not a lot of dentists, it’s a good concept. Let’s be honest, and so whole technique with children. Really good concept. Yeah, let’s be honest. But the success rate of this treatment, after the beyond our study, whatever, it’s not so good. If you just look at the numbers, it’s mainly 60%. We have had really strict success criterias if it’s not working on the cold test anymore, where basically you said that’s the failure, but it’s really strict. But if you look at other studies, newer studies 90 percentage area with the success waist, and we don’t- [Jaz]Vital pulpotomy once again. [Georg]For me, irreversible pulpitis, everything you want permanent teeth. And that’s a lot and then you basically think last beyond our heads 11% success with partial pulpotomy. And you basically, ask yourself, what did they do wrong? And it’s not written in a study. And it’s not a criticism. I mean, it’s a great study in the evidence is much higher than everything else. But we don’t have any comparison studies. And of course, everyone in university, ‘Oh just do a randomized control trial.’ I don’t know how to do a randomized trial. It’s kind of even, like when you think about it, I would like to do a randomized trial, but I don’t believe in selective caries removal. So, I should do something I’m not believing in, guess the results! Probably it will turn out better than my vital pulpotomy. And that’s something because I’m just biased. Even with like, a lot of centers, you will get basically, this result, either one is trained in the vital pulp therapy on the selective cariers removal. And I don’t condemn myself, but I for myself, from my experience with my failures by the pulpotomy, and selective caries decided, I don’t want to do selective cariers removal anymore. And I hope I am not will be like so. You noticed all dents like in the early days, we did all this review with all the carriers. And it works much better when you’re selective approach. And, you know, I’m not sure about this. And I’m not following up on my cases to really know how my success rate, and my weaker rate would be really bad. But that’s a problem in all dentistry. And it really depends. Now, I’m basically in private office, I have time to place my rubber dam treatment plan. Of course, it will work in my hands quite good. And let’s be honest, if I would believe and select cavity, these cases would all work very good as well. Yeah. So, I don’t like this dogmatic approach a while. There are some reasons to look at the pulp and see if it’s vital. Like I’m just kidding. Yeah, but it’s nothing I would say to vet or vet. But for us in the practice, and I worked in a rural race, just remember the tooth with a deep caries, and so we’ll be ended for sure. And I don’t really have time, Z has good cases to start. Because you don’t have anything to lose. And it’s not an experiment. I really hate about experiments. Sometimes you’re doing experience. It’s nothing new. It’s probably even older than spec. I think, even like before the First World War, some people were doing research on it. And it was just forgotten knowledge. I mean, even selective caries removal is nothing new vessel really nice this article about it from the 50s where we extracted first molar of children and kind of compared selective carious removal and they use the full caries removal, new metrical calcium hydroxide back then the MTA of that time. So we’ll come in waves and just to complete it, I’m not dogmatic of any way. And I would really be happy to see some literature that I know is a functioning group and Berlin is working on it, I would say, there’s not a perfect study you can design to really convince everyone due to the bias, and- [Jaz]I mean, yeah, clinical dentistry is played with this issue of not having amazing evidence when you compared to other fields. So, this is what we have to accept. So, there’s still a lot to be discovered in terms of what are the best definitive protocols. So, I very much appreciate that. And let’s not be dogmatic, and it’s one of my favorite things. There’s no place for dogmas on this podcast. And I thank you very much for giving your time to discuss this. You’ve opened my mind, Georg, because you know, to think that irreversible pulpitis does not equal RCT anymore, does not equal pulpectomy. anymore, is very fascinating. And I’m very much my background in training is never exposed. That’s just like, ingrained in me never expose. But really, and I’m open to listening to you and then finding out more, which is in some cases, actually, there is a place for pulpotomy in the adult tooth, which has been carious and the dubious pulpal status. So, I think what we’ve done is open everyone’s mind, what do you think is the next step? Because I don’t expect for intelligent dentists listen to this one podcast episode, and then just start cracking on and guessing how much MTA they need. I do feel that perhaps there’s some training that’s merited? Where does one get some training and some knowledge? And also, one more thing actually, is, if I’m working with an endodontist in the practice, and before I started sending him cases or advising him, you really need to have an endodontist who is on board with you. Right? And I think that sort of team approach, it is really important to have that open line of conversation with your endodontist. [Georg]Yeah, I was at ease, you don’t find any endodontic conference from now on probably ’til the next 10 years, which is not talking about vital pulpotomy. It’s the hottest topic of office. No, I wouldn’t say so of this decade for sure. Because now the AAE had a position statement and the ESE. And basically, we were just waiting for 10 years data and there’s like something like a little fight between the cariologist and the endodontist. And so cariologist will win because they’re much more, that’s fine. To get your endodontist on board, it’s a really cool idea. Janet, basically tell them, you basically just do the root canal. And he’s just doing what is on the first sheet. Because that’s a different topic as well. Actually, I have an old lecture at Dentinal Tubules with to show a couple of years ago, actually, just when we started talking, I thought I really have to talk to Drew to update it. Because some of the things I say I would frame them differently now, which is fine. The answer is, you see how it’s Bob’s. And I’m pretty sure there’s training out there. But most of the time, people think it’s so specific, probably no one is interested. And actually, a view if you call it pulpotomy of permanent teeth, every dentist understands it, it sounds something new. And just start your cases, document it and you can do some local lectures for sure. [Jaz]Well, what I appreciate is we’re not trying to make something more complex, because I’m not going to name any names here, Georg, but there are some sub specialities let’s call them all disciplines, new disciplines of dentistry emerging, which I think are trying to complicate dentistry, and they’re giving new names and new acronyms to things which is already in the on the old textbooks. I think, you know what I mean. And I like- [Georg]It’s just biomimetic. [Jaz]I got so many biomimetic friends and guys, like don’t get any offense, right? They’re great. And you gotta love what you do. But when did we stop calling it adhesive dentistry and just change it to biometric? I don’t know when that happens. But yeah, what you’re doing Georgie, I appreciate that, that you’re saying that, ‘Oh, no, it’s not vital pulp therapy.’ Why don’t we call it a pulpotomy of vital teeth [Georg]Pulpotomy of vital teeth and one thing, biomimetic dentists are afraid of the pulp I don’t know why, but they’re afraid, I would say but it’s basically due Tuesday based in the US, they have to refer I think to the dentist and they lose money on it. Just really a simplification- [Jaz]Very cynical, but yes. [Georg]Therefore, they want to tend to have anything inside and then therefore this concept of selective caries removal works very good for me. I’m personally, I’m not afraid of the pulp. Not at all. You don’t need to be if you see the pulp, just refresh it a bit. If it’s bleeding to hard remove a bit more, if it’s still bleeding to hard, remove the whole pulp chamber. And when you have RCT, which don’t have to do if you don’t want to do RCT, just stop there after the full pulpotomy and place some ledermix pellets.  So, your endodontist will love you for that. And the patient won’t hate you because they basically out of pain. So, everything’s fine. You don’t need to be afraid of anything of not exposing. And there’s one German study where we’re exposed to pulp and that really bad results. And when you look at the studies, treatment was done by dental students. They used carelife and dycal things which don’t work. Plus replaced the temporary filling on it a GIC, which is regularly a good material, unless you have exposed pulp, when it will be a success after six months. And you basically can wait for, it will be not a success. It will be failure after six months, because the backs are going downward, and you’re gonna love to kill the open pulp. And that’s pretty easy. So you find today, literature for anything, but you don’t need to be afraid of the pulp. [Jaz]Guys no longer are we afraid of the pulp. I certainly won’t be. Georg thanks so much for giving our time, really appreciate it. Check out SaureZähne. Hope I said it correctly. We’ll put the link on and again, thank you so much and good luck to Germany advocate a Qatar. I’ll be rooting Amrita, I’m cheering three teams, England, but today I paid five pounds in the sweepstake at work, and I got Argentina, and I got I paid another five pounds and I got Spain. So, my three teams are England, Argentina, Spain, and if I win, I win 150 pounds, and I will treat the entire staff to pizza. So, that’s the plan. [Georg]That’s a good plan. Jaz’s Outro:Thank you so much. Oh, there we have it guys. Look, I’m really sorry if I offended anyone towards the end. I’ve got some really great friends who are Biomimetic Dentists like Germàn. Germàn, I know you listen to this. Thanks so much. Look, you know, I don’t like to offend anyone. And I really mean it a bit tongue in cheek. I mean, it as a jest. But what we’re trying to say. I mean, Georg meant was that sometimes we need to simplify things and not complicate it. And I think what Georg suggested was that biomimetic dentists are afraid of the pulp. We know that’s not true. We know you’re trying to preserve the pulp as much as possible. And I get it and that’s awesome. So, love to all, respect to all, let’s listen to everyone, but do what feels right to you. So guys, don’t just jump in and do a vital pulp therapy, aka pulpotomy. Maybe read a little bit more around the subject and then commit to it but at least it has given you a reason not to be afraid of the pulp anymore. Thank you so much for listening all the way to the end. Claim your one hour plus CPD by answering a few questions below if you’re watching on Protrusive Premium. Thanks as ever for joining us today.

Did you know that Dentistry was voted the unhealthiest career in the world? Multiple times. That’s right, we’re number one! The grim reality is that we take on all sorts of professional and personal risks on a daily basis. I had the opportunity to sit down with Dr. Rohan Verma, a clinical dentist and fitness coach to record this wholesome episode. We talked about what steps we can take to improve our health. At the end of our conversation, we also talked about diet as well. I hope this episode will address our unique professional challenges and help you become healthier and more mindful about everything you’re doing for mental and physical well-being. https://youtu.be/xubc_XpSrzI Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 1:51 Dr. Rohan Verma’s Introduction 3:46 Mental Health Awareness 6:39 Biggest mistakes dentists are making with their health  11:09 Posture Issues 14:50 The significance of sleep 16:52 Importance of setting a routine for better health improvement 24:16 Working out routine 29:09 Dr. Rohan’s stand on different kinds of diet 31:29 The benefit of calorie counting Check out Dr. Rohan Verma’s Instagram to get some tips on how to improve your health – as well as a Dentist he’s an online fitness coach. Monitor your calorie intake with this MyFitnessPal: Calorie Counter available on: iOS: MyFitnessPal: Calorie Counter Google Play: MyFitnessPal: Calorie Counter 📨 Download Protrusive App and Claim Verifiable CPD/CE + EXCLUSIVE content: iOS: Protrusive App Android: Protrusive App If you enjoyed this episode, then do check out 5 Lessons from Lincoln Harris  Click below for full episode transcript: Jaz's Introduction: Did you know that Business Insider ranked DENTISTRY as the MOST DANGEROUS PROFESSION in the whole world for your health, and they did this multiple years in a row. So, why is it? Why is our job so dangerous? Jaz’s Introduction:I think we know the answers. We’re in this horrible posture, we’ve got this infection control risk, we are sat in this four walls with just one other person, usually. That’s gonna drive you mad, as well as the extreme stress that we undertake in our profession of clinical dentistry. So, whether you are a dentist, a nurse or a DA as they’re so affectionately called in the US, or if you’re a therapist or hygienist. I think you have something to gain from this episode about looking after your health in the space of dentistry. Now, who better than Dr. Rohan Verma, who is a clinical practicing dentist, and also a fitness fanatic and a fitness coach to professionals. So, I brought him on to talk about different things like what are the big mistakes we’re making in our profession? In terms of how we’re NEGLECTING OUR HEALTH? How can we IMPROVE our WELL-BEING in this profession? And we also pivot and talk about some other things that I’m quite interested in like towards the end, we talked about diet, right? I know many of you know I do a lot of intermittent fasting. So, I will not eat my first meal quite often until, you know, one or 2pm and then I’ll have like a five or six hour window where I consume all my food. So, what does Rohan think about that? What does he think about paleo diet or carnivorous diet or keto? So, I asked him about this kind of stuff. But before then, we talk about how we can recognize that something’s not working for our health and what are the actionable steps that we can take to better improve our health. Welcome to the podcast. My name is Jaz Gulati. You are the Protruserati because now you’re listening to this and if you’re new to the podcast, welcome. This segment of the podcast is an IC, so an interference costs. So, slightly pivot away from clinical dentistry. If clinical dentistry is more your thing, then most of my episodes are that but I do like to talk about things that I’m interested in. So, whether it’s well-being, getting more sleep, or this fitness and health, reducing your stress or health. That’s what we’re talking about today. So, hope you enjoy this episode with Dr. Rohan Verma. Main EpisodeDr. Rohan Verma, welcome to the Protrusive Dental Podcast my friend, how are you? [Rohan]I’m very well, man, thank you very much for having me. [Jaz]Like many of the guests that I have on, we do go way back and I’ve known you from undergraduate days. Even then you always say, I had this amazing physique and of knew, okay, these guys are definitely gonna pivot into, as well as, being an awesome dentist you are. You’re into the health space and fitness space. So, it would be fun to talk about that stuff, but for those dentists who haven’t come across you for around the world. Tell us about you Rohan. Tell us about you as a dentist and you outside of the remit of dentistry in terms of all the other things that you do in the space of health and and well-being. [Rohan]Awesome! Well, firstly, hi guys, nice to meet you. I’m Rohan. I’m a full-time private practice dentist working at Cookham in little village near Marlow, Henley, Reading area. As Jaz very kindly said, yeah, I’ve been into fitness for a long, long time. Just like everyone here, I was very fit and active at school. Did the standard things, did rugby, football, karate, those sort of things. And then it wasn’t until I hit University. And then that’s really when my fitness journey kind of really began a little bit, probably, in the most conventional way. My mental health, unfortunately, took a turn for the south. And I really started to become quite anxious. I noticed that there were certain traits of my, sort of like perfectionism coming through which naturally led as dentists, as one thing, I think I noticed that very much. So, the more I talk about it, more people and more and more aware about it, and I needed an output. And it took me a while to find my own feet with it. But in essence, I realized that I missed my fitness. And I miss doing active things that used to be like sports, rugby, karate, as a kid. But when I go to dentistry it was, okay, all or nothing with the books. And I think, that aspect of being very much all or nothing made me realize I had no balance, and I needed to find some outlet. And that’s where the gym came for me. I could do it my own time, my own space, and it was just the perfect outlet for me. [Jaz]If you don’t mind, Rohan just talking about that. I think it’s really good of you to mention that, you know, you had an adverse experience with your mental health, as we all do. We’re all human. As dentists in this high pressure job that we’re in. And we’ll talk about all those sorts of things later on in terms of general well-being and obviously fitness and health. But also mental health sort of being so key. A, how did you recognize this issue? But then B, did you seek professional help? Or did you just do some introspection, self-discovery, and discover yourself that, okay, what you are missing in your life is the things that made you happy in your childhood. Which is the exercise and the fitness and the x and the sort of the fun things that you did extracurricular and then you just pursued that or how does that come to be? [Rohan]To be honest, I think if you’re aware of mental health, I think you’ll realize it’s not something which suddenly appears, it’s something which you’re always dealing with. I mean, to this day, I would still say I’m dealing with my mental health. It’s there’s peaked and troughed throughout my dental career, definitely for sure. I think the first time I experienced it was first year, undergraduate BDS, an anatomy spot exam. I remember it so vividly. I was always that guy at school. I worked hard. I will do extremely well at school and I wouldn’t actually worry about it because I knew if I put in the work, I would get the results. Then you come to dentistry where everyone is super smart. Everyone is of that top tier kind. The first few days, and it was overwhelming for me at first. And I remember to study for that spot. And it just no matter how much I tried, I looked at those that the court required and try to memorize those, those anatomies diagrams as much as I could, coloring them and everything. It just didn’t work for my brain. And I remember sitting there in the exam, I wanted to put pen to paper. But I physically couldn’t move. I literally felt almost stuck. And I think that was the point when I realized something was brewing in me. And it wasn’t probably till I started to speak to loved ones. I mean, fortunately, my mother’s psychologists and therapists, and she started talking to me saying, ‘Look, I can’t help you, because obviously, there’s a clash of interests here. However, I do think there’s something going on.’ I don’t think I was in the right sort of headspace at the time to first deal with it at university. And it wasn’t actually until maybe years later that I actually sought professional help. And actually, that really has been a big turning point for me. Yes, fitness has helped. But I wouldn’t say that’s the only word on it. Yeah, so it’s been, it’s been a journey, man. Don’t get me wrong. Like I said, I think I’m learning each day. [Jaz]We’re all on this journey, everyone’s in a different place. And it’s like a different seasons in our physical health, which I’m at the moment, that at this time of recording with you. Diwali 2022, I can’t be in this moment, right now. I am, Happy Diwali, Rohan, I am neglecting my physical health. At the moment, I can say that I haven’t made peace with it, though. Because that’s not how I wish to live the rest of my, not only year, but rest of my life. But it’s just a season at the moment where I know that okay, my health is suffering, because of various circumstances in life. But it’s really good to have that self reflection and self-awareness. And it’s really good that you did seek what you did. But pivoting on to the most of the physical health, which ties in so much of the mental health. [Rohan]Yeah. [Jaz]Dentists in terms of, when you search the jobs in the world, and there’s a huge quite, it went viral amongst our community of all the jobs in the world, every single job that is like the most dangerous if you like. And a couple of years in a row, dentistry came out as the most dangerous job because of various things like exposure to radiation. The fact that you’re in this posture in this room, diseases that you can catch, for example. So, put all those metrics and suicide rate. So, all these metrics are fed into fact that dentistry was the worst for your health, or dangerous in that category of all different professions in the world, which is crazy. So, having said that, and in light of that, in that context, what are the biggest mistakes you think dentists are making with their health? And just to give those a little background and context, Rohan being a dentist, but also helps dentists and other professionals improve their well-being and health. So, you know, you are the best person to speak about this. [Rohan]I’ve been in the fitness industry for 10 years and haven’t practiced now since 2013. So, the best part of nearly 10 years, I’ve seen very much certain correlations between the two favorites in dentistry of what we do right, what we do wrong. The big one, and we kind of already touched on it already, Jaz, is an essence that, we spend our entire days at dentists between the hours of eight and six, nine and five, call it what you want, focusing in on other people. But often we neglect ourselves, it comes at a detriment to our own well-being. I mean, tell me the number of times you’ve gone to work. And then you’ve had a busy back to back patient list. And in that time, you haven’t drank any water. You’ve had to run late through lunch, you maybe skip lunch. You’ve not perhaps time to prep your meals. So, therefore you’re going to order delivery, when you get home from work. You then go out, you sit with them and have you cooked dinner. And in essence, you have now to go back onto work, to do some clean checks because you know, you’re gonna plan your Invisalign cases without thinking, ‘Oh, it’s 11:30 I’ve got to go to bed’, and then start that routine all over again. We neglect ourselves and we forget how stressful the environment is. We forget that we’re not nurturing ourselves. We’re not thinking about our sleep patterns. We’re not thinking about our well-being both physical and mental. Because those things impact us not just in the moment when you feel tired. These things add up. So, when you start thinking, ‘Oh, is my mental health gonna suffer?’ Of course, but we’re neglecting ourselves. So, I think that’s the first thing I’d say is we hinder ourselves with. [Jaz]Rohan I just want to mention that for those listening right now. And if you’re driving, please drive safely because if like me, you’re listening in your a little minute just there. Describing all the things as though you’ve got a CCTV camera of my life. I know there’s hundreds of dentist driving to the Capitol, okay. But people watching you driving, who’s guys listening to rock music or something like bobbing their head along? So yeah, totally, man, you hit the nail on the head. I know so many dentists of all, you know, no matter if they experienced dentists, or new dentists, that describe this. Exactly, this sort of rat-race kind of mentality that we have that we give everything in our day. We’re sort of expanded. We’re absolutely just smashed. So, we come home, and we want to take away and we neglect ourselves. [Rohan]I mean, often people say look, it’s about that, you know, we have that all or nothing mentality. That’s why we got here. That’s why we’re successful. But you’ve got to you’ve got to ask yourself, how long can you keep that up for? And I think the big question I get asked by people who either interact with me on Instagram on social media, whether it be for example, just people asking me for advice day to day when I meet them at weddings, and they say, ‘Oh, what do you do?’ I say, look for a balance now, in my opinion, and it’s very cliche, there’s no perfect balance. There’s no such thing. However, you have spinning plates. You have work, you have family life, you have friends, you have dentistry, you have perhaps maybe an Instagram profile you’re trying to juggle. There’s so many things, you’re constantly juggling. At times, you just need to know when to put the pedal to the metal and when to ease off a little bit. So for example, okay, I’ve got an Invisalign Open Day, yeah, I’m gonna have to put in some hours to prep that, cool. But then perhaps the next week, the next few days after that. Put some time into your well being maybe go for a walk with your loved ones, with a little one after work. Maybe spend half an hour. Go for a small workout, even a small one. Just do something, she knows is going to nurture you. Because finding that structure, which helps you and also you can stick to, and you’ll hear this me say throughout this whole podcast today. That’s the crucial recipe. It’s not about finding the perfect solution. It’s about finding the solution that works for you. [Jaz]And what are the associated in terms of themes? Is that the main one that you can focus on before we move on? Or is there another big health mistake? So number one, just to summarize is we don’t look after ourselves? [Rohan]Yeah, I think number two, I mean, I can go all day. This is what I love to talk about it’s like a goal day. The second thing I would say, is we tend to find we’re looking for the quick fix. You mentioned a statistic about how we start off with back pain, neck pain, it’s guaranteed. If you’re gonna be sitting there doing two hours and those three hour composite build up cases, you know, doing big case, we have work like yourself Jaz, you’ve got to realize you are stuck in the most unnatural position all day long, perhaps maybe your necks gonna suffer, your back’s gonna suffer, your posture is gonna suffer. And I see it quite a lot. And don’t get me wrong, I’ve done it myself. The first thing we think we turned to is ibuprofen and the chiropractor or the physio, so we look for the quick fix. Whereas as dentists, I thought we were meant to be out there planning for longevity, planning for the long-term. So, while we’re not looking at the cause, we’re not looking at, okay, do I need to address perhaps, maybe it’s going to be buying some loops, maybe it’s going to be perhaps maybe working on a saddle chair? Or more importantly, what about building up the muscles of our neck or back or shoulders or spine? So, that’s what I’m trying to unpick this sort of health, the habits we have at the moment. So, going to work is great. Doing a long day at work is great, but what are you doing after work to help nurture those problems that you’re feeling when you’re sitting up late at night time having back pain, etc? Don’t just go for the quick fix. It’s almost like you broken that lower left six visa lingual cusp. Do you stick on a GIC? You do an onlay. Do you do the quick fix? Or do you look for the long term solution? That’s what I feel that we need to start- [Jaz]I’ll start recommending to our patients is not what we’re repeating ourselves. [Rohan]That’s the thing. And it’s it comes again, back to what are we doing for ourselves? That I guess is the overall encompassing problem. But what are we doing also to help ourselves? I think the other big thing is, and I see it a lot, in a lot of my clients who tend to be doctors and dentists ends up being like, we need to appreciate that our environment that we work in is extremely stressful. Guaranteed. Very intimate, very precise work and there is a huge demand to provide amazing outcomes, whether it be aesthetically functionally, hopefully everything all together. So come Friday, come 5pm. And I’m culprit to it too. When that drill goes down, I want to pick up a Corona and I want to chill. However, it comes back to that work-life balance. Are we finding perhaps maybe that balance, which may be actually not necessarily nourishing our well-being? So, don’t get me wrong? I do think you should go out for, perhaps a nice meal with loved ones. I do think you should go out for a couple of beers. But do we know how to find that sort of sensible approach to it? Do we looked at, potentially, looking at, okay, maybe I’ll go for a walk with my family tomorrow morning. Maybe I’ll go for a workout because I can still have that structure, that routine of knowing how to work hard, play hard, but also think about my well-being in that process. It’s not just remembering to push yourself but knowing when to like look after yourself as well. [Jaz]Very good. And, Rohan, I want to trace back to the point you made, again about how we go for the quick fix. And you mentioned about the posture issues. And I linked that back to the earlier point I made, were the some of the theories as to why there is such a high, you know, depression or suicidal alcoholism right in dentistry, traditionally, I don’t know what the latest stats are. But this is what we’re led to believe, when you speak to our more experienced colleagues, you know, in terms of historically. And so one of the theories is because we are in this sort of slouch posture, that sort of physiology feeds into our psychology and it’s completely the opposite of power posing. So, power posing, you know, you’re looking at, you see how your physiology and posture affects your psychology. So, there’s a whole dimension of okay, yes, we’re neglecting our physical health, but that ties in better with our mental health. And you mentioned about the quick fix. I think I also mentioned that, okay. We want to aim for that quick fix. But what about the importance of sleep somehow, which is overarching in terms of your health. How do you coach your clients in terms of sleep? Is that the kind of do you have discussions about sleep? [Rohan]Absolutely. I mean, look, sleep is a huge part. In my opinion, if you think about your bedtime routine, you’re setting yourself up for the next day. I think often we forget to realize that your sleep is linked to everything. Your sleep is linked to your stress. It’s linked to your hunger levels, your digestion, your energy levels, your hormones, everything. In essence, when you’re sleeping, your body is resting and recovering. So, if you’re doing four hours, five hours a night and it’s broken sleep. You’re waking up to go to the bathroom. You’re waking up thinking about stuff. Maybe what you got to do in the morning. Maybe that first difficult patient you got in the morning. That is going to be setting you up for a very challenging day. And then that’s going to roll on for days after days, weeks after weeks, month after month, it’s going to have a huge impact on your health. I mean, the sort of key, sort of number, there’s no perfect number. I mean, if you tell this to a young mother, I said to her, aim for 7, 8 or 9 hours asleep, she’s going to look at me like you’re having a laugh me. But I would say if you can try to give yourself I think working backwards and pitching it backwards helps a lot more. So, give yourself almost like a non negotiable you’re aiming for. So for example, Jaz, your little ones getting up, you know what time you gotta go to school, we’re trying to get your dream drop off. So, this thing backwards with your routine. What time do I need to go to bed to aim for, ideally six and a half to seven hours of sleep. And then give yourself a half an hour buffer. Listen, I guarantee you when you finish your day. You know you shouldn’t be but you’re probably gonna be sitting there, scrolling on Instagram, or checking your emails, checking that you’ve done everything you need to do for the next day. So, give yourself that half an hour buffer. And then allow yourself that six and a half to seven hours. And if you can get that sleep in the next day, you will wake up feeling potentially more refreshed, less likely to pick on, excuse my language, crappy foods. Because you’re not feeling as hungry and perhaps lethargic and tired and generally low your self-esteem and fear and feelings. Because that’s where we reach out for the junk. That’s where we reach out to doing very little of sitting on our butts, we got home from work because we’re just tired. [Jaz]And you gave that one piece of actual advice already, actually in terms of how to set a better routine and to get better quality sleep. What are the actionable, to something that we can action as dentists that, if there was like one thing that you hate about what we do to our health, and you really want to change that and shake it up and start doing this one thing. You talk about the problems and the issues and how we look after ourselves. If there was like a magic wand and we change one habit about what we do. As a stereotypical profession, what would that be? [Rohan]That’s a tough question, man. I can’t say one. I really couldn’t say one. Well, I couldn’t say to do one thing is go to my Instagram and click my link bio. No plug intended. But seriously, as a free sort of like seven step process of how to kind of take your well-being into, perhaps another dimension, perhaps would be looking after yourself in a more manageable, more longevity approach. So, for example, that I talked about, in that, that seven step process, like you said, sleep, we talked about that six and a half, seven hours of sleep a night. Hydration, trying to aim for the appropriate amount of hydration for yourself. Now I get asked how much should I drink? How much water should I drink a day? How much fluid to drink a day? Just think of it this way, per 25 kilo grams of your body over one liter. And when you started to put that into context. You probably realized God, there have been days where I’ve probably only had maybe one liter, one liter and a half max and I guarantee you you’re under hydrate yourself. There’s no way you can do the the intricate work that you do every day and still feel like you’re going to perform to your best and feel energized. So, definitely think about your hydration levels. The third thing is- [Jaz]You might know about coffee, then because I’m a huge coffee drinker. I wonder if you know this. They say that if you have black coffee, the content of water, the hydration in that may negate the dehydration effect. Is that is that a myth? Or what’s your rule or advice on coffee? [Rohan]I personally feel that’s completely fine. And I’ve looked into the research behind caffeine. And they do say that the hydration levels, whatever it is, it helps negate it. So, I call it as a total fluid intake for the day. But what I would say about caffeine and you should bear this in mind is that it has a half life. And I don’t know if you guys remember back in the day learning this at University. But in essence, the half-life of caffeine is six hours. So, if you’re drinking caffeine, and you’re after three or 4pm, and you’re trying to go to sleep at around 10 or 11, you’re shooting yourself in the foot. Because it’s still gonna be lingering, your system is still going to be there. And you’re going to be keeping a nighttime, perhaps maybe making being the reason why you’re struggling to sleep and having that broken sleep. So, just give yourself an earlier cut-off point- [Jaz]It affects everyone differently. Right. So, I could actually have one at 8pm and still go to bed at about 10. I’m a coffee drinker of crazy levels you want to do. [Rohan]For sure. I mean, to a degree, you’re probably caffeine intolerant, and that you probably actually, you’ll find Jaz, that the impact of caffeine on you perhaps is so different to me. I’m not trying to beat myself up here, but I don’t drink enough coffee because it used to make me quite anxious. But what I’ve noticed now, is the more you drink it, you do have a caffeine tolerance and then that sort of boost and pick me up effect is negated by the fact that you just drink perhaps maybe two or three, four or five throughout the day. So, just maybe just be more mindful of that. Maybe try and consider, perhaps maybe a caffeine detox. [Jaz]What was interesting research I read on BBC One. So, a couple of times they sort of recycle the same article every 18 months, is that what they found is that the benefits of coffee were truly realized after drinking four or five cups a day. So, they found that actually, coffee is a good thing, but you kind of need to have four or five cups a day to get all their antioxidant benefit. So, when I read that it was a dream to read that it was like an open license to just crack on. But obviously, everything within reason gotta respect your body and how it affects you and your own individual tolerance. [Rohan]100%. Ultimately comes down to, like I said before, what works for you, for what works for one person may not be the perfect recipe for the other person. If it works for you. It helps you get through a day, then please do but if it’s affecting your sleep, if you’re feeling perhaps maybe a little bit more on edge more anxious, you’re waking up with broken sleep, maybe then you want to think about okay, do I should I scale it back? What time do I finish my coffee intake? Have a look at it that way. [Jaz]And one thing I really like that you said about just the hydration thing, it’s such a huge thing for me. And some days, I have good days. And some days, I have really bad days. And I feel as though is one thing that I think is the most important thing for me to improve and keep our stay level is having that hydration because I’m so dehydrated. Especially, when you got lots of new patient consultations or checkups. You’re talking, talking, talking, talking, talking, and you’re sometimes running late, because you’re talking so much, and you’re explaining, and you put your heart and soul into it, you’re absolutely parched. Therefore, having that bottle is just a number one hack to have, any other hacks you can give to stay hydrated? [Rohan]Yeah, I mean, to be honest, I carry. I haven’t got it with me right now. But I have a water bottle, which has the hours of the day written down next to it. And it’s so useful to one liter bottle, and it makes it so idiot proof. It just says, ‘it’s 1pm, have you drank this much?’, ‘it’s 2pm, have you drank this much?’ And that’s just like a gentle reminder to help you kind of keep going. And I sometimes end up realizing I have to like chug because I haven’t done it for a little while. But at least you just have that sort of measurable goal. I think that’s one of the big things is having something measurable to work towards, which will always help us kind of stay on track. The other thing I tend to recommend is, when it comes to lunchtime, dinner time, breakfast time, get one of those half liter bottles like from Kirkland, or even just a glass it just fill it up and drink that glass with your meal. In essence, if you’re doing that you’re getting in some thick. I see one of the biggest, sort of perhaps, maybe sort of mistakes or hurdles we as individuals incorporate when we’re trying to get into a fitter well-being with fitness space is that we tend to try and do too much too quickly. I’m going to take the perfect amount of water and get the perfect amount of steps. Gonna have the perfect calories going to hit. Six workouts a week. Why run before you can walk. I mean, I usually say to start off by doing something simple. Add a glass of water to your main meal, that will be enough. You start with that then after two or three weeks time of doing that consistently, then build it up. Don’t start looking, as I’ve got this pub podcast, this guy is telling me to drink two liters of water, I’ve only drank half a liter today. Go from 0 to 100 is going to be in essence a recipe for failure. It’s going to set you up for a little bit of disappointment in my eyes. [Jaz]Absolutely! [Rohan]That kind of like links to one of the the other points I mentioned in my 10 Step Guide is, when it comes to working out. I think, there’ll be a lot of people and a lot of listeners today who will be able to relate to this. The number of times you thought, okay, I don’t feel comfortable how I look, or I don’t feel great right now. I know I need to get into shape. I need to go to the gym. And they’ve gone from doing nothing to try to hit, like I said maybe five or six workouts. No matter what you can do, just do something small. So, the week after, if you know you can do five workouts do two, stick to the two, even if it’s just two simple workouts do two, the week after do another two, the week after that, do two again, once you’ve done it three or four weeks on the charts, and you found it manageable, you will actually realize I can keep this up. The problem is if you go and try and do six workouts in week one, you might keep it up for week one or maybe week two. But after that, life happens, your kids start crying and saying that I want to play with you. You might want to have to go to, I don’t, go to the cinema, or go for a meal. You will realize you can’t keep that up. And once you feel like you can’t keep that up, it does make you feel a bit frustrated, then you might just sack off the whole mentality of going to the gym. So, rather say stick to something you can manage. And then build it into the point where you realize, okay, this fits now in with what I can do on my day to day life. When you find that sort of solution which fits in and it’s manageable. That’s when you found the right solution for you. [Jaz]I love that advice. Because what I’ve been affected by, you mentioned it already, Rohan, is this perfectionist attitude we have. And I’ve always been all or nothing. So, if I can’t do a full hour workout, then there’s no point even going. What’s the point of doing a 20 minute. But now I’ve changed my ways. And I know that if I can get that all important 20-30 minutes when I can three, four times a week as my usual aim. I’m so much happier and grateful that I did it. Whereas before I’d be like. There’s no point me going. My dad’s does that, if you can’t get as couple hours in the gym as ours, there’s no point me going. So, I think we’re all susceptible to that. [Rohan]It’s totally, I think that’s again, it’s one of the reasons why we’re so good at what we do. We don’t do things by half measures. But if you’re looking to do something so drastic like that, it’s just going to be putting yourself In a position which is going to make you feel almost frustrated when you can’t meet it. And the big thing about gym and motivation is that nobody likes doing it even I’ve had moments where I don’t want to go. But what helps me is routine. Routine is crucial. And I think when you find that routine, which works for you Jaz, you’ve got your style. I know what mine is. When I started fitness, it was six times a week. Now, with the fact that I’ve got two businesses, a lovely wife to come home to, a family I want to spend time with, a social life. And perhaps I need to sit there and plan Invisalign cases and rehab, etc. I know for me four times a week it’s my non-negotiable. And I can do that. And I could stick to that. And it makes me happy when I see that, I’ve ticked that little four workouts in because I can actually stick to it. It is my manageable target. So, I think we need to kind of sometimes take a step back, rather than aiming for what the Men’s Health magazine recommends. We have to recognize our jobs, our lives are very unique. And we need to adapt around that. [Jaz]Brilliant! So, the advice there guys is to find your non-negotiable, and it doesn’t matter. If you’re not able to do the full whack, try and find something that you can routinely carry out week by week. So, I love that. Let’s go to the final segment, which is I was actually most excited for is DIET. Right? Because this has fascinated me. I know, it’s probably fascinated you and you talk about a lot on your Instagram. So, really excited to actually hear about it. Because I know you’re someone who’s actually sat down and read papers about which diet and in terms of longevity and health and you probably are into that space and then absorb that information. So, I want to extract that from you. You’ll be like the, here’s my five minute guide more than what all the last research I’ve done last 15 years, etc., right? So, I’d love to know from you. But I’m into intermittent fasting, I’m a big fan. I have a 72-hour fast for charity recently, which is really pushing my limits. And I did it and I was meeting a race of money for Ukrainian refugees and whatnot, which was a noble thing to do. And it went really well. So, thanks to everyone who supported that. But I just wanna know, what kind of diet do you follow yourself? I want to know. Are you vegan? That kind of stuff. And then what do you think from everything you read is the ultimate diet? Because some people like, I know a dentist and she swears by carnivore diet. She actually swears by carnivore. I know some keto fanatics. I know some people who, yeah, so I know some people in all these spaces. Where are you at? [Rohan]I’m gonna have to be careful what I say. So, I’m a carnivore, I eat meat, but I wouldn’t say I preach any particular diet in per se. Every diet works. And we start by saying that every diet works paleo, keto- [Jaz]But like, kind of wasn’t like you only eat meat? [Rohan]No, no. I eat meat, I eat vegetable. I’ll talk about my diet in a second. I have a pretty normal diet. [Jaz]Because that other dentists I was referring to by the way, she was actually like the following the actual carnivore diet. [Rohan]Oh, okay. Literally, only meat. Okay. Wow. Okay. [Jaz]Yeah. Like, you can’t have lagoons and you can’t have this. And it’s very like almost like paleo, but even more extreme than paleo. [Rohan]So, okay, let me break down what I do. And I’ll tell you about what I think about other diets. In essence, what I kind of preach is an 80/20 rule. If I can eat 80% of the time, whole foods, things which are least moderate processed. So. for example, opting for things like potatoes, rice, grains, couscous, lentils, and then I supplement that with my diet with a good amount of protein. I typically aim for two grams per kilo of my body weight of protein a day. And I try to think 80% of my diet should be Whole Foods, 20% should be crap, i.e., things I enjoy tasty foods, processed foods, cakes, biscuits, sweets. Because for me, having done this now for over a decade. Having worked with hundreds of clients. Having helped people get into shape, I’ve seen what works and what doesn’t work. For some people, it might be like you said, going ketogenic, which means cutting out all the carbs and go really high fats. For some people maybe eating very paleo, so keeping it really natural, very unmodified, unprocessed for some people in- [Jaz]Hunt together. [Rohan]Hunt together style. Yeah, if people like yourself who are the- [Jaz]If, as [Rohan]If is out here who tend to like to starve themselves for a long period of day. Whatever works for you. And you can enjoy and it works for your fitness goals, your health goals, and you can sustain, that’s the diet you should do. Try them all out. But in my opinion, carbs are bloody tasty, shouldn’t get rid of them. They help you feel energized, they make you feel happy. Why would you want to get rid of them? That’s my personal feeling on them. If works because I think for some people, they like to eat a lot of big portions. And when it comes to calorie control and not putting on weight, keeping that calories down, is the crucial thing. Or if does is gives you a smaller eating window. So, let’s say you have your dinner at 8pm and you don’t then eat until the next day at 1pm, 2pm, 3pm. You’ve just, in essence reduced an eating window to five maybe six hours of the day. So, what happens then when you’re eating is you have very little time to eat a lot of calories, keeping you fuller for longer, and making sure let you enjoy your meal. So, you could have maybe two, like 1000 calorie meals, which is pretty epic. But I know I’d fall asleep in the chair, if I tried to do that. I don’t think my patients would appreciate me like literally struggling to stay awake while trying to do some on mates. So, what I do is a diet for me, which works for me, which is spread my calories throughout the day. I have three or four main meals, and I just tried to make sure that each of those meals, there is some good veg, there’s some complex carbs in there, like oats or rice or potatoes or pasta, Bagels breads, not bad. Please don’t say breads, bad, by the way, whoever thinks that and they should think they should stick to white bread or brown rice over white rice. You know, there’s so many mess I could debunk right now. But just find the diet which works for you. That’s the crucial thing there. [Jaz]I think in terms of making time for yourself and, you know, get you care, we care for others, it’s important to care for yourself. And part of that is actually experimenting at various seasons of your life where it’s possible to see which diet is best for you. I’ve had some friends who went keto, their IBS got better, or whatever, you know. And had they not done the due diligence to experiment with their body and it is experimentation. So, you got to kind of make sure it doesn’t affect your patient care. Right. So, I’ve tested that, okay, I can intermittent fast, safely 24 hours without affecting patient care. After 24 hours, I don’t know. Therefore, when I did my 72-hour fast, I make sure I timed it and the weekend I wasn’t working. So, there’s no risk of patients being affected. So, you have to always look at, you know, patient care. Just bring it back to dentistry and how we all can apply it to our lives. [Rohan]For sure. I mean, I think the biggest thing which everyone should do, if they haven’t done it already, is start tracking their calories. It’s probably a controversial thing. But I feel that we should because when it comes to your general health and fitness, it does come down to a simple calories-in versus calories-out. If you feel that you’re feeling tired and sluggish. And you feel like you’re putting on weight, you’re possibly over consuming too many calories and not moving enough. If you’re feeling like you can’t put on weight, you’re feeling like you’re again tired and sluggish you possibly also under consuming. So, the first thing I would recommend anyone out there who’s listening is go on to the App Store, download my Fitness Pal, it’s free. Have the basic version and just track your calories. You’ll soon realize where you are potentially shooting yourself in the foot and maybe over consuming or under consuming. I mean, one of the big things, and this is one of the things I kind of alluded to earlier Jaz is, dentist, typically, Monday to Friday are very, very good. We’re very mindful. We don’t over eat. We tend to have quite sensible portions become a weekend, I guarantee there’ll be a big portion of us out here who are slamming in the calories or takeaways that alcohol or perhaps maybe undoing a lot of our good healthy habits during the week. Now, if you start becoming more mindful of where those calories are creeping in. Maybe having four or five pints and having a couple of cheesy chips on the way home and then Nando’s and the Domino’s the day after. When you start adding those up and realizing, okay, maybe I am consuming about five or 6000 calories for the weekend. And you start looking at how you can regulate your portion control, you’ll realize that, okay, I can have a better balance. And it comes back to that point again, where is that balance for you. So, I would definitely recommend start with my Fitness Pal. You will see the foods that you enjoy. Some which are more potentially nourishing. Some which are potentially not as nourishing, more calcolo caloric, and then you will start making better course. [Jaz]I’m so glad you mentioned the M word mindfulness because as you were saying about calorie counting, it’s not something I practice, but the biggest benefit I see in calorie counting is that you have to then think about your food and look at your food, actually, spend a minute to analyze, okay, what’s inside this? How it’s gonna affect me in my body? And therefore, it’s a means for someone who’s not typically mindful about their food now becomes mindful about what they were eating, which is the great benefit, I think. [Rohan]Totally! I mean, if I was to be really honest about what I feel the most biggest benefit about My Fitness Pal is, it’s not the actual process of tracking and sticking it in your diaries, it’s like you said, it’s the thought which goes behind it. Once you’ve done it for a couple of weeks. My aim after a while with my clients is for them to have almost a knowledge and understanding about portion-control about nutrition fiber, which one’s going to be processed with fatty trans fats which are potentially risk of heart disease. What are good fats, which are bad fats. So, they now know if they go to a restaurant, how to make the call and a decision which is going to help nourish them. Now, if for example, you’re a traveling dentist and you’re working up and down the practices across the country, you can’t sit there and track calories, let’s be honest, we know that. But at least you’ll have the understanding, okay, I can make some better decisions whilst I’m traveling up and down this country to choose foods which are going to be potentially less processed, less junkie and they’re going to help me feel good and perhaps maybe hit my nutrition goals and my fitness goals. So, it’s almost that awareness, that understanding which comes through practicing and implementing this over a period of time for you to then become okay, I know what to do now. [Jaz]Amazing! Well, I’ll put the link to My Fitness Pal. I’m sure everyone can find it quite easily. But we’ll make it helpful for you in the in the show notes I’ll also put Rohan’s Instagram page which you guys should all check out it’s wonderful content. I love the kind of the funny things that you do Rohan. Please tell us your Instagram handle once again. And I think we’ve covered a good few things to help people become healthier and more mindful about everything they’re doing mental health and fitness well-being. [Rohan]Thank you. So, if you want to follow me check me on Instagram. It’s Dr_RV fitness. I talk about everything fitness, dentistry, alcohol, well-being, mental health, physical health, it’s all a compass. I mean, as I said, I do think if you just do one thing today is to start thinking about yourself, guys. And I promise you, I think that will go a long way in terms of serving you in your professional career, but also your family and career, every aspect of your life will benefit from this. [Jaz]Amazing! Rohan, thank you so much for your time. I know you’re so busy with clients and whatnot. So again, thanks so much for speaking about something you’re so passionate about as a dentist that’s going to help other dentists. [Rohan]Thank you very much for being on here. So honored to be a part of this podcast, man, you guys are doing. Jaz, you’re doing an incredible thing to help us, not only improve as dentists but also outside of dentistry. So, I thank you for your time. And I hope everyone’s takes care of themselves and has a lovely day. Jaz’s Outro:Well, there we have it guys, thanks so much for listening all the way to the end. In the show notes, so if you scroll down below, or if you’re watching on the app, you can just scroll down and see all the links that are put on to Rohan’s Instagram page and how to learn more from our hand. And for those of you on the app, you’ll realize that this episode wasn’t eligible for CPD. But don’t worry, I’ve got some really cool things coming just for you Premium Members of the podcast, so you’re gonna get access to my Vertie prep for plonkers entire series, we’re gonna do a 30-day photography challenge. These are all things I’m working on, as well as access to a walkthrough of a full mouth case from beginning to end with my friend Alan Burgin. So, we’ll talk about a lot of different cases, one to one exclusively for Protrusive Premium. So, if you haven’t already downloaded the app, it’s a free download, go on Android or iOS, and search for Protrusive. And you can download the app straight away. So, if this is your favorite podcast, you need to take action and download it so you can get the maximum out of it. Again, thank you so much for listening all the way to the end. I’ll catch you in the next episode.

Do you believe that Resin Bonded Bridges are exclusively a temporary or short-term solution? Lots of our colleagues around the world mistakenly believe this. It’s not a secret that I am a fan of this treatment modality—I want to break down the misconceptions about them because IN THE RIGHT CASE they can be a very predictable tooth replacement option. In this episode, Dr. Salman Pirmohamed shared successes and failures and what we can learn from them to improve our clinical protocols from abutment selection to adhesive techniques. Claim 75 minutes CE on Protrusive App. https://youtu.be/rKJyqcb6uqI Check out this full episode on YouTube The Protrusive Dental Pearl: Always visualise your path of insertion – do you need to do some additional prep to get a more favourable path of insertion? It’s not just for dentures! For any indirect crowns/bridges, it is important to assess for a path of insertion. Make a visualisation of this – you may have to prep more or prepare the adjacent tilted teeth to allow for a suitable path of insertion sometimes. Salman’s Webinar on Sunday 4th Dec LIVE: https://buy.stripe.com/4gw14Pb8Q47Q8yk5kk Need to Read it? Check out the Full Episode Transcript below! Highlight of this episode: 1:48 The Protrusive Dental Pearl 3:17  Dr. Salman Pirmohamed’s Introduction  8:16 Resin-bonded Bridges being underutilized 9:43 Resin-bonded bridges over the years and its Protocol 12:18 RBB – functional for patients? 17:26 Case Selection Criteria 20:25 Case Number 1 22:43 Case Number 2 23:16 Dahl Technique on RBB 24:57 Cantilever as the standard design of choice for RBB 27:40 Case Number 3 29:25 Case Number 4 32:47 Mesial cantilever vs Distal Cantilever 37:34 RBB Lab Prescription 39:43 Incisal Overlap 42:06 Pontic Design ideal for RBB 47:48 RBB Clinical Protocol 1:00:09 Zirconia RBB protocols 1:06:46 Periodontal Splinting 1:15:21 Two failures with Resin-bonded bridges Have a read about this evidence-based literature as referenced by Dr. Salman Survival-characteristics-of-771-resin-retained-bridges-provided-at-a-UK-dental-teaching-hospitalDownload Also, check out this paper written by Dr. Jaz Gulati Resin-Bonded-Bridges-−-the-Problem-or-the-Solution Part 1Download Resin-Bonded-Bridges-−-the-Problem-or-the-Solution-Part-2Download If you loved this episode, you might also love this Group Function talking about Dahl Technique and ‘Maryland Bridges’ Click below for full episode transcript: Jaz's Introduction: This episode is dedicated to any dentist in the world who thinks that RESIN BONDED BRIDGES, or dare I say Maryland bridges are a temporary or SHORT TERM SOLUTION. Jaz’s Introduction:I’ve got plenty of friends in North America and in Singapore who felt that way. And I just feel like it’s a massive misconception because resin bonded bridges, or sticky bridges or adhesive bridges, call them what you want. They are such a fantastic and UNDERUTILIZED TREATMENT modality to replace missing teeth. Hello, Protruserati. I’m Jaz Gulati. And it’s no secret that I’m a huge fan of these bridges. I’ve published about this technique before and something that I did a lot of in dental hospital. And I took this into private practice. And the funny thing is that when I started to work in the practice that I work in now in Reading the dentist whose list I inherited, who was working there for 30 plus years, he was also a huge fan of resin bonded bridges. So, I’ve had the privilege of looking after and reviewing patients who’ve had their resin bonded bridges, both anterior and posterior in service for 34 years, 32 years loads in the 27, 28 year mark, plenty in the 20 year plus mark. So, he was fantastic at doing them. It really validated my belief system in resin bonded bridges. But I know what you’re thinking, you’re thinking, ‘Jaz, that’s like N equals 15. How is that even valid in this world of evidence based dentistry?’ Well, let me tell you, the evidence is out there. And we will discuss it today because resin bonded bridges are extremely successful in the right cases. And we’ll discuss what those cases are and what clinical protocols we use to get that kind of success because I’m joined today my buddy Prosthodontist Dr. Salman Pirmohamed, who you may remember from Episode 97, about face bows. If you want to learn more about face bows, when to use them, when not to use them. You can go back and listen to that episode. The Protrusive Dental PearlNow for this one, I’ve got a Protrusive Dental Pearl for you, which is relevant to resin bonded bridges, but also all types of indirect work. The Pearl is to always picture your path of insertion. Now, when I say path of insertion, most people usually think dentures right, we will always talk about path of insertion and a path of removal for your denture. But path of insertion is also relevant to crowns, onlays, and resin bonded bridges or any type of bridge. When you look at your prep, you have to visualize how is a technician going to insert and remove this indirect piece of dentistry. Because sometimes if you’ve got adjacent teeth that are tilted, it can really complicate getting a good path of insertion, in fact, recently had a tricky case where I wasn’t able to achieve a vertical path of insertion for my onlay so meaning, the technician agreed for a buccal path of insertion, it worked really well. It’s not something I do routinely or want to do. But it’s just something that worked out for me. And it’s really important to just keep that in mind, especially when it comes to resin bonded bridges, which we’re talking about today. Whenever I’m doing a prep for resin bonded bridge, and let me tell you now, let me give you a spoiler is that there’s not much prep involved. But that doesn’t mean no prep. Minimal prep can often mean making guide planes and reducing maximum bulbosity. So we’ll talk about that today. But a little bit of work can go a long way to get a more desirable path of insertion. Let’s join Dr. Salman Pirmohamed now for the main episode on resin bonded bridges, which I hope will change your mind if you’re someone who is a doubter, a non-believer, then I’m hoping that will convert you to thinking a bit more about using resin bonded bridges successfully in general practice for definitive and long term replacements of missing teeth. Salman Pirmohamed, welcome back for the second time to Protrusive Dental Podcast, we had you before on the face bows, you know all about when and why to use a face bows and you did such a great job. And we’ve been geeking out on social media, by the way your posts, dental_story, you got to follow that account is brilliant. So educational, I’m loving it. And you’ve been posting a lot about resin bonded bridges. Main EpisodeSo, let’s come on. And let’s help those who are either not warming up to the idea to resin bonded bridges. And we’ll talk a lot about that or who just want to improve their workflow. But for those who didn’t listen to the episode yet, please remind ourselves, tell us where you’re at in your career. The moment Salman tell us how you fell in love, like I did with resin bonded bridges. [Salman]Okay, so Jaz just to introduce myself again, because that was quite a while ago, we did a podcast on Facebook. So, my name is someone I’m qualified about six years ago. I’m currently at the Eastman doing my specialist training and prosthodontics and that’s three days a week. So, under the three days a week, very busy practices. Jaz found out this morning from my daily list three days a week in general practice, do you combination restorative and implant work. Resin bonded bridges like the real passion came about from quite a few things actually. The first thing is Jaz mentioned, I’ve been posting a lots kind of clinical cases on my Instagram page. And the topic I get the most questions about is always resin bonded bridges and mainly from the international crowd. So, I think the UK-based census uses a lot more and maybe NHS hospitals have changed the way we replace missing teeth. But the people abroad they”re like ‘What you’re doing that you must be doing something wrong here. How is this working? How’s the occlusion settling down?’ And that’s why I thought this podcast might be a good idea and I’m happy that Jaz invited me on because I feel quite privileged to be in a crowd of people that he gets on. [Jaz]It’d be so good because I see the kinds of cases you do. And you also told me that at Eastman, you you guys are really pushing the bow, you got really pushing it to the extreme limit in terms of what can be possible with resin bonded bridges. So, we’ll talk about that a bit later in terms of okay, how far can you go? But yes, please carry on. [Salman]And the second reason is because at Eastman, as part of our specialist training, we have to have a thesis project or dissertation topic, and mine has been on patient satisfaction, it’s going somewhere quite a long title but, ‘Patient Satisfaction for Replacement of Missing Lateral Incisors’, and comparing orthodontic camouflage, dental implants and resin bonded bridges. And what’s odd is that we often recommend patients in different clinical solutions. But a lot of it’s not actually evidence based, a lot of prosthodontics is opinion, a lot of it is expert opinion, we say on what we learn from our teachers and our VT trainers along the years. And I’m finding that from the research that I read, actually, that resin bonded bridges come up with an almost equal or even higher patient satisfaction rate than dental implants. And then Jaz, to finish the story here with the last reason I got interested in resin bonded bridges, because I started a new private practice about a year ago, and mainly to do some implant work. And I thought we were doing a lot of implants and a high number of them. And these patients are coming in for free implant consultations. And it’s a great way to improve my communication skills. But what happened is they were all working out with two implants for resin bonded bridges and my principal flagged up said, ‘What’s going on? We’re not ordering implants anymore.’ And I just realized that there are some really underutilized treatment modality that can give a massive benefit to our patients. And I’m sure Jaz share the same stories with the ones that he’s done also. [Jaz]Hugely underutilized. And that’s the first thing I want to tackle with you today Salman. Because just give you a bit of story when I was practicing in Singapore, if you remember I used to be in Singapore some years. And that’s when I realized that actually, it’s only in the UK and maybe some few select other countries in Europe, that resin bonded bridges are done to a high standard with good longevity and popular that even in the UK. And then when people talk about it on Facebook, they say, ‘It’s not going to work. No, it’s not going to work. You know, it needs a wing and a prayer.’ And all those funny jokes come out and whatnot. But I realized it to the extreme level when I was in Singapore because not only did the local Singaporean dentists have zero faith in resin bonded bridges, the US dentist that were working as expert dentists in Singapore had zero faith in resin bonded bridges that they thought was like just it’s a very, very temporary solution before you have an implant. That was the only sort of indication for resin bonded bridge. And even then they weren’t convinced by that. And that and so what happened and the third reason why I think it’s underutilized is commercial. Because what happened when I was in Singapore, I was working for a corporate, I’d written my paper by then dental update, so and I was doing a bit public speaking in Singapore, and I said, ‘Hey, guys, you know, we have a monthly corporate study clubs, I’d be more than happy to come in because I realize no one’s doing this. I’m more than happy to share with you some protocols, so everyone can feel more confident doing resin bonded bridges.’ They always reply to my emails and never reply to that one. Okay, because the most of the lectures were about implants and referring to their in-house specialists for implants, because what’s going to generate more money? Okay? Implants? Now, by the way- [Salman]I would argue with that. [Jaz]Well, yeah, I would agree with you. But actually, if you do resin bonded bridge as well and charge for them, they give you a good hourly rate, and how many years ago you got to it in terms of how much you spend, that ratio will be good as well. And I know I’m gonna go in that scenario. But as a commercial viewpoint as corporate, does it want to push its dentist to refer to implant or just for multiple implants versus, resin bonded bridge? I think they had a commercial motive not knowing that, okay, resin bonded bridges can work well as well. So, that is some of the things that I found when I was there. How about you, my friend, because you’ve been reached out on social media, international dentists not having faith, why do you think they’re underutilized? [Salman]I think with the American dentist a lot, they actually do a lot of resin bonded bridges, but it’s always seen as a temporary solution. So, the implant guys will always show like a big surgery. And then I have a resin bonded bridge in situ. And I say, ‘Yeah, we’ll take it off in three months and then restore the implants.’ And I just think like, well, if you just left it on, how long would it have lasted because it’s been pretty predictable, so far, without proper like bonding protocols and material selection. And I think that’s really funny Jaz with like resin bonded bridges as UK dentists, we’re often made fun of from the rest of the world in terms of our occlusal management, in terms of our restorative case selection. But I think in this one scenario, there’s a lot that we can teach other people or just share different treatment modalities, because it’s working in this public healthcare system that’s kind of really made this treatment modality so successful. The question of working in a hospital is yes, there’s less risk involved and things fell, there are patients are paying, there are patients for free. But it’s when we really push the boundaries to the extreme where then the more routine cases become so predictable when I do them in private practice over here and charge patients appropriately for what you do because it will give them that quality of life that they want. [Jaz]So, Salman just a little history lesson for us how far have resin bonded bridges come over the years in terms of technology, why are they in a better place now, in terms of protocols? [Salman]So Jaz, I think enamel bonding has been around for I think 70 or 80 years a long time ago it’d be on a core in a study on acid and acrylic bonding and enamel etching and then resin bonded bridges has started about 50 years ago, initially Rochette bridges, so you’d have this metal retainer, they’d be stuck to a tooth, and you’d have holes within this retainer because everyone could stick figure out how to bond the enamel, but no one could figure out to bond to the metal. So, they made this because they needed macro mechanical retention with HGSC or composite resin cement, we then went ahead in the University of Maryland figured out an extra chemical etching with the basic figured out that if you get a specific procedure to the metal, then our resin cements or bond really predictably and made our bridges is kind of stuck as a terminology, but actually the correct term is now resin bonded bridges because we don’t do the electrolytic etching the way the University of Maryland did, Kuraray came up with MDP primary, which has changed zirconia bonding and changed metal bonding and that MDP primary is how we figured out how to get really predictable bond strengths, and specifically to non-precious metals, because they’re the ones that get a thick oxide layer, very predictable bonding. And that’s how it started. And now it’s come even further now we’re looking at zirconia resin bonded bridges, but yeah, it’s been a massive evolution in the last 50 years. [Jaz]It certainly has now, I got a couple of points there. Maryland bridge, I know is not the appropriate time to use them all. But you know what, with my patients, I do use it. With my clinical community. I use resin bonded bridges, patients identify really well. They don’t like the term, I’ve just trialed it, you know, for has a nice ring to it. ‘Maryland. Oh, why is it called Maryland? Oh, from USA! Oh, okay, this is interesting. I like it.’ Resin bondedbridges sound too jargony. So that’s- [Salman]I call it a sticky bridge. [Jaz]Sticky bridge is also a good one. So, that’s good. And then as they evolved in terms of how we use it, and I think he’s really great, you mentioned about the MDP being so important, and allowing us to get some confidence. And a lot of the studies that we’ve done in the UK and abroad, but so much good stuff coming out from UK authors, which is why I think it’s done so well like my principal, who was in the same practice for 34 years and who I took over from. So, he was leaving the practice no longer principal as I took over, so all these patients in their 60s and 70s, I’ve taken off the list, they’ve all been seeing Giles for 34 years, loads of them have resin bonded bridges. And then I’ve seen quite a few which had been there for 32 years, I’ve seen some for 25 years, and maybe at like the 15 year mark once it came away. And that’s it. And that’s just because I’m interested in this, I’d like to ask those patients, but so many of them have lasted so long and patients are really happy. But back to that question I was gonna ask you is to what degree do you think it can actually facilitate or become functional for the patient as in your sticky bridge or resin bonded bridge, do you expect your patient to be able to function on them? [Salman]Yes, I have a very, like long consent process for my resin bonded bridges. And as time goes on, even though I feel they’re becoming more predictable, I think we’ve always done the things Jaz of under promise and over deliver, right? And resin bonded bridges are very much like the rest of our treatment modalities. And when I give a patient the treatment options, the resin bonded bridge solution for me is non-invasive solution that has all the benefits of aesthetics. And I promise them really good aesthetics with that ponti, didn’t work for metal retainer are one of the sub optimal aesthetics with the metal retainer. And I’m often going for incisal overlaps when it comes to discussing function- [Jaz]And we we will by the way, we weren’t for those listening, we will talk about incisal overlap later is really important. So, we will touch on that in terms of designing your resin bonded in bridge. But yes, please carry on. [Salman]For me, when I go to the functional units, I tell the patient this is not a true functional unit. Because if you think about it, you’ve got one fake tooth attached to one real tooth and one real tooth is taking two teeth weights. And so I’ll say, ‘Always be gentle with this tooth, don’t use it like a normal tooth.’ In the back of my mind. I think if they use it like a regular tooth, they probably function just as well as a regular tooth. But I always wanted to be careful. If they’ve got one resin bonded bridge in their mouth and remaining unrestored dentition. I want them to be avoiding this area of the mouth because naturally that will prolong the longevity of what we’re providing. We know that our cements are good in compression, and they’re not so good intention. And I designed my retainers in such a way that generally that retainer is always gonna be under compressive load. But if the patient is careless with its bites and forking the wrong way, it’s in the wrong direction, that’s when your cements are going to fell. And often if you talk to patients as to how to dispose them when the bridge come off, it’s so easy, just a random chewing motion. It’s usually, ‘Oh, I knocked it or something happened and then it came off and I regret doing that.’ So, they do work in function. But in terms of consenting patients, I say it’s not true functional unit and that’s the best way to look at it. Because the majority of resin bonded bridges have been done for aesthetic reasons, not for functional reasons it is postulated, which I’m sure that, later it’s a very, very different discussion. [Jaz]100% agree and so the commonly replacing lateral incisors, you know, using a canine or central so that’s the most common scenario and even lower incisors which I’m really passionate about. I’m so passionate about how we often use resin bonded bridges to replace lateral incisors and one thing I’m really passionate about Salman and I don’t know if you are as well, is I think as a international consensus in dentistry you know how they had the York consensus about the standard of care should be two lower implants for the lower denture of this person right, I think the standard of care for a missing lower incisor where appropriate should be a resin bonded bridge. Okay, Exhibit A. Exhibit A I’ve got my own resin bonded bridge replacing my two lateral incisors. After some orthodontics there’s one a pontic space and I’ve seen, I don’t know if you’ve seen before, some implants in place in a lower incisor region that’s just been absolute nightmare. And so I always think such a narrow space and- [Salman]I’ve got better story for you, Jaz. [Jaz]Go on, go on. [Salman]So, I’ve taken this audio clip from my iTunes podcast from my practice right now, my principal about 15 years ago, his associate was doing an implant training program and my principal with hypodontia, his lower incisor, so we did an implant placed, squeezed in between the two lower incisors. And about eight years later, he began having the complications from it. And so he lost both of the adjacent teeth. And that was three incisors and is mainly because someone tried to squeeze in implant and for an implant need that seven millimeters of interdental root space which there wasn’t in that case. And for me, the solution I know is narrow implants out with these implant companies. But often it’s just easier to look at simpler solution like resin bonded bridge, my principal now has a resin bonded bridge, which ones from the lower right canine to the lower left canine. And that’s even more these years hitting off another implant solution because he had that bad experience in the past. And I think we also need to look at modes of failure, right? If you try squeezing an implant in what are you going to cause what’s the complications of it, just because the patient pays more initially doesn’t mean things are gonna last, they may last longer but the cost of complications is a lot greater. So, there’s a lot of factors to consider. [Jaz]Lower incisor region for sure. 100%. So that’s the main message I gave in. You know, I talked the talk when I walked the walk when it comes to that, but on that topic or function, so part of my consent is I teach my patients about how it works. And I really say like, ‘You know, can you believe that we’ve just stuck a bit of a thin strip of metal to your tooth, like how amazing is that? It’s just stuck onto your tooth. Now can you imagine someone just peeling it away? And then, ‘Oh, yeah, it could peel away.’ So I say, ‘Look, you can do what you want. Just be careful not to bite sellotape on it, not to bite into a baguette and tear the baguette using your fake tooth, you can use the good tooth next door, but you can’t use my fake tooth.’ So anything that requires you to put the food first or a tool on that fake tooth, and you’re going to lever it off. And I think that message really gets through, the whole tearing the baguette, tearing a crisp packet. And I think as long as you avoid that, these sort of freak of nature kind of incidents, you know, getting elbow and stuff, then they enjoy a really good longevity. And patients don’t often think about it during function to avoid or anything like that. It’s more about not doing anything stupid with it. Would you agree with that? [Salman]Yeah, no, I fully agree completely. It’s just about advising his patients properly about how to take care of her. So last and the longest time possible, completely. [Jaz]So on the topic of lasting as long as possible case selection criteria, because I’m sure dentists message you saying, ‘Is this suitable?’ And I get lots of messages saying, ‘Is this case suitable?’ And thankfully, the ones I get are quite sensible. Actually, though, the ones I get quite sensible, I don’t get too many far fetched ones thinking it’s a bit of a push, occasionally, you get one which is suboptimal? Because let’s talk about what other kinds of features that think that lend themselves to resin bonded bridge. And then what are the features that don’t? [Salman]Or what are the red flags, right? Essentially what you avoid? [Jaz]Red flags, how can we avoid being too ambitious? [Salman]So, let’s go through the positives first. The things that lend themselves towards a good resin bonded bridge, which I think for me like first thing is enamel. It’s just enamel, enamel, enamel. I don’t know if people talk about Dentin bonding now but for me, enamel bonding is what’s always give me predictability for a resin bonded bridges and I’m very open and honest about my failures too, even on my Instagram. I’ve had two resin bonded bridges that failed, and one of them was pushing the limits, and it’s purely because of substrate that I wanted to. I was trying to replace a lower incisor and both the adjacency for post full mouth reconstruction and had quite composite on them. And I thought I can get by composites fresh and it didn’t work. And it’s purely that quantity and quality of enamel. The it is the first main thing you need for predictability of your resin bonded bridge. [Jaz]100%. And you can also- [Salman]Would you agree? [Jaz]Yes, please. I was gonna say one thing that I know we’ll touch on is favorable occlusions and unfavorable occlusion bite but I know you’re gonna come to that as well. [Salman]So ideal patient, anterior open bite? [Jaz]Huge class 2 div 1, anterior open bites [Salman]Class 2 div 1, is like the opposite? Exactly. So I’d say bruxists are for me a warning flag for resin bonded bridges, especially when I tried to maybe go further back in the mouth to replace the missing teeth. So for me it was when the bridge is usually when you’re retaining to be larger than your pontic tooth or more stable. So people often look at either replacing natural incisors of the essentials or the canines. I’m quite happy to do that. Because the mouth we know it acts like a lever the functional forces are heavier at the back of the mouth, like a nutcracker in the lower at the front. So for me resin bonded bridges will last better at the front of the mouth. More and more people say why don’t you do posterior resin bonded bridges and I have shown a few cases of mine on social media. But for me, they’re really really really case selective. So for me, posterior resin bonded bridge to replace, for example, an upper second premotor or for first molar is, it needs to be the perfect case there needs to be some existing into space. I don’t want to be relying on the DAHL approach too much. Because I know the occlusal forces there will be greater and so I’m worried about bruxists. [Jaz]The first ever group function I did was a question someone asked about, ‘Can you do DAHL using the resin bonded bridge technique?’ And yes, obviously we can. But then when I talk about that scenario with the first molar on adult I’m a bit more reluctant in private practice to do that. But in hospital I’m sure you’re seeing loads of the 17 year olds post orthodontic hypodontia probably using the canine as the abutment tooth in DAHL so the only contacts are on the retainers and then everything just settles. Am I right that you guys are still doing that? [Salman]In terms of replacing lateral incisors, Jaz? [Jaz]Yeah. [Salman]Oh, yeah, that’s a routine case for us. I just fitted a resin bonded bridge to place an upper five off an upper six. And we often know that post ortho patients may not end up in the most standardized occlusion. So this- [Salman]Split, split, nicely. [Salman]I’m very diplomatic, Jaz. So, we were looking at the existing volume of bone to replace the upper second premolar and we did all the implant planning, she’d been consented we took a CB CT, and we found like half a millimeter bone heights and it had been a major sinus lift to make an implant work in that area. And when I took the study casts, back to the lab as we do at the hospital and actually match them on the articulator, I noticed that the patient’s palatal cusps on 6s was fully out of function completely, there’s about a millimeter and a half of opening. And for me, it was just screaming resin bonded bridge, like you can bring the six back into function, you can keep your five pontic almost out of occlusion and very, very light occlusion. And we wrapped the whole winger and entire portion of that first molar. I’ve got photo Jaz if I can figure out to share my screen with that help with this? [Jaz]Let’s do that. So, for those guys that are listening right now we’re going to skip. You won’t get obviously see the cases because you’re listening not watching. For those watching on the YouTube or the app, which is going to be access point for general soon, you’ll be able to see the video, but first, we’re gonna skip past the video put components for those listening. Please describe what you see my friend, obviously people are watching but yeah, sure. Tell us about this case. Is that the case that you just described? [Salman]Exactly. So, this is the resin bonded bridge case we were planning an implant replacement, replacing the upper second premolar. And you can see when you had these articulate the study casts, the buccal cusps this patient six was actually crossbite. So I put buccal cusps in function. But the palatal cusps was totally out of function. As we managed to make a really thick, bulky looking retainer which had a maximum wraparound, which didn’t include the occlusal scheme at all. So we managed to give her a nice second premolar with a partial occlusal coverage of the six with a wraparound metal retainer. And Jaz, when I tried this retainer, when I tried the resin bonded bridge even without cement, I could barely get off the tooth. [Jaz]And that’s a very good point. And that’s all about respecting the path of insertion. If you’ve got a nice path of insertion, that really helps as well with some stability. Also, having an adjacent tooth next door as well, will help into positional stability as well, which is a good thing. [Salman]So, that’s one case and two most I have got dahl cases of 60s to where I have had to do them on some patients because some patients are not keen on implant surgery and they say, ‘Is there any other option?’ And I think as part of their consent process, as long as we advise them the risks of different options, we do it. So this is a patient, I fitted a resin bonded bridge in supra-occlusion. So, this is an upper six again replacing upper second premolar. It’s full occlusal coverage and we maximize all the way and you can see the occlusion as propped open and I think Jaz our international audience might be listening wondering, ‘What are these guys talking about?’ But yeah, this patient was asked to be occlusion on the anterior teeth and they came back in about three weeks and to stay with ICP contacts. So, it does work but my case selection is very much younger patients. [Jaz]I love the amount of wraparound you have on all on the occlusal surface there. I mean that is textbook from the classic studies that looks really great. And for those wondering what the hell’s a DAHL technique, please check out the episodes with Tif Qureshi, we talk all about the DAHL and there’s some I just want to point out, there’s some great work being done in the UK by Riaz Yar, really looking deeply into each and every dahl case. Monitoring them, getting digital prime scan records at every stage. T scan records before and after. So, watch your space because I think the DAHL technique understanding of how the biomechanics of it works is about to go a notch higher which is really exciting. [Salman]Yeah, so I’m not someone who’s going to advocate putting resin bonded bridge at the back of everyone’s mouth. So, firstly the mouth is a lever and if every millimeter we open up at the back, we’re opening three millimeters at the front and so your case selection needs to be really good because if you put a one millimeter thick resin bonded bridge retainer at the back, you’ll open up three times as much at the front but it works the reverse way around if you have a resin bonded bridge anterior in supra-occlusion you’re not waiting for much posterior DAHL to take place and the issue with that is it’s by its nature unpredictable. We don’t actually know what’s happening, which tooth is intruding, which one’s extruding and so you need to really limit your reliance on it as much as possible. So I’ll pick this posterior RBBs for very very similar cases. And I’m like you Jaz, the more I work in private practice the more I think, there was patient just go for an implant is a bit more predictable in specific situations. For anterior teeth, it’s almost my go to approach and I’ve got Sanj, good volume of an enamel. [Jaz]I’ll show you a risky one. Can you see this? [Salman]Oh my. [Jaz]Check this out. The same thing but it’s zirconia man, but this is an very favorable patient like he had a lot of space here. It’s just the way it worked out but this, it’s been going strong for about three years now so far. But yeah, this did sent shivers down my spine as I was doing this. Am I doing the right thing here? So, got some guidance because he is a cantilever resin bonded bridge and oh gosh, we didn’t talk about that actually the importance of cantilever as the standard design of choice and lot this busting this myth that actually you need to go for a fixed-fixed. So just talk about that, Salman. [Salman]Jaz, I recently had like a change of not a change of heart, I’d say. So, the evidence that everyone wants to look at is there’s a PA King paper 2015 which was the one done at University of Bristol. They went through like a whole bunch of resin bonded bridges in a hospital setting. [Jaz]So, the 800 I think it was. [Salman]The good for looking at that paper is they fitted them in all parts of the mouth. And it was done by a variety of people in different levels of specialty training, different registrars as they chose consultants and looking at differences in success rate between those people. But for me Jaz, fixed-fixed and cantilever I think our reports are like a two and a half times increase failure rate for the fixed-fixed resin bonded bridges, 2.34 I think or 2.74. But for me, it’s a bit of cause and effect also, like, so I’ve noticed that people will often sometimes pick a fixed-fixed resin bonded bridge, when they think it may not work in that specific situation. So they’re pushing the boundary, and then they go for the fixed-fixed bridge, and then they get that unilateral debond. And I completely understand that the benefit of having cantilever resin bonded bridges is you know, when it’s the bonded, you know, it’s come off, you know, you have to fix it. With fixed-fixed. If you get a unilateral debond, you get that secondary caries. And you never figure out that debond in the first place. But I’m sure there’s some cause and effects hypothesis happening here, Jaz. Because there’s some fixed-fixed bridges that are ideal, so lower incisors for me, if the quantity and quality of enamel is equal on either side of the pontic, I may choose a fixed-fixed design in some specific situations, because I’m not worried about a differential rate of debond between those two retainers and the movement of those two teeth is pretty equal. Does that make sense, Jaz? [Jaz]100%. And I think I’ll just add to that, and I think what Salman trying to say is that, think of the way, let’s imagine you’re replacing a central and you’re gonna use a lateral and the other central, then yes, the ligaments, the teeth want to move in the same direction. What you want to avoid, let’s think about this scenario you want to avoid is doing a central with a canine which want to go in different ways, right? And that’s when it’s going to lead to more stress in the cement loop on one of those retainer wings. So yes, similar teeth that move in similar directions like lower incisors. I agree. And actually someone I regret not choosing a fixed-fixed on my own lower incisors. I regret it. [Salman]Because? [Jaz]Because post orthodontic retention, so sometimes you want to do post orthodontic retention. Now a bit of history here, I do have a degree of mobility on my lower incisors, orthodontics in the past is a funny little thing. So for that reason, to give me a some splinting effect. And for more predictable orthodontic retention, which actually a little bit of gaps are opened up, basically. So I wish I could have done that. And I think sometimes for the sake of orthodontic retention, or stability, when you’re dealing with mobile teeth, it can be favorable. So don’t think that oh, just because someone said you can’t do fix fix it’s not for all cases. There are certainly some indications [Salman]So, Jaz, I’ve got a few fixed-fixed bridges to show you. This is the first one. And it’s been five years in situ, going from the canine to the first molar. [Jaz]And just to clarify that it’s not a crown. It’s kind of like an onlay. It’s an onlay. [Salman]Exactly, yeah. So, we actually needed to raise this patient’s occlusion to restore them to place implants in the lower posterior sextants. Place the resin bonded bridge on the upper is a temporary measure with an onlay to open up the bites. And actually, what ended up happening was the resin bonded bridge, the patient was so happy with it, she has refused to have it replaced. So, this has been five years in situ. [Jaz]Can I ask about that Salman? Path of insertion, like I’m trying to like imagine bonding that so this four unit, technically four unit, so two abutment teeth, two pontics there. You’re trying to place it on the sixth through a sort of vertical path of insertion, but the canine probably can just ensure there was some vertical path of insertion there. But was that tricky to place? [Salman]Not really. No, you know, Jaz, soflex discs are really, really good for getting guide planes accurate. So, we want resin bonded bridges to be minimal prep, but sometimes just smoothing out the mesial aspects of that six with a soflex disc in any areas of undercuts can just really help open up everything. There wasn’t an issue at all. And Jaz, you mentioned about and post orthodontic retention, what we sometimes have to Eastman is when we have resin bonded bridges anteriorly on your metal retainer, you can actually create a little loop for your fixed wire to go through. And that can still connect as part of the fixed retainer, or you can do this, which actually a section from your paper, you recognized that Jaz. [Jaz]There we are. So, central is joined together as like double abutted if you’d like. Replacing two lateral incisors. I imagine this patient well, I know this patient had a diastema or unstable sort of risk of opening up the diastema. And this is a really clever way to to get retention as well. [Salman]And I’ve got one last one to show you Jaz. This is actually another one of my mouth, I say failure in my eyes, but as a success of the patient’s eyes. [Jaz]Great. Well, I want to talk about a failure I had seven months ago. Debonded on someone who’s dentures are replaced with a resin bonded bridge anteriorly, a couple of them central and lateral. And the lateral came away from a canine because he went to the fridge, he had some cold chocolate, and he rested it on his pontic and bit down. And so that was a freak accident because he then realized that oops, I wasn’t supposed to do that on that tooth. And otherwise, that’s yeah, don’t get many failures, but recent one share and that’s how it happened. [Salman]And here’s an another one Jaz. So, this is a patient who once again, we were waiting for them to be suitable for implants. They were 17 years old we’re waiting for- So, the whole point I’m sure people are aware with implants, facial growth continues with life. And it’s especially quick up to the age of puberty. So for men, we usually wait till the age of 25, with girls, at the age of about 21 because if you place an implant too early and facial growth continues, you get relative intrusion of the implant, you get much shorter clinical crown and the gum levels don’t equalize. So, resin bonded bridges we often use in NHS hospitals. Even practice outside when we get referred them from orthodontics like this patient was willing to delay the placement of implants and give them a fixed solution. In the meantime, now this patient came in with missing upper laterals and upper canines, and I placed the fixed-fixed resin bonded bridge from the central to the first premolar. And on the other side from the other central to the first premolar. [Jaz]Wow, so central, lateral, canine, premolar, that’s four units right? [Salman]Four times two, yeah. So, we placed this and you know, it opens up the bite really nicely Jaz. But occlusion settled in about four weeks really quickly. And this patient actually decided to not go ahead with implant treatmemt five years later, so he’s going to wait it out with his bridges, because he’s happy with the function, he’s not gonna have any problems. And he’s not keen to undergo surgery. But my mistake in this case, and you might notice is look at the incisal translucency, Jaz, I lost it. And this is the case where I was beginning to use Panavia and I wasn’t checking on my nurses opening and I use tooth colored Panavia instead of opaque Panavia. That’s resin bonded bridge and much greater loss of enamel translucency and I had this grey, I looked at and I thought oh my god I’m gonna have to clean this all up patient looked at it and said, ‘I’m totally happy with it doesn’t trouble me.’And I said, ‘Let me know if it does.’ And it’s been five years and it’s still fine. [Jaz]Ver good. But yeah, great point make sure using the right cement and use an opaque cement like you know mean we both use Panavia opaque well signs of it, which is yeah, which is a fantastic cement for that reason. But you still have to warn even with the opaque cement that okay, there is gonna be a degree of graying and it depends on the degree of translucency of that tooth. [Salman]So yeah, so another disadvantage of resin bonded bridge is that. So yeah, lots of incisal of translucency is an issue. It’s often why- We found replacing and lateral incisor my ideal abutment is nearly always a canine. I don’t like centrals for several reasons. The first one is patients will often notice a mismatch between two central incisors because they lose symmetry. Centrals have more incisal translucency. And finally, we said that the DAHL approach is unpredictable, right? It’s very difficult to know which way teeth is moving. And I have a feeling that sometimes when I fit the resin bonded bridge going high on the central, I think there’s some elements of labial shift of that central incisor going on- [Jaz]I agree. Some plane. [Salman]Exactly. And patients will notice because it doesn’t match up the central. [Jaz]That’s a great reason to consider the canine. How about this whole mesial cantilever, distal cantilever? So, when I wrote that paper, I struggled for hours, my biggest time on research was finding good evidence to suggest that other than just expert opinion that the whole distal cantilever versus mesial cantilever actually has a wealth of evidence behind it and I couldn’t find anything, Salman. So, just to clarify for those things. So, mesial cantilever would be like going from a first molar to a second premolar your cantilevering mesially. A distal cantilever would be going from a first pre molar to a second premolar your cantilevering distally. So, any guidelines terms of to you, is it a relative disadvantage for you to go distal cantilever? [Salman]So I think for me like firstly, we know that forces are great with the back of the mouth, right? Always. And when we often fits our retainers in supra-occlusion, we want our pontics have been very, very like it. Well I say lots of guidance in very, very light aesthetic occlusion. I think it’s very difficult to get that pontic in the occlusal scheme. If you have a distal cantilever going backwards at the back of the mouth, it’s more challenging to do that. And that will then put your cement in tension which then leads you to a greater risk of debond but that’s just me logically speaking, completely agree there’s not very much evidence and mesial and distal cantilever because at the window when we look at the anterior part of the mouth, right, central laterals, canines, we don’t consider it. [Jaz]It’s not so important. [Salman]Yeah, I would never consider placing a second premolar off a first premolar. I can’t see a case where I’ve seen that happen because I usually use the first molar and go mesially but the only distal cantilever I do regularly is first premolar off the canine and that’s a regular to do- [Salman]Okay. Yeah, so I’ve done a few of those well raising a first premolar from canine. But I have seen a second premolar, I’ve seen quite a few actually of second premolars being replaced by first premolars at Guy’s Hospital when I was there, and it’s always because there was no molar to cantilever off right and the patient wasn’t suitable for implant. So, they essentially did the shortened dental arch principle by using resin bonded bridges to distal cantilever off the first premolar. Now, one thing I remember my consultant saying at one of those clinics is that actually she’s noticed that the first premolar you get a bit of mobility, not periodontal disease, a little bit of occlusal trauma, but it seems to be persistent and not progressing throughout the years. [Salman]So, that’s very common complete denture patients. So, upper complete denture patients who are opposing lower four to four. I’ve often seen this sort of cantilevers off first premolars. And that’s the only time I see it because obviously if you’re opposing a complete denture, you’ve taken occlusal considerations into account you’re not expecting that risk of debond. So that’s the common one that I’ve seen. [Jaz]And another lesson there you just shared is, if you’re posing and complete denture go crazy. Do it All. [Salman]Similar to open bites, yeah, take a risk, it’s fine. But first canine retainer on the canine. Pontic first premolar that seems to work really well, this canines, naturally you get really good amount of enamel. You can implement incisal overlap, you got a good root there. So, another contraindication to resin bonded bridges for me is looking at the abutment tooth selection. So good enamel, we’re looking at bone support, looking at crowns-root ratio, I do take a little bit into accounts. And because I know that I’m going to be putting that tooth in supra-occlusion, when I’m relying on the dahl approach, and it was taking all the load and make sure it can sustain that kind of load, that’s going to take. [Jaz]Very good and just last point where we talk about the clinical protocol, seeing some lower incisors with a bit of bit of mobility, I find that as a good feature to have. If he’s got a little bit, I’ll give some example, periodontal disease, and they’ve had some little bit of bone loss. That for me is not a contraindication to resin bonded bridges, as long as the perio is controlled, but actually it can act in our favor. Because what we find is that as the pontic is loaded, instead of the forces now going into the cement, it’s actually going into the PDL of the tooth is a little bit mobile, so it gives a bit and then the cement gets loaded. So, we think it’s got a cushioning effect. Have you found that with these slightly grade one mobile patients that these these are lasting well? [Salman]Yeah, Jaz, mobility is not a contraindication. For me, it’s all about the stability of periodontal disease, you’re going back to those papers about like primary and secondary occlusal trauma, they went through my first year of specialist training where there is, they put the teeth in Super occlusion and they found that any mobility you get from that occlusal trauma from that heavy loading is reversible mobility, and there’s no and pocketing is reversible as long as there’s no bleeding and probing. So it’s all about periodontal disease stability. And for me resin bonded bridge is like the ideal solution for perio patients right? Because implants we know about the complications even unstable perio patients, implants wouldn’t have a greater complication rates, peri-implantitis very expensive, very difficult to manage. And for me go to treatment for private patients is a resin bonded bridge wants to stable. [Jaz]Brilliant, I’m definitely agreements. So, let’s talk about the clinical protocol. Let’s say you’ve done your design, but you’ve opted for the incisal overlap. So, what what we mean but just describe what you mean by the incisal overlap to someone who may not know this. [Salman]The docket is in my head like I just reel through every time I show you the same once you’ve got a docket in your head for your lab. I’m very, very prescriptive about how I design my resume bonded bridges. [Jaz]So, talk through the lab prescription, then. [Salman]Okay, so let’s say we’re mock example, we’re replacing a lateral incisor off the canine tooth right? So, my lab prescription, let’s say we’re looking at metal porcelain resin bonded bridge. So, we’re not looking at zirconia for now, first thing I do is I say which teeth is the Ponce, which uses the retainer because labs will get it mixed up because communication is not always the best. So, pontic on this tooth, retainers on this tooth and it’s a two unit resin bonded bridge in case they decide to go fixed-fixed suddenly, okay. Retainer design is then I say I want to base metal alloy. So, either cobalt, chromium or nickel chromium. And I want it in minimum thickness of at least 0.7 millimeters. So, for me thickness is that really important thing I found some labs, they try to fit your resin bonded bridge into the occlusal scheme of the patient because the wider of propping it open and it’s when your metal wing is too thin that you then get that tension, you get the flex and you get the debond. And what you really want is rigidity with your metal wings so that you don’t get that tensile force on your cements. [Jaz]Just a little bit on that Salaman, before you continue the prescription I went around to a unnamed lab and I won’t name the lab and I was like they had a whole table of resin bonded bridges. And I started to go around I got my ones engaged to measure these wings okay, and not a single one was more than half a mil, not a single one was more than 0.5 mil and so we had a nice little chat about okay, why it’s important to respect that because that’s what you know, the papers have shown when they followed that protocol they’ve got success so why not copy that. [Salman]Jaz, we like the CQC for resin bonded bridges that’s in. So yeah, so retainer thickness and then I say I want maximum coverage all the way to gingival margin and on maximum wraparound wherever possible. And for me personally, I want a little lip over the incisal edge, okay two benefits and maximizing enamel and I’m also creating a bit of resistance form and it’s a seating trigger at the same time for me, so I know I’m going to cement it in the correct position. My pontic design would either be ovate pontic or modified ridge lap pontic. So modified ridge lap is my go to for healed sites [Jaz]Can you just because the young dentists listening, so you mentioned the incisor overlaps. I just want to touch on that so yes, cover a third to a half of the actual incisal table, incisal edge or the canine really, really great because it helps you to- [Salman]I’ll show you some examples Jaz. [Jaz]Seating lugs. Yeah, sure, pull up some photos as we’re talking. It acts as a seating lug or give you some index so sometimes when you go for a resin bonded bridge without a incisal overlap or without a seating lug. You’re sort of sometimes positioning how’s it going? It’s kind of fits in multiple positions. It overcomes that issue easily because it gives you something to grab on to incisal edge. So location wise it helps when the pontic is loaded. Now, the cement is in compression. So, that’s really Good feature as well. So, it’s a great thing to do. And aesthetically, when a patient smiles against the dark oral cavity behind the backdrop, it kind of disappears. But it’s not for every patient. I think it’s fair to say. [Salman]You can always trim it back. Right. So, for me sitting and I just trimmed back gradually trim are sufficiently happy trim more, trim more. And usually I get to this kind of balance where I’m happy, and the patients happy with the aesthetics. And so I get both. And I’m not worried- [Jaz]Do you tend to trim it the same day as a fit, I tend to do at review appointment. [Salman]Yeah. So, I was told to wait two weeks. For me, I’ve not noticed any difference Jaz, so what I’ll do is I usually wait a good 15 minutes that it will set Oxfam really OCD. I literally won’t touch it for a good five minutes. And obviously God , now for the next 10 minutes I’m taking off, use your personal photos, or cleaning up all the excess cements, make sure the patient’s happy. I give them all the positive instructions, and then I start trimming back gradually. But- [Jaz]Okay. [Salman]Maybe reviews a safer thing to do. I know a resin cements says, you should wait. And but not necessarily increasing the ones. Can you see this photo here Jaz, in this incisal overlap? [Jaz]Yes. Perfect. [Salman]There you go. [Jaz]A great thing to do. And then the next point that you made sorry. So we just talked about the incisal overlap and the importance. And then you switch gears and you’re talking about pontic so for the young dentist listening, can you explain what is a modified ridge lap design? And what is an ovate pontic? [Salman]Jaz, last thing sorry. Sandblasting retainer wings is really really useful. [Jaz]Let’s talk about that completely separately after because we need to talk about that give it some love. [Salman]To hide the metal shine, for incisal overlap. [Jaz]Okay, fine. Sorry. Sorry. To hide that. So yeah, that is relevant to hide the shine that the sort of the twinkle that when they smile basically makes it more matte. Yeah, absolutely spot on. [Salman]So, we always as undergraduate is four different points of types. But for me to go to is the ovate pontic, or some people might call it a bullet shape pontic. And the second is the modified ridge lap. So the ovate pontic is literally a totally convex profile that sits against the soft tissues is shaped just like a tooth underneath in terms of the bulbosity. And the ovate pontic is my go to when I’ve got like an immediate resin bonded bridge. So, I’ve kind of taken an impression, when I put my resin bonded bridge two weeks later in a patient’s quite like a retained root in situ. And on the day of fits, I extract the tooth, extracted roots, I’ve got a nice little space, I’ve asked the lab to create an ovate pontic with like a two millimeter extension into the socket, I fit it and then a soft tissue is really nicely hug around them and you get a really nice natural emergence profile. The modified ridge lap is a technique where essentially buccally you following the ovate pontic design, you got a nice convex profile you extending all the way aesthetically to where you want to be. But palatally with the patient doesn’t see you’re cutting back your pontic completely just clear the soft tissues. Theoretically, it’s a more cleansable design, it’s much easier to keep clean with floss, and it’s still got convex profile. But because you’ve got healed Ridge, you can sit a modified ridge lap against it without any issues. As time goes on and my patients are becoming more aesthetically concerned and finding a way to more and more ovate pontics so, I’m doing a lot more soft tissue shaping and with Essix retainers or dentures to create an ideal emergence profile. And I’m going for an ovate pontic design. And some people used to say, ‘Oh, it’s very difficult to keep clean.’ But as long as it’s convex, for me, it’s very, very easy for patients that don’t have food trapping, and they seem to like it better. Which goes against my undergraduate teaching. [Jaz]Yeah, there’s something really quite beautiful about moving that Essix retainer which you’ve got the composite side to mold the soft tissue or the denture or however you want to do it, pick your poison, and then take it out and use that lovely recipient area of the future. pontic just looks so natural in terms of emergence profile. Nowadays, what I’m doing is what I’m doing, not a immediate resin bonded bridge, but just a routine. Let’s switch your dentures for a resin bonded bridge kind of thing. I’m assessing the volume of soft tissue and I’m using a thermacut bur to just heat and remove this sort of architecture of the pontic I want to be and that helps it to go not 100% ovate but like in between ovate and modified ridge lap you have a spectrum goes more towards over it but I agree that you need that convexity for cleansability [Salman]Who was even modified ridge lap. Labs really find a struggle to make it, we asked them for a convex, so I always say when convex fitting surface. But actually if you look at healed ridge, we need to empathize with our lab that’s almost impossible sometimes to get good aesthetics and a convex emergence profile. There’s no good saying into the lab and saying achieve this. We have to help them along the way and create a profile that they need. It’s yeah, it’s always working together. That’s what it’s all about. [Jaz]Brilliant. And then was there anything else on the lab docket that you have mentioned yet? [Salman]Occlusion, so retainer, one chapter, pontic one chapter so I say and then occlusion. So, I say I’m going for conventional dahl approach depends on each patient’sleave the retainer minimum 0.7 millimeter thickness in supraocclusion and the pontic at this stage will be fully out of guidance and maybe lightly in occlusion. It is okay if other teeth are out of occlusion essentially, I’m okay with that. Because I’m going for a full dahl approach in this situation. [Jaz]Brilliant. You know what we talked about lower resin bonded bridges. But you know what? They can be really tough. Just like upper central to matching this upper central to another central, or even lower incisors. It can be really tough for ceramists. [Salman]Yeah, so resin bonded bridges. So if we’re looking at specifically metal resin bonded bridges, a set of photos helps massively. And the tips of metal are I’m sure you notice Jaz, mirror handle behind that tooth. So holding a mirror handle behind the tooth and then taking your photos will mimic the lack of incisal translucency you’re about to create in that tooth. [Jaz]Okay, I didn’t actually know that. Just a tip for me my friend. I love it. Thank you. [Salman]So, that’s the first one second thing what I sometimes do if I’ve got really concerned patient, I do a metal frame of trying. So, I’ll get the metal framework from the lab before they cast the porcelain, I’ll put that on the sides. I’ll take a photo and they’ll mimic that metal behind. And they’re gonna be really extreme, which is not necessary Jaz, but this is what you can do. You can paint dycal on the metal framework. [Salman]Yes. [Salman]Can sees in the mouth. It mimics Panavia opaque, take a photo- [Salman]That’s what I do. [Salman]That’s what you do then. Yeah. So I had to do, it’s yeah, it works really well. It mimics Panavia opaque right? And then you know. [Jaz]It does and just on that topic, photos are really important. And I use the cross polarization filter like e-lab and that gives them a bit more in terms of getting the aesthetics right of the pontic and then seeing the the deeper removing the specular flash as well so yeah, that really helps in shade matching technicians seem to like it. One story about a consultant actually taught me another thing with shade matching is that she will fit a resin bonded bridge from a central replacing lateral and the patient was like, ‘You know what? The shade is not right.’ And at that point they bonded it. So, what she did was that she got a palatal non precious metal veneer with it for the contralateral incisor to make it look duller as well which I thought okay you know can either another way to do it rather than kind of bridge off why don’t you stick something on so that was an interesting one. [Salman]Years for that, yeah? [Jaz]Well in hospitals Yeah. You can get away with it a lot I think. [Salman]Now and then Jaz I always say make sure there’s a good contact point between the pontic and the adjacent natural tooth because I feel like there’s an anterior rotation resin bonded bridges and when the contact point is good, I feel like a better stability. [Jaz]Absolutely, having something next door where you floss, you feel a nice contact will give it some some security. That’s a great point. And you know what, it’s good to mention that in the lab docket so they just pay a little bit more attention to okay, this was one of the requirements one of Salman’s requirements, I’m going to tick that off. So, that helps technicians at all. [Salman]I think you’re so silly but I’ve noticed like we use the same labs in practice mean other resources and the quality of work I always get back seems to be better and better and better because the lab knows you’re going to be checking this stuff. The lab knows you can’t. [Jaz]They know your anal. They know you’ve got your iwanson gauge, measuring the thickness and- [Salman]Yeah, they do know. It does make a difference. So yeah, hold yourself to that standard. [Jaz]I agree. So let’s briefly talk through the clinical protocol. You’ve got your resin bonded bridge back, you’ve tried to and you’re happy with the shade, what are the little mini steps that you can do to bond including with or without rubberdam? I’d like to know what you currently do. [Salman]Okay, so anterior resin bonded bridge, yeah, we’ve tried to own in the patient’s mouth, happy to fit, patients can find the shade. And you can actually get Panavia opaque try and pastes. I’ve got some recently. So, double check with that also. [Jaz]And also, just on that point, really important to rehearse your try in and rehearse it, practice how it goes in so that when a really important moment comes that you’re not fiddling around that you know, okay, this is how it goes in. [Salman]Yep, exactly. Yeah. So for me, Jaz, no rubber dam for bonding resin bonded bridges. Actually I’ve done it with rubber dam and without I feel like it compromises the way in which I do it. I can’t check complete seats. And for me resin bonded bridges are all of us the proper seating, because you want that cement to be minimum thickness. And if you don’t seat it correctly, that’s when you will get those debonds in these cements. [Jaz]I’m the same, no rubberdam. Occasionally, it’s split dam, especially for lower regions. You know, if I’m doing a lot of premolar, for example, split dam has its benefits and keeping the tongue and stuff out of the way. But yeah, mostly, you know, Richard Porter taught me many years ago, rubberdam is either helping you or is hindering you. And it comes to resin bonded bridges, I think it’s hindering you because you’re gonna go all the way up to the gingival margin or just shy of it. And just that’s exactly what rubber dam wants to be in. I’ve done it before, because I’ve done so many now where I put the resin bonded bridges and I’ve pinched the bloody rubber dam into my resin bonded bridge, I’m trying and pull it out. So yeah, I learned the hard way rubber dam can sometimes get in the way. [Salman]So my protocol for cementation, I ask my lab to extend the metal wing all the way to the gingival margin. On the cementation what I then do is add a decementation and place retraction cord. And that gives me that extra half millimeter to make sure we expose that bit of two so I can clear up any excess cements. So I don’t take an impression from resin bonded bridges with a retraction cord is known as a nightmare. isolates include the effects of cement on the day of fit, okay, the second thing is I do PTFE tape isolation not on the pontic side but on the retainer side. So, let’s say I’m cementing a resin bonded bridge, retainers on the canine and the pontic is the lateral incisor. I’ll do a PTFE wrap around the first premolar, let’s make sure don’t block that contact points up then the protocol is for your metal base resin bonde bridges I’m sandblasting with 50 micron Illumina and then applying an MDP Aloe primer so I think the Panavia V5 the new one has got its combined clear for ceramic primer plus has saline and MDP in it. [Salman]Yeah. [Salman]But that one’s appropriate you put that one on you leave that on the site for a couple of minutes while I work on the teeth. On the teeth, then I’ll apply my etch and then- [Jaz]Air abrasion on the teeth? [Salman]Oh sorry, Air abrasion first, 27 Micro Illumina, etch, And then apply my bond. Don’t cure your bonding agents. For tooth primer again Panavia is my go to. Panavia V5 [Salman]Yeah, you don’t need to cure that. Absolutely you wait for the cement. [Salman]The only other cement I consider for resin on the bridges that I’m using is RelyX Ultimate, which I’ve used once or twice. And that’s their protocol involves using scotch bond as the bonding agent of choice because this is universal adhesive contains MDP if you are going to do that don’t cure the Scotch bond on the tooth. The manufacturer says that if you want to RelyX Ultimate mixes with the Scotch bond that creates like a self cure setting reaction, which is pretty cool. But to be honest, my go to is Panavia, I’m just used to the handling it works, there’s no reason to change it. [Jaz]Another top tip here from Luz McKenzie told me that the Panavia proper protocol is to get it out of the fridge. Firstly, I post about some on my story. And people were, ‘Wait, is it supposed to live in the fridge?’ I’m like, ‘Yes, supposed to be in the fridge.’ So take it out of the fridge about 15 minutes before you need it that allows it to reach a more appropriate temperature, which apparently reduces how many bubbles you’re gonna get. So yes, use whichever cement you want, as long as it has got MDP. And you are familiar and comfortable with the full protocol. That’s, I think the main message. But yeah, if you don’t know what we use Panavia, and I’ve also used RelyX Ultimate as to I haven’t used anything else. And all I want to for resin bonded bridge if I didn’t have those two, and for some reason I was working in practice, I would actually change the appointment, I wouldn’t fit it, I wouldn’t fit them. [Salman]I’ve just I’ve had to order into back some I started a new practice to order in first day as I can’t actually work without this. Panavia for me like there’s different types, right, so there’s Panavia V5, which is a new one, which I’m really enjoying actually works really, really well as we’ll make using Panavia F2.0 Make sure you don’t miss Panavia SA, the Panavia self adhesive version. That’s the only Panavia that’s not suitable for resin bonded bridges. [Jaz]I didn’t know that because I’ve never used it. So that’s really good to know, actually. So in case you think you’ve got Panavia or I’ve got Panavia and it has SA version, then as someone says don’t use it for resin bonded bridges. Very good to know that. I think when it comes to cement, you have to be a little bit anal in terms of respect what the literature works well, and what works and people who’ve experienced hands and my principal or my ex principal for 30 plus years has been using Panavia for donkey’s years, basically for at least the last 15 years. So you know, use the cements that have got good proven track record. [Salman]You’re already taking a risk with this adhesive dentistry. If you’re going to be popular, you already buy the book in this case. Yeah. [Jaz]Absolutely. So you’ve put it in. And I like to really pinch with my finger in the thumb. The abutment tooth and the wing the retainer together and really make sure it’s really well seated. I don’t do anything else. It’s not tidying up just yet. How about you? [Salman]Yeah, same thing. So my consultant used to tell me that after cemented a resin bonded bridge, your fingers should be hurting when you take it off. After five minutes. That’s how you know you’ve cemented it properly. And the reason why it incisal overlap helps so much as you know you’ve got full seating, because when that cement goes, it’s very, very difficult. It’s surprisingly difficult to spot whether you sometimes you get like a shift in the bridge, you can’t tell this as overlap. Once it’s seated, I know I’m in the right position, and then I can just hold it over there. [Jaz]Absolutely. Oh, one more thing I forgot to mention about cement. I believe I’m very cynical. And I believe that the only reason Kuraray who manufacture Panavia, the only reason they sell 2.0 and all the other ones, is so people still buy them. And should they stop making it because V5 is the newer, better, sexier version, should they stop making it there’s a risk that they’ll stop buying, and they might then switch another cement. So these manufacturers the reason they make older generation still is because people still buy them. And that’s what I think so I think you’re gonna buy for the first time just buy V5. Yeah, [Salman]For me, it’s V5. The great thing about it is it comes in different colors, right? So you get like a variety of colors if you buy the full kit, and then you can use it for other bonding protocols. So gold, non precious metals, ceramics, zirconia resin bonded bridges is basically covered in that one kit in V5. By not the hospital will not switch to V5. So yeah, people are using it. [Jaz]Whoever’s in charge of ordering it still got the old system and no one’s changed it and no one dares touch it. Right. So, occlusal check. So you obviously you’ve been careful in terms of cleanup, micro brushes, probe, anything, any fancy clever tips when it comes to cleanup? [Salman]So, cleanup for me. So, I think V5 has tack cure mode, right? So I just light cure off it. So that helped me do a bit more to clean up before it gets to full sets. But otherwise, I’ll be honest Jaz, I don’t want to take my finger off that retainer wing when I’m cementing, that’s my priority. And so cleanup is a bit of a headache. So I call the patient back two weeks later to do another thorough clean. And that’s when I also scaling on a bridge straight we have to fix- [Jaz]Same. [Salman]Two weeks later, and I do find excess cement and it does happen on resin bonded bridges because I’m so OCD about just making sure I’ve seated in the right position. And the PTFE will mean that my contact points are fine. I got TePe brushes on the side. I used to brush this for my cementations now to regulate multiple air quotes and enhance civil status. They work really well. [Jaz]Yep. And as I’m pinching and holding the resin bonded bridge, my nurse will be using a long handled TePe brush, pink one. So just go inside in between the teeth as I’m still pinching and that helps to get rid of some of the bulk there as well. Only caveat is that if some reason you got up some inflammation is be careful with bleeding basically. [Salman]I’ve got about 10 Micro brushes for every fit for resin bonded bridges. So I keep 10 because- [Jaz]I think we’re very similar on that. [Salman]Each time I pick up cement, I use a fresh one for each time because if you go through one, you actually work through the tissues in Panavia everywhere, and it sticks to everything. So yeah, it’s a fresh Micro Brush each time I use it and you just keep going through them. It might not be the most environmentally friendly thing to do. But yeah, in this case, I’m okay with it. [Jaz]In terms of occlusion checks, to what degree are you checking and adjusting as you just fit the resin bonded bridge and it’s fresh? [Salman]So this is where I’m becoming a bit more reasonable, I think so. So I know my lab, if I’m going for the DAHL approach has been a really thick retainer at this stage, which is a minimum of point seven millimeter thickness. So when that patient bites together, I’m expecting essentially all my contacts and maybe one at the back, which is possible sometimes to be on that metal link. And I’m definitely not expecting any context on that pontic. So the only adjustment I usually make is that pontic. If there’s any occlusion on there, I can get it into guidance pattern, or make an adjustment to that pontic to get it out of guidance. [Jaz]Get it out of any excursion, right? Anything dynamic on that pontic, get rid of it. [Salman]Exactly, yeah, even if it looks heavy to me, I lightened it. Like let’s say I want it like almost shim drag, you know, we have implant crowns, pressingly with a resin bonded bridge pontic. And that’s how like some different occlusion. So I don’t like prepping for resin bonded bridges. And I know some people say it’s only point seven millimeters, why not just reduce the tooth a little bit, and you can stop relying on DAHL as much. And I do see that. But it’s very difficult if you prep to then maintain that space until your next visits. So what I sometimes do is if I think a bit of prep is required for this specific situation, I’ll consider the patient at the impressions appointment. There might adjust a little bit of your opposing tooth on the day of fit. [Jaz]Yeah, absolutely. [Salman]And they know it’s not like if you said too late, it’s an excuse, right? We’ve said before, it’s an explanation, all that stuff. So yeah, you want them at the impressions appointment. [Jaz]And very often you look at the opposing tooth and there’s a nice sharp, useless piece of enamel that’s unsupported that just as begging for a soflex disc to it. And that’ll give you you know, 0.3, 0.4 millimeter sometimes. [Salman]Or ideally a restoration. [Jaz]Ideally restoration. But yeah, I’m not afraid to polish any sharp enamel bits to give him my space. So that’s an often as young dentists was scared, you know, they’re scared to look at the opposing and adjust it. But if you make a calculated decision and communicate it from the beginning, then that is another neat way to gain a bit of space and not have to rely on DAHL so much. So absolutely. That’s brilliant. So we’ve covered with cement as well which brilliant, we covered the clinical protocol. In terms of occlussal- [Salman]I forgot to mention. [Jaz]Yes, please. [Salman]I forgot to mention connector thicknesses. [Jaz]Yes. [Salman]Connector thickness is really crucial here on the lab prescription, I’ll actually write ensure maximum height connector possible in this space, ensure maximum thickness because once again, with the metal base resin bonded bridges, you’re trying to avoid any flexion of that metal. And for me like connected thickness, making it as like thick as possible makes it rigid means I get less deep ones. [Jaz]Now connect to someone like young dentists and now is probably a year Qualified Dental School, I would not have been able to tell you what the connector even is. Right? So when it comes to a bridge connector, resin bonded bridge, can you just highlight exactly what you mean by the connector? Which part of the connector? And what do you mean by the height and also why the width of it is often underappreciated. [Salman]So the connector is the bit of metal in a resin bonded bridge that connects the pontic to that metal link. Okay, so that bridge and metal you have between the two. Now we look at it from an apical, coronal dimension and a buccal lingual dimension for the connector. Right? So if you’re looking at case selection for resin bonded bridges, if you’ve got a perio patient move very, very triangular teeth, big black triangles, you know your connector might be limited in the apical-coronal dimension, you may be limited in terms of heights of the connector. And so once again, that might preclude you that might say you don’t do a resin bonded bridge in this case, because your connector will be so thin. And this patient is not going to accept any metal show in that black triangle limits in your connector heights. [Jaz]Or you do some proximal adjustment if you can to reduce that black triangle and then increase the height of the connector. Yeah, increase the height of the connector and the apical-coronal direction. So yeah, that can sometimes work to Detriangulized a tooth. [Salman]You stole my point, Jaz. [Jaz]Sorry. [Salman]Yeah, that’s alright, I forgive you. So just yet I know so buccal labial. So adjusting this is sometimes a very convex, like you know, more or less when you’re facing second premolars, you’re very convex, a mesial wall. If you flatten the soflex disc, you get greater connected thickness both buccal palatal and you get better parts of insertion also, to get maximum wraparound. And so all these factors come into my mind. So that’s connected thickness. So aesthetics also is an issue like sometimes to maximize connector heights, you’re going to compromise aesthetics, if you got very triangulated teeth, very short teeth and that’s also a pontic size shape and even makes a difference. With the U shape your pontic sizes, you get a greater connector heights. And I think this study shows Jaz, there’s like a low beams but connector height is the most important factor. Compared to connector width. So for me, connector height is always what I’m most concerned about. But we look at it in cross section. So I want a minimum of about 90 millimeters squared cross section from metal based resin bonded bridge in terms of connector dimensions. [Jaz]It becomes even more important. I think metal is very forgiving. I think with the zirconia, go to the zirconia, you really, really, really have to really maximize as much as you can not only the height, but the width as well. And that may even impact on your aesthetics a bit because of how thick that connector needs to be. So really crucial because the most common modes of failure of zirconia resin bonded bridges is fracture of the framework, which I’ve seen before. I’ve got some photos of it. Anything you want to add to when we start thinking about zirconia. This has finished on the zirconia and how we’re changing our protocols perhaps for zirconia. [Salman]Because for metal for your resin bonded bridge, your whole aim is to get rigidity in metal fracturing. With zirconia, it’s a naturally rigid material, you still need to study up to worry about thickness because then you’re worried about fractures rather than rigidity with zirconia. With zirconia once again, like it is new to a lot of people when I make a as zirconia resin bonded bridge, I specify to my lab, what type of zirconia they should be using. So it has to be three wide zirconia and for zicornia resin bonded bridge, because it will be three wides to Konya, they’ll be opaque. So I’m expecting them to be laying porcelain. And if they’re learning porcelain, then you want to ask them to make sure the porcelain is well supported to reduce your risk of fractures. [Salman]Yeah, that’s a great point. So if you haven’t listened to already that Ed McLaren episode, I think it was 117. Please check it out. If you wanna learn about 3Y, 4Y, 5Y. So a great point, you want to use this the strongest, technically least aesthetic, but that’s the monolithic product when you layer it with your layering ceramic, then you get that lovely aesthetic. So great point. Is there anything different that you’re doing, even when you’re maybe your preparation design or any other factors that could be different to what we discussed in the previous parts of this episode, comparing metal based resin bonded bridges? [Salman]So what’s interesting if you look at the zicornia resin bonded bridges and the evidence, Matthias Kern got like quite a few long distance study, longtime studies looking at successes of zirconia resin bonded bridges. Now the king paper I mentioned earlier, looked at metal base resin bonded bridges and came up with like an almost about 80% success rates, while Matthias Kern comes up with a more than 90% success rate at over 10 years with his zicornia resin bonded bridges but firstly a case selection so the king paper looks at and this is where like I guess specialist training comes within such as you can kind of critically evaluate papers because the Matthias Kern paper and look says specifically anterior based resin bonded bridges with pre existing adequate into occlusal space. And if they didn’t have it then prepare the teeth to reduce the reliance on the DAHL approach should have a very specific preparation protocol. And it was done by I think more experienced clinicians while the NHS hospital base picking paper fits in metal base resin bonded bridges all over the mouth. All kinds of designs on NHS patients are choosing hypodontia with no preparation at all. And so my go to bridge for predictability for my patients is still metal based resin bonded bridges and zirconia I still feel very hesitant prepping teeth for zirconia resin bonded bridge. Because for me the whole benefits is a non invasive solution to meet this patient’s treatment need because then when that mode of failure happens, it’s not catastrophic. And I’ve got full back option in the future. But I know his paper specifically has his preparation protocol. And I’ll follow certain elements of it. So with zirconia I’ve realized my lab cannot finish it to such a nice knife edge margin. So considering a small Shaeffer prep or finish line for the seating of the bridge, and you can’t have an as nice in incisor overlap in ciconia. Because with metal you can thin it down with a bow you nicely. With the zirconia I don’t want to be adjusting because I’m worried about subsurface cracking. So I want to make sure that when I fit the zirconia bridge, I want to do minimal adjustment. So I may not go for that full incisal overlap President I’ll be cutting things back. I don’t have to polish it to a knife edge because there’s a cornea doesn’t work in thin section country with what we will tell you it does crack with a splinter. And so you want a nice thick section resin bonded bridge with zirconia that fits and you forget about it and you know it’s fully seated on that date, too. That’s my kind of thought process behind what I do for zirconia. [Jaz]Yeah, brilliant, I’d say the same. The only thing I also want to add to that is when you’re looking at your preparation of your abutment now, but most of these all I’m doing is a soflex like we said proximal wall, get a nice guide plane, but I would just you know we know where the metal like let’s say you’re replacing a canine from a first molar. [Salman]Interproximal box [Jaz]And not even the box actually know the box is there to maybe to give you the connector width and whatnot but it’s more the fact that as the metal transitions up the palatal wall to the actual cusp as well. If that transition is sharp for metal, I might accept it. It’s okay. But for there’s zirconia I’m going to get a yellow or red microfine and just smooth it and make the internal walls as smooth as possible which is better for ceramics basically. That’s the only a difference comes from, I’m just casting that one more eye, okay feel my finger is there any sharp? With metal it doesn’t make a big difference, I mean metal can tolerate that. [Salman]Yeah, anyway metal is good like you want as much of those random surface features as possible for metal because you’re getting that back from mechanical retention from this. The ceramic and the smooth flowing probes you see people do for overlays the same thing. I’ve done quite a few zirconia resin bonded bridge now. Metal’s still might go to. I don’t know how is it for you Jaz, the more I do I still feel like when I fit that metal bridge that seat still feels maybe I’m just old school in the way I do it and maybe I need to do more zirconia even when I consent my patients I say that there’s two options. One was a predictable, one will be more aesthetic. If you don’t mind aesthetics, this is the one to go for. And if they pick zirconia one I’m still learning expectations massively because for me it’s still new, I still don’t have those tenure data studies was the zirconia that made me back that type of resin bonded bridge design. But as I move more into private practice, and I see more and more patients, they’re refusing metal for the first time. And I’m noticing more and more and more I don’t know post COVID? People seem to be looking at their smiles. And soon, they actually saying I’ll never have a metal wing, when beforehand, they’d be quite happy to have one. [Jaz]I’m the same. So I say to my patients, do you want beauty? Or do you want longevity? But which is a lie. Because we know the current paper shows that it can work and I believe in zirconia bonding and whatnot. But you know, I do agree at the moment, I’m 50/50. So 2% chance we’re gonna go to zirconia or metal that some years ago, it was like 100% metal, obviously, then it transitioned a bit more zirconia about 50/50. But if I could have it my way and keep my risk lower, then I still bias metal. I agree with you. But maybe we’ll speak again five years and see if that changes. [Salman]Any case, where pushing the limits, which you see from my Instagram, I do quite a lot sometimes. [Jaz]Anything risky, then definitely don’t risk your material. [Salman]Exactly. That’s essential. So I did a perio splint case. You might have seen it Jaz. I had a patient come in this really interesting case. So I can pull up the photo Jaz, if you want. [Jaz]Go for it. [Salman]So, Jaz, if you look at this, this is an ovate pontic this is what we get with immediate resin bonded bridges. So this is a lateral incisor. And here we go, it is very interesting patient. Can you see that, Jaz? [Jaz]Yes, yes. [Salman]So this patient was really interesting patient who came to see me in private practice, and said he wanted replacement of his lower left central and lower left lateral incisors. But he’d gone to see five other people for consultations beforehand. He hated the denture he have at the moment. He wanted to fix solution whereas lower right one and lower right two are grade one mobile, but apparently stable, otherwise, he had actually had perio work done, he said it’d be mobile for the last 10 years. And his main criteria was he did not want to lose any natural teeth. Because all the implant dentists he’d seen earlier, had told him in order to do implants for this case, you need to remove the lower right central or lower right lateral incisors and have a two to two implant bridge for this to work. With a long shot of expectations and what he actually wants it and after a while, the patient just wants a fixed solution, and is happy for reduce remakes. And his main criteria is anything fixed, that can work that also allows me to stabilize lower at one or two, that’d be amazing. And so in this case is perio splints using resin bonded bridges can work really well. And aesthetically yes, metal is a compromise when his patients opened really big and looks in his mouth, you’ll see this metal lingually. But for a patient in his mid 60s and male patients based on fixed teeth, and they will function and he’s actually more comfortable with his resin bonded bridge. Now, this lower right one and lower right two are stable. In his lower left one, two a pontic. So then a six unit resin bonded bridge from the canine to the canine. [Jaz]I mean, that’s some lovely ceramic work, you see the mimicking the root dentin, root cementum. That’s really lovely. But if you again, if you you know, obviously, it’s not so important this case, I’m sure it looks good in conversational distance, but look at that the value is a bit higher and stuff like that. Compared to the natural teeth. It’s really difficult to get the shade perfect are obviously in any sort of dentistry, but I always find it. I always look I have yet to do a restaurant and I thought you know what? Absolutely nail the shade is really difficult. You know, like you’re replacing centrals in any case, it’s really tricky. [Salman]Yeah, no, exactly. Yeah. And Jaz, like, once again, like the risk of failure, you’re back to where you started. Or worse you lose us. Yeah, it’s I can always fix in house and do something else. And the more implants I do, the more resin bonded bridges I’m doing. That’s what I’m finding. And this is a nice podcast is to say, like, don’t do implants and implants, all these negatives, because they’re amazing treatment solutions. But it’s really nice to have different tricks for each and every patient, and all your consults will you give me a unique solution to each specific patient scenario. And that’s what makes prosth so interesting, right? Because you’re doing problem solving all the time? [Jaz]Absolutely. Now, I think we covered a lot of ground there resin bonded bridges. Salman, I think you do some teaching on resin bonded bridges. Tell us more about some courses that you run. So if anyone listening can attend one of those. I’m a big fan of going to live causes like yourselves. [Salman]So actually, this is a shout out to Jaz, isn’t it? Because so resin bonded bridges is like a passion of mine because of the thesis I’m doing currently. And yeah, I’ve run a few webinars and you can message me on Instagram, @dental_story to find out more. But really me and Jaz talked about resin bonded bridges, and I said, ‘Jaz, I don’t know if I want to do a podcast because you run a really, really amazing course on resin bonded bridges. And I don’t have any conflicts of interest.’ But actually Jaz is such a welcoming person. He’s invited me to speak on resin bonded bridges as well. So, I’d say message me, message Jaz because he runs an RBB masterclass, which a lot of my colleagues have actually gone on and said it’s an amazing course to go on. But generally, I think the main thing I want is I just see patients coming in and we’d like perio patients with implants, implant complications, patients who have not been offered this treatment modality and especially if the more international patients I’m seeing it’s such a nice thing to offer patients that will solve so many of their problems. I think we have a duty to offer these patients the options and that’s really the main reason for this podcast and I just feel like something everyone should be aware about. It’s a really good way of making good money in a minimally invasive way. [Jaz]Hey, we haven’t talked about money. I mean, if you can just let’s talk about money if you don’t mind revealing this, how much will you charge privately for resin bondedbridge? [Salman]So Jaz even in practice privately So, NHS mix practice if a patient came in with one missing tooth or needed an immediate denture, for example, which would be the go to solution, I began practicing the immediate resin bonded bridge because even on a bank three charge for patients which I think 280 pounds, it’s still for me more predictable and more profitable than being an immediate denture because immediate dentures you often have that replacement, the redo and as long as you want patients for me the resin bonded bridges, yes! Your main industry done in about six months and everything heals up and we can do another one at that stage is perfectly fine. So even that is profitable when private practice from using our private laboratories. Chairside time is about half an hour. Yeah, it’s a 15-minute scan impressions and photos for the shade. [Jaz]By the way. I’ve discovered today that Salman is like speedy, Dr. Gonzales, Dr. Speedy Gonzales, right. So anything that a man does, you triple it for the time that I need, but carry on. [Salman]My main criticism at the hospital is I need to slow down. That’s just how I’ve always worked spending years in NHS practice. He just wants to do these things for these patients, but 15 minutes for impressions, photo scan, and then maybe another 15 minutes. To us My main resin bonded bridge part of the point is a consent discussion. So a good 15 minute chart of photos of showing them what it looks like. If it does come off in the future. They kind of say, ‘You know what, it’s come off exactly what we discussed this to what we discussed, either remake or recement.’ And then the fifth visit as well. 30 minutes but other 45 if there’s any issues, it’s very relaxed appointment. There’s no injections, you can try and everything properly, you can do cement nicely, and you review again for 15 minutes. A few weeks later. My charge for resin bonded bridges about, depends on I work at three different practices, but usually about I’m charging mine 900 pounds, because my hourly rate for implants have exactly the same. So I have no bias even my crowns and practice such as exactly the same for every single crown I do because I want to select what’s best for my patient, and not any financial really discussion involved. It’s just I think this is what suits you. That’s my recommended option is your other options. What would you prefer? And I don’t mind which one they pick. [Jaz]Mine’s from 900 for sure. Odd time I’m doing a very high demanding patient central incisor if I’m going to zirconia you know, up to 1400 Sometimes So the range is there so that the lesson here guys is that don’t think that resin bonded bridges and therefore it’s a cheap thing. You’re still replacing a patient’s tooth, you’re still enabling a patient to smile. Because the common thing I found our colleagues do is under charge and not feel confident charge privately for resin bonded bridges, which is ridiculous. You’re giving a patient a freaking tooth. [Salman]I think you have a tendency to under charge when you’re not sure something’s going to work and that’s usually when you get the biggest problems of all. Charged appropriately you had the time for reach. Like you know the best thing is with resin bonded bridges? You know when a patient was well cared for and it doesn’t fit the shades on right and taking temporary off, remake a temporary recement. Resin bonded bridges they come in to try and I call this Fit visit, try and visit so the patient thinks they’re coming fine and then I told them okay, everything’s perfect. You know what we can fix this today and a second other positive on top of that appointments. While others are trying to come in. You tried to shade, there’s no temporary to worry about. There’s no like excess cement to remove, you try then you’re like you know what colors are perfect. Take a photo, come back in two weeks, there’s no pressure on you whatsoever. And it’s a really satisfying thing to do for patients. No injections like it’s such an easy racking to offer. [Jaz]It is a fantastic massively underutilized treatment modality. So, I think those listening in the UK, they all know this stuff, right? Yeah, we went through little details in gems, which I’m sure they picked up. But this is really for you guys in the states, Protruserati in the states. Australia Protruserati should be pretty good with this. They’re pretty hot on this. Scandinavian good. But yeah, US guys? Come on guys. You know, we love you so much from across the pond. But you guys need to appreciate that resin bonded bridges can play a role in your practice. So please do follow @dental_story, check out those cases, check out Salman’s webinar. [Salman]I had a patient from Canada came on my webinar a couple of weeks ago. [Jaz]A patient from Canada? [Salman]So I’ve seen in fact, this one dentist from Canada, came on my webinar a few weeks ago said he’d never provided a resin bonded bridge. Been qualified about 15 years. It’s like, so I run like a two and a half hour webinar on resin bonded bridge is just an A to Z, everything start to finish. And at the end of is providing like definitive. As soon as you provide something, you suddenly see these cases popping up everywhere. And when you have the confidence to provide something, you suddenly start offering it to your patients. And it’s a duty of consent that we do offer these two modalities. And this is something you need to refer out. I mean, any general dentists can provide a really, really high standard with good luck communication, I think lab communication makes up 90% of it, because we’re not doing much in the chair. But it’s the interaction between you and your lab you need to get right and you can get amazing results. [Jaz]Resin bonded bridges are minimal invasive, they are time efficient, patients high satisfaction and if you play your cards right with communication, it works well in long term and I do think you know even by saying that last little bit if you you know communication, blah blah. I’m not saying we get a lot of debonds at all. They are incredibly successful, but as long as they know not do anything stupid, then you get the real success I think because as long as you’ve got a case elections, good occlusion and enamel, your right prescription, you really can’t go wrong unless the patient has a fall or eats cold chocolate from the fridge exactly on your pontic. [Salman]And there are two failures Jaz, but one on a bruxist, or replacing a posterior tooth pushing the boundaries. And the other one bonding to existing composite on adjacent teeth, a free place of I think over 200. Now I keep an audit some of these but yeah, of patients who I know of two out of 200 is not bad. I’m sure the rest would come back. If there was debond because I haven’t we’ve practices I said at the same place. [Jaz]That is a really powerful in terms of learning. And I think this is why I’m finding with Giles, who I used to working where I said before, so many resin bridges out there in Reading at the moment, and I see them for checkups, and they’re still there and they’re doing great. So patients do not need to worry about it being a short term thing, you need to change your mentality, guys, as long as your case selection is good, because if your case selection is crappy, you’ll get a crappy result. So Salman, thank you so much for making time for this. I really appreciate it always, always great to chat with you and see your funky cases pushing the boundaries and whatnot, of course, talking through more straightforward stuff as well. Really great. [Salman]Thank you Jaz, been a pleasure. [Jaz]Absolutely. Jaz’s Outro:Well, there we have it, guys, thank you so much for listening all the way to the end, always appreciate so much. If you liked what you heard, but you want to learn more, you want see some more cases. You want spend a couple more hours with Salman then check out his webinar on resin bonded bridges happening on the fourth of December, I’ll put the link below. So if you’re on my website or the app, or if you’re on Spotify, you can read the description and find that link to get on the webinar. It is an absolute bargain. If you missed the webinar, and you’re listening to some point in the future, then you can also check out rbbmasterclass.com. That’s my online course, for resin bonded bridges. I do recommend the live interaction that you get with Salman on his webinar, I think it’s always fantastic to have these things live, where you get to ask questions, and you’re kind of committed to be there and give your full attention. But if you missed that, and you want to have something that you can access on demand for the rest of your life, then you always got the online course as rbbmasterclass.com. That cost’s 97 pounds. That includes tax and whatnot. It’s roughly around about $110 US, but I’ll teach you how I do these bridges. And I charge about 12 to 13 times more than that for a single resin bonded bridge and how you can feel confident in charging that to your patient because you have faith because ultimately you’re providing patient with a tooth, you’re providing a patient with a replacement for a missing tooth. That’s a big deal. And that’s why I teach that you should be charging appropriately for resin bonded bridges and definitely not underselling yourself. One last thing is that if you listen all the way to the end, and if you’re listening or watching on Protrusive Premium on the app guys, if you haven’t downloaded the Google Play or the Apple app, download Protrusive App and make a free account but if you want to get CPD and the exclusive content please do subscribe. It’d be great to have you as a Protruserati on there and you can claim CPD now just scroll below and answer four questions. My team will send you a certificate and you always get access to episodes first before anyone else. So, thank you again for being a true Protruserati listening all the way to the end. I’ll catch you same time, same place next week.

How often do you review your risk management? Do you follow the appropriate radiography guidelines or palpate canines when you are supposed to? These are not the exhilarating or rewarding parts of our clinical practice but they are fundamental and foundational. In this episode with Dr. Lucy Nichols, a general dentist who also does some dento-legal work in the UK, she shares her 10 commandments for safer dentistry and avoiding dento-legal claims. https://youtu.be/0MhOC-LLxbI Protrusive Dental Pearl: ‘I don’t have time’ is just not true. It’s a lie we tell ourselves. We should reframe it. Instead, we should say “I’m not making [task / activity / necessity] a PRIORITY in my life right now”. We should reflect on what are we making a priority in our lives right now. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 1:17 Protrusive Dental Pearl 4:33 Dr. Lucy Nichols’ Introduction 8:08 10 Commandments for Staying Out of Trouble: Thou Shalt Take Bitewings on Children 9:08 Thou Shalt take Bitewings on Adults 13:31 Thou Shalt Always be Suspicious of a Non-healing socket 15:29  Thou Shalt Always be Suspicious of Sore Patches on the Side of the Tongue or on the Cheek 18:21 Thou Shalt Know How to Deal with a Hypochlorite Injury 21:24 Thou Shalt Not Use Chlorhexidine Mouthwash as your Root Canal Irrigant 30:34 Thou Shalt do Further Charting when you have 3s and 4s on your BPE 35:06 Thou Shalt Not Rely on Only a Single Visit Scaling without Local Anaesthetic on Patients with Increased Pocketing 40:42 Thou Shalt Not Underestimate ID Nerve Injuries 45:29 Thou Shalt Always Palpate for Canines at Age 10 53:39 PDF Infographic available in the ‘Protrusive Vault’ in the App (iOS and Android) Check out Dr. Lucy Nichols website If you loved this episode, please check out Passion and Values in Dentistry Click below for full episode transcript: Jaz's Introduction: When was the last time you did some risk management CPD? What I mean by that is, you went on a course to learn about how to be a more careful dentist, how to follow appropriate radiography guidelines or cross infection protocols, that kind of stuff. The stuff that's not sexy, unfortunately, right? Jaz’s Introduction:Let’s face it, you know, it’s a composite veneers. That’s where we gonna go on. But you know, this is super, super important stuff. And today’s episode which we streamed live to Facebook. So thank you, Dr. Lucy Nichols, for being part of that live. And so we do have a few shoutouts here and there. And thanks to all of you who joined live on Facebook, it’s on the Protrusive Dental Podcast facebook page, if you’re not part of it already. Occasionally we do the live and it was a great episode. These are the 10 COMMANDMENTS FOR STAYING OUT OF TROUBLE. And where they stem from is Lucy Nichols who is a general dentist, she does some dental legal work. And as part of seeing lots of cases, she saw a pattern that dentists, us dentist we’re getting in trouble. And were tumbling down as easy victims, booby traps, were falling into these obvious errors, which she wanted to share with you to make sure that we can be SAFER DENTISTS and avoid getting claims and having legal troubles. So, hopefully you’d like all these 10 Commandments by Lucy, so I only knew the first one and I loved it so much. I said, ‘Okay, come on. Let’s do the podcast, tell me the other nine.’ So, we’ll share them all with you. The Protrusive Dental Pearl:The Protrusive Dental Pearl I want to share with you before we get to that main episode is kind of related to the first thing I said in my introduction, which is DO WE MAKE TIME FOR THE RIGHT TYPE OF CPD? And on that topic of time, let’s take a step back right? MAKING TIME. We all have just 24 hours a day, every single one of us whether you’re Richard Branson, or Rishi Sunak, the new Prime Minister of the UK, I try not to get into politics. So, I’ll stay away from that one. But we all have a finite amount of time. And so really, we can’t say that, ‘Oh, I don’t have time for this, or I don’t have time for that.’ And I used to say this, ‘You know, I don’t have time for this, or I’m too busy for that.’ And really, we should reframe how we say that. We should not say that I don’t have time for something. Instead, we should say, ‘I’m not making that thing a priority in my life right now.’ So let’s say one I’m guilty of, okay, I’ve gotten the gym membership, I want to go more. But at this moment in this season, it’s not that I don’t have time for the gym, is that I’m not making my health a priority. And so once you identify that, you have then listen to yourself, and then listen to your feelings in terms of, how does that sit with you? So, that thing that you’re not making time for whether it’s further education, these not so sexy topics, or something in your life that you think you should be doing, but you’re not doing it that you’ve chosen to make it a low priority in your life, once you recognize that you’ve made it a low priority. If that makes you feel happy, then great, keep making a low priority. Never do that thing. But for like me when I listen to myself say, ‘You know what, I’ve not been going to a gym in the last couple of weeks. I feel bad. And I don’t feel good about it.’ But that is a sign that okay, we need to change something. So it’s not that I don’t have time for certain things is that I choose to prioritize certain things of others and you gotta then listen to yourself, does that sit well with you? And then make changes accordingly. So, reflect on that Protruserati, what do you make a priority in your life? And what should you be making a priority? All I appreciate that all things that could be doing, you’re joining me and my guests on Protrusive Podcasts really means a lot that you’ve joined us here today. Whether you’re driving, chopping onions, or watching on YouTube, or wherever you are. Or on the app, this one’s eligible for CPD just four questions after you listen or watch, and then you can get your CPD certificate. There’s lots of premium content coming. So next week, myself and Alan Burgin on the premium section have a whole one-hour video of discussing FULL PROTOCOLS STEP-BY-STEP, a full mouth rehab case that blew up on social media when Alan posted it. So, shout out to Satnam Uppal, who recommended this episode to come into fruition. So that’s coming next week exclusively on the app, this won’t be on YouTube, it’s gonna be on the app only. So, download the Protrusive App on iOS or Android. To download the app, it’s absolutely free. But if you want to unlock a few extra features, it is a subscription which I hope to deliver immense value to you. Anyway, let’s join the main episode with Dr. Lucy Nichols. We are going live now. So hello, Protruserati. Welcome to this very rare live podcast I’ve got today. Dr. Lucy Nichols who does lots of dental legal work. And you’ve seen the title is The 10 commandments, which are Lucy told me were her 10 bugbears which I absolutely love and I’m really excited to get stuck into these. Usually when we do a podcast with a guest, I kind of know the questions I’m going to ask already but this is a little bit different. It’s one that’s I’m very excited for it because this is one that actually Lucy will be leading in a way that she is going to be guiding me through a 10 bugbears because she does so much dental legal work and has been involved in this space, she’s got these things, which I think are going to really help us to stay out of trouble. And that’s the purpose of this podcast to help you all STAY OUT OF TROUBLE, help me stay out of trouble. I don’t wanna get in trouble. [Jaz] Main Episode:So Dr. Lucy Nichols, I know we both qualified from Sheffield at various times, and you do a lot of, you’ve done lots of dental legal work over the years. Just tell us a little about yourself before we get into the 10 Commandments of Staying out of Trouble. [Lucy]Okay, well, hi, Jaz, and thank you so much for having me on. So yes, I qualified from Sheffield, just like you but a good few years earlier, I did a year of vocational training there. And then I moved to London and did a couple of years of hospital jobs in oromaxillofacial surgery. Then I went into practice, mainly NHS mixed practice, but mainly NHS and did that for a little while. And then I started to become a little bit disillusioned. I wasn’t enjoying it very much. I was starting to wonder if Dentistry was the right thing for me. And I reached a point where I realized that the question I had for myself was, is it dentistry that I don’t like or is it NHS dentistry that I don’t like? So I decided before I quit dentistry, I needed to try quitting NHS dentistry. And it can be quite competitive getting jobs in London. So I decided I needed to upskill so I started doing an MSc in restorative cosmetic dentistry, and- [Jaz]Was that Eastman or Kings? Or? [Lucy]It was uwchlan. [Jaz]Okay. [Lucy]And partway through that I moved to working in fully private practice. And through the process of doing the MSc and moving to working in private practice, I started to really love dentistry again, and was much, much happier. So, that worked out brilliantly. It was a fantastic move. And I’ve really enjoyed working in dentistry since then. It’s always- [Jaz]It’s very common, Lucy isn’t it in terms of going through that period in your career? Were thinking is it actually right for me? And I hear this from dentists all the time. And I think you summarized it really well. And you know, let’s forget NHS one, whatever environment you’re in, it could be a private practice, but in a toxic culture, a toxic environment. So, it’s really all about your environment. It might not be dentistry that you don’t like, it’s your environment that you’re not getting fulfillment from at that time. [Lucy]Yeah, absolutely. But also I find what’s really important for me is to keep learning. So even just enrolling on the masters and starting that program just reinvigorated me, I suppose and probably other people can as well. You get bored doing the same things all the time. So, when you’re learning and then doing new things, it just helps to keep it interesting. So, that’s what I’ve done, I guess. And over the years that I’ve been working in private practice, I’ve learned new skills, I started to do Invisalign, I started to play some restore dental implants. So you know, I’ve always been looking for what else can I add to keep it interesting. And then a few years ago- [Jaz]And then dental legal work? [Lucy]And then a few years ago, I started getting involved in in dental legal work, I’ve got three children. And it was something that allowed me to work part time clinically and part time from home. And that’s led to like a really good work life balance. My kids are getting a bit older now so that makes it easier doing the work at home. So, now about half of my time is clinical work and about half of my time is dental legal work. And I love that balance. It’s amazing to be able to sometimes work in my pajamas in bed if I want to, which I never thought I’d be able to do as a dentist. And just generally, I love the balance of having the clinical and the non-clinical works really well for me. [Jaz]Fantastic. Well, I just want to say some hello’s. Hello to Suleiman from West Cumbria. Hello Narni, from Sheffield. Narni is always a pleasure to see you on here. And guys, if you’ve got any questions, please come on in. If you’re on here, and you’re enjoying the themes that we’ll be covering, please share it to, you know, the Protrusive Group or any other groups that you’d like share it to. Any friends that you want to join in this live version, it’ll go in the main podcast, Spotify, etc. But there’s a magic about being live. So Lucy, when you spoke on the phone, you shared your first bugbear with me, and I loved it so much. So, why don’t we start with the top 10 commandments, which stem from your frustrations and the angle and the approach and correct me if I’m wrong, Lucy if I’m putting words in your mouth, but the reason you’ve identified them is because you almost got sick of seeing people falling into the same booby trap. People point the same traps, they must think will save so much money by GDC and medical legal costs. If this if this these 10 things were done better. Would you agree with that? [Lucy]Yeah, absolutely. Absolutely. So it seems to be things that maybe some of them are people realize they should be doing. Maybe some of them aren’t quite so obvious, and that they’re things that people maybe don’t quite realize that they need to know. So yeah, I’m really hoping it’ll be helpful for people. [Jaz]Well, let’s go with number one, which I love. And I told you not to tell me the other nine because I want to do it live. So, just remind me and everyone else are watching from it probably in their pajamas right now. What is the number one bugbear, not necessarily the most important, but just on the one on your list? [Lucy]Okay, number one on my list. Yeah, so number one is, ‘Thou shalt take bitewings on children.’ So I don’t know where this comes from. But it just seems to be a thing that dentists don’t take bitewings on children like literally none. You know, I see cases with children been going to the same practice every six months from when they were really young. Through 6, 8, 10, 12, 14, 16. No bitewings at all. And when you have a child who has kept primary carriers to the pulp, and they’ve been going to the dentist every six months, then how are you going to be able to defend that in the claim if you’ve never taken bitewings? And I think sometimes people assume or they might even have written in the notes that a child is low-risk for caries. But how do you know if you’ve not taken the bitewings? Because it might well be that there is carries there that’s developing and progressing towards the pulp. And you just haven’t seen it because you haven’t taken the radiographs. [Jaz]Very true. And you’re eight times more likely to diagnose caries through bitewings. Just compared to just clinical examinations, there’s this staff I remember from Helen Rod at dental school at Sheffield. So it is fundamental, and I wholeheartedly agree with you. I think we do as a profession needs to take it is. As though we look at the guidelines for radiograph taking and we completely blur out and ignore the children recommendations which mirror- [Lucy]It’s bizarre. [Jaz]Well, the adult ones completely agree. So it’s a massively frustrating thing, [Lucy]They mirror them. But the FGDP guidelines for taking bitewings are to take them for adults at 6, 12 and 24 month intervals for high medium and low-risk for caries. But for children, that are actually 6, 12 and 18 month intervals. So, they’re putting in more emphasis on potentially taking them more frequently for children than they are for adults. Yet what happens in practice is people just don’t bother taking them at all. It’s bizarre. So I don’t know, why- [Jaz]Why do you think that is? I mean, is it just to save time and just be quick in and out? [Lucy]I don’t know. I mean, for me working in private practice, if I take x-rays, I get paid for it. So I understand that it’s difficult for colleagues who are working in NHS practice either they take X-rays, it’s not going to get them any extra few days to do that, I understand that they are under a lot of pressure. And that is difficult. If you do take the bitewings though, and there is caries, it might allow you to get the three As that help you to meet your targets. And also you’re potentially going to avoid getting sued from because you’re not going to miss the caries. And you know, and ultimately, it’s the right thing to do because it’s proper patient care. So- [Jaz]Yeah, agreed. So guys, let’s start taking bitewings in children. If your practice doesn’t have biting holders for children, that’s the first thing to do tomorrow morning. Just get those audits, right? As if we know, the smaller films. [Lucy]Yes, smaller films. That’s what I was gonna say. I think what maybe puts people off as children not being able to tolerate them. So if children aren’t tolerating them, make sure that you’ve got smaller films. And I think even with the smaller films for children, sometimes what you also need is the little paper tabs, because the holders can be too bulky and uncomfortable. But those little paper tabs that they’re really quite comfortable. I think that they’re not too awkward in the mouth compared to what a film holders like so I think children tend to get on pretty well with those you can manage to get bitewings on pretty young kids with those. [Jaz]See, I’m just thinking that bitewings are nowadays, it’s like a birthday present when you’re 18. [Lucy]Yes. [Jaz]It was like that really? Right. So fine, let’s get the correct films and correct holders guys and let’s crack, get cracking. We know we need to do this. Let’s do it. [Lucy]Yes. And do at 6, 12 or 18 month intervals, as your meant to. [Jaz]Any guidelines to what is the lower limit in terms of like age three, age four? What guidelines can we use for the younger patient? [Lucy]Well, for the age to start doing it- [Jaz]The first bitewing. [Lucy]The first bitewings? Well, I think the idea here is to do it once the contacts close the interproximal contacts between the deciduous teeth closed, which is about the age of four or five. I mean, I think in reality, it is going to be challenging to take x-rays on a lot of four or five year olds, but I certainly think by eight to 10, you shouldn’t be attempting and if they can’t tolerate them, they can’t tolerate them. But you’ve you’ve tried, and you’ve written in notes that you’ve tried. So, you know you’ve done your best and you’ve covered yourself and that’s all you can do. [Jaz]So ‘Thou shalt take bitewings for children.’ Number two, Lucy. [Lucy]Number two, very similar, but I’ve made it slightly separate. ‘Thou shalt take bitewings on adults.’ So, the reason I made them separate is because it seems to me like this thing with children is a really, really specific thing that people just aren’t bothering to take X-rays on children at all. So I put the adult slightly separately as it is I feel like it’s a slightly different issue. People generally are better at taking bite wings on adults, but I really feel like they’re not good enough. I do still see it far too often that people take them somewhere to rack erratically or still often it’s not that unusual for me to see people who just for years and years and years and just don’t take them at all. [Jaz]What I’ve seen a lot of Lucy in practice I’ve worked in is that they like clockwork but every two or three years and then they like clockwork so that it doesn’t change dynamically as a patient changes. It doesn’t become 18 months. It doesn’t become annual for the right indications for higher cariers. It just stays. ‘Oh, it’s been our last time 2019, it’s 2022, okay, it’s been three years, let’s take it because we’re gonna cover ourselves all over.’ So, it needs to be a bit more bespoke to the individual. [Lucy]It does, it does. So, people seem to ignore caries risk. And like you said, they just take them too early for everyone. So, the guidance is six monthly for high-risk and 12 monthly for moderate risk and 24 monthly for low risk. So, it is really important to pay attention to the caries risk. And another point that I find as well is you can take bitewings on patients who are pregnant, the guidance says it’s safe to do so. Personally, I always give patients the option, I let them know that the guidelines says safe to do so. So usually they will have it, but if if they would rather not, then that’s fine. I’ve offered it, I’ve given them the correct information about the guidance that they’re saying that it is safe. But at the end of the day, you know, we can’t force patients to do anything. And if they choose not to, then that’s their decision. [Jaz]Yep, absolutely fair. Number three, thou shalt. [Lucy]Okay, number three, ‘Thou shalt always be suspicious of a non-healing socket.’ So, don’t keep treating a socket as a dry socket when it’s not healing. Beyond two weeks, you would be surprised the cases I’ve seen where even after two to three months, somebody keeps coming back to the practice. Keeps having the sockets irrigated and Alveogy put in. It’s just not normal. I mean, why would you not think that something’s up, you know, two months after a tooth has been taken out when somebody keeps coming back? So, the funny thing here is that in the NICE guidelines about oral cancer, non-healing socket does not get a mention, it’s a bit of an anomaly. I really strongly feel it should be in there. I do feel that it is basic undergraduate knowledge. It was certainly something that we were taught at Sheffield, I was in my year, I’m sure you were as well. [Jaz]Probably by the same person, Mrs. Freeman et al? [Lucy]Probably. Probably. And it was certainly an undergraduate textbooks. So, I’m not sure why it’s missing from the NICE guidelines, but it definitely should be. I’ve come across a few of these cases now. And when I think about my own practice, you know, you get patients who come back with a dry socket from time to time. Usually they come, you’ll irrigate the socket, but put some Alveogy in, they won’t come back again. Occasionally, they’ll have to come back for a second time. And you’ll do that again. And I think maybe I can probably count the number of times on one hand that somebody’s had to come back on three occasions to have a socket dressing. And I would I’m pretty sure that’s all been within the first two weeks from extraction. [Jaz]Yup. [Lucy]But beyond two weeks, that’s not something I see. I don’t see people coming back with problems with the socket after two weeks. And if I did, I would be concerned. So, obviously it could be cancer, but it could also be osteomyelitis. It could be medication-related osteonecrosis. So you know, MRONJ, so and if it’s not cancer, if it’s osteomyelitis, or MRONJ either way, you’re going to want to get that referred ASAP. [Jaz]Yeah, I’ve seen a few MRONJ. But nothing like a cancer from an underling socket. But yeah, I’ve seen a few MRONJ. And it’s very simple to diagnose, of three weeks where the mucosa is, is it’s still not looking like it should be. And sometimes a patient’s not even feeling discomfort, but it’s an observation that you’ve made, because maybe the first few few days that they were in discomfort, then you review them. And if you’re still not looking better, get that referral sorted. [Lucy]Exactly. Yeah, I mean, either way, whether it’s any of those things the cancer, the osteomyelitis, MRONJ or whatever it is, you need to get that referred as soon as possible beyond two weeks, just get it referred. Don’t mess around. It’s because it’s not normal. [Jaz]That’s simple. I think that’s a simple and self explanatory one. Very good. Let’s have number four. [Lucy]Number four, ‘Thou shalt always be suspicious of sore patches on the side of the tongue or on the cheek.’ So, I see cases where people will come and they’ll complain that the side of the tongue is sore, and the dentist says it has a look in the mouth and writes in the notes that the cusps of the molars are rubbing on the side of their tongue. So, they don’t write that the cusps are fractured, or a fillings broken or that there’s any reason why these cusps are suddenly making the tooth sore when they never did before. But they take a bath and they drill down the cusps a bit and they write that they’ve smoothed the cusps, and then the patient comes back and the side of the tongue is still saw. So, they write again all that that cusps are rubbing the tongue and they smooth it down a bit more. So, this just makes no sense to me. If the cusps weren’t rubbing the tongue before, why have they suddenly started doing it now? You know, it just makes no sense. Similarly, with with cheek biting, if somebody’s got a lesion, the back of the mouth and it you think maybe they’re biting their cheek? You know, you’re going to review that. But it seems to be a recurrent problem. Do they just keep biting their cheek? Or is there something else going on? Is there maybe an underlying mass that’s pushing the tissues out so that they’re getting bitten more often? Because the patient might actually say I’m biting my cheek. But why have they suddenly started biting their cheek when they didn’t before? Don’t just assume that because they say that they keep biting their cheek, that it’s as simple as they keep biting their cheek, and you need to drill the cusps down a bit. So yes, this is- [Jaz]In those scenarios, it would be a pitch a guideline, like if someone does come in with a some sort of, we suspect at the time, trauma from a broken tooth, a sharp filling, and usually, hopefully, we’ll see something sharp rather than just smoothing out enamel basically, that’s not associated with a fracture or wear or whatever. [Lucy]Yeah, exactly. [Jaz]And then, we’ve seen them again, in two weeks is a fair recommendation, you think? [Lucy]Yeah, see them again in two weeks. And the problem is that I’m seeing cases where people are drilling down cusps on teeth, where it’s just the same cusps that have always been there, and they’re not broken teeth. So, there’s no reason for this to happen. And then when they come back, and the problem is recurring or still going on, then the dentist is thinking, still thinking that they keep biting. And they’re not realizing that there’s something else going on. So, you need to be suspicious of sore patches on the tongue and cheek, even when the patient might say that they’re biting their cheek or that they’re catching their tongue. You need to think why. [Jaz]Always, always there should be something obvious there. [Lucy]Not just assume it’s friction, trauma, because that’s what the patient said. And that’s what the patient is implying anything. Why would that suddenly start happening out of nowhere? [Jaz]See them again, two weeks? And if in doubt, refer, don’t just keep smoothing teeth. [Lucy]Exactly, exactly. Especially when the teeth weren’t even broken. So, there’s no reason that should suddenly be happening. [Jaz]Very good. Number five, please. [Lucy]Number five, ‘Thou shalt know how to deal with a hypochlorite injury.’ [Jaz]Oh, this is a good one. [Lucy]Yes. So, one of the things that happened when I see these cases is and I’ve seen a lot of hypochlorite injury cases actually, and they can be pretty horrific. I see the patient’s account of what happens and they describe how it felt. So, they always, always describe that even though they’re completely numbed up. The moment that hypochlorite hits the tissues, they feel an immediate burning and stinging sensation. So, they’ll immediately tell the dentist. They always say they immediately told the dentist when it happens, so they will tell you straight away. So, when they tell you this, you need to get in there straightaway and irrigate with water or saline if the nurse needs to go to a different room to get some saline and it’s going to take them a few minutes to get it, just use your purified water that you’ve got from the chair but just get something in there and irrigate immediately. Just think of it if you burn your hands, you’re going to want to get that cold water on it straight away every second that hypochlorite is in there on the tissues undiluted, it’s causing damage and that will happen very fast. So, you need to act really, really quickly. And you need to really get in there with the irrigation and you’re not going to irrigate for two or three minutes. You need to irrigate for 15 minutes with saline or water. [Jaz]Good tip there, okay. [Lucy]Keep irrigating, keep irrigating, keep irrigating. So, what happens if you don’t deal with this properly, then people can end up having these areas of necrosis and ulceration where it comes through the soft tissues which look horrific. [Jaz]They look like they’ve had a facial trauma, sometimes a bruising and looks very nasty, very concerning for the family. [Lucy]Yeah, absolutely. They can have facial deformity. I’ve seen a couple of cases say an upper pre molar hypochlorite injury, where in the longer term after all the initial healing, it’s caused the tissue damage and fat necrosis that has been caused by the hypochlorite injury means that they have a dent in their cheek. So, then the parts of the claim can come sometimes become having filler injections to repair, then fill out the dent in the cheek and they will need to be repeated every couple of years for life. [Jaz]Lucy, just had a question or are we talking about this from Mark? Hi Mark. Mark is asking, when you irrigate with water, any guidelines in terms of like, do you do it with pressure? Because I mean, on that same note, when I irrigate with hypochlorite the safe technique I was taught is I don’t use my thumb. I use my index finger and I always find that a safer way less likely to put more pressure it’s a bit more controlled. But then perhaps if I was to cause a hypochlorite or not cause but if a hypochlorite accident was to happen because sometimes anatomy lends itself to it of the tooth and then do I want to go in with pressure with the water try and chase it down? Are there any guidelines we can follow? ‘Cause it’s very scary thing if that happens. [Lucy]Yeah, I’m not sure that there’s any, I haven’t read any specific guidance telling you that when you’re irrigating after it’s happened, how much pressure to use, I would assume that you will need to use a little bit more pressure because if you’re doing the super careful, gentle irrigation to try and stay in the canal or not go beyond the canal that you would do normally with the hypochlorite, then yet then obviously that there’s a risk that it won’t get through the perforation perhaps this happened or whatever it is, or the overprepared apex or whatever, you’re going to need to get through that for it to actually get into the tissues and dilute the hypochlorite. [Jaz]So 15 minutes of caline or water? [Lucy]So, 15 minutes of irrigation, and then you want to give them a short course of, so I’ve had a hypochlorite accident happened once, and luckily I dealt with it very well and the patient absolutely fine afterwards. I had caused a small perforation, which luckily I was able to repair well and everything worked out but when it did happen, she immediately told me about this burning, stinging sensation. I immediately realized I did the copious saline. And I- [Jaz]Was your heart racing, were you? [Lucy]Yeah, I wasn’t happy that happened, that’s for sure. So, I prescribed antibiotics to prevent any secondary infection occurring from the potential tissue damage, so short course of amoxicillin three days and a three-day course of dexamethasone. So, a lot of patients with hypochlorite injuries end up in a&e later. And quite often they will be prescribed steroids in any. So, I feel like let’s cut out the middleman and get them on it straightaway. Because they’re going to benefit from that. I don’t want them sitting around- in Singapore [Jaz]In Singapore, Lucy, I used to work in Singapore, we used to give it after surgical wisdom teeth. And from the papers, I’d read the time as well. It’s great for reducing inflammation after surgeries like that where is quite involved. Now, I’ve never actually prescribed it in the UK. Any guidelines because I’ve read many indications to prescribe dex for to help with post operative pain, any guidelines to how you prescribe that you keep some of the practice in your private practice. How’s it work? [Lucy]No, I don’t keep any. So, I’ve only had to do this for once. And I’d probably, if I didn’t do the dental legal work I do, I wouldn’t have done it because I wouldn’t have known but because I’ve seen it been prescribed in a&e when people have gone there after having hypochlorite injuries, I knew what they prescribed, I had made a note of it for future reference. [Jaz]And was it a private prescription? [Lucy]And yeah, it was a private prescription. So, it was four milligrams, three times a day for three days. So, the patient was taking TDs for three days, both amoxicillin and dexamethasone, and I told her to use cold compress as well. And she was absolutely fine. No problems or whatsoever. [Jaz]Amazing. [Lucy]So luckily, that worked out. But also very important point to note as well is make sure that this is on your consent form. Because when a hypochlorite injury does occur, and somebody hasn’t been informed that this is a risk of root canal treatment before they agreed for you to do it, then it’s going to be found potentially by the court that you didn’t obtain fully informed consent. [Jaz]Okay, I’m gonna get my slap on the wrist. And this is why we do this podcast I’m learning all the time, I will I will start to make a big deal of it. Now, consent forms, when I do a consent form, I’ll actually go through it with a patient. I’ll annotate it and I’ll make a point of going through that from after this podcast. Let’s just talk, just start to spend labor on it for too long if it’s a simple anatomy, which talk about sometimes the good stuff goes through and it can be burning let me know if you feel any burning. [Lucy]Yeah, I say that there’s a very, very small risk of a chemical injury that can cause tissue damage or nerve damage because actually these on my list I think I didn’t mention one of the things that can happen as well as the necrosis and the facial deformity, you know, a dent in the face for example, is quite often an area of paraesthesia that is quite a typical long term outcome after these kinds of injuries. [Jaz]It’s a rare thing but it’s a significant thing that needs to be known so it’s a rare but significant thing that should be mentioned. [Lucy]That’s why it’s really important that when it does happen, you need to be prepared. [Jaz]Brilliant. Well, I will definitely change that in my practice. So, that was a good one, was a meaty one. I think people in the chat were a bit more engaged on the live so guys, I’m appreciating the engagement. Silliman and everyone, Mark, just any questions as we go along. Please bring them through. So, just summarize the five so far. Guys if in case you’ve just joined us, number one was take bitewings for children. Number two was take bitewings for adults. Come on guys, don’t just do it every two years, look at the risk of the patient. Number three was be suspicious of non-healing sockets. Number four was be suspicious of a sore tongue or a sore cheek and it’s not affiliated with a sharp cusp or a broken filling and don’t just keep smoothing it. Think what might be going on because something else be going on. And number five just now was a quite a meaty one, it’s hypochlorite incidence. What to look out for, what to do afterwards, ie flushing with the saline 15 minutes, antibiotics, steroids. And I guess we didn’t talk about this but you know, that’s kind of patient you want to invite the next day, that’s kind of patient wanna hold their hand. Call them on phone and really just follow up and show them that you care. [Lucy]Yeah, absolutely. And what I didn’t say but I hope it’s obvious is how to avoid doing it in the first place is, you know, use a side venting needle. Don’t use too much pressure. And don’t drill through the roof to any old angle to create a massive perforation and then pump hypochlorite through it hard, which unfortunately some people do [Jaz]Very, very sound advice. Okay, brilliant. So, we’re past the halfway point, Nazar just asked why we’re on here in your consent. Okay. Well, it’s interesting. So Nazar asked in your consent, do you actually mention that hypochlorite is used? Now, interestingly, when I’ve seen this make the news maybe you’ve seen the same article I had some years ago, where it was like a Daily Mail thing like, Dentists use bleach inside her tooth and cause all these issues and like, how do you even begin to talk about that kind of stuff? But Nazar is asking. Thank you Zara. Do you mention that you’re using sodium hypochlorite? [Lucy]On my consent form, it doesn’t say sodium hypochlorite. But it does warn of a chemical. I think it says chemical injury caused by disinfectants. [Jaz]Sometimes I’ve told patients that okay, we use bleach to clean out the bugs, and they’ve been okay about it. But I can see that it’s a little bit of a funny thing. So I think it’s a chemical that can cause damage, that’s a patient need to know it’s a disinfectant. So fair enough. Thanks for answering that. Thank you Zara for asking. This episode is brought to you by the good guys at Enlightened Smiles, the premium brand of teeth whitening who do a fantastic training seminar online for any dentists even if you haven’t used them before, or you just want to learn more about good quality whitening, what are the parameters of success? What are the things to avoid? What about the trade designs? The gel concentrations, the A to Z is covered by that man, Dr. Payman Langroudi. So, check out the training, you need to go to protrusive.co.uk/enlighten. Wherever you are in the world, you can join this education for free. So, check it out now. protrusive.co.uk.enlighten. Payman and Team Thank you so much for supporting this podcast. So number six, please. [Lucy]Okay, number six. ‘Thou shalt not please don’t, thou shalt not use corsodyl mouthwash as your root canal irrigant.’ Who is teaching this? [Jaz]Amen. Tell me Jaz, who is teaching this? [Lucy]Tell me Jaz, who is teaching this? Who is it? We weren’t taught that in Sheffield, were we? [Jaz]No no, no. [Lucy]Who is teaching people to use corsodyl mouthwash to irrigate root canals? Because I’m telling you, a lot of people are doing it [Jaz]That’s like, what it’s like 0.02% or 0.05%. [Lucy]It 0.2%. And it is not effective at disinfecting root canals. It’s a mouthwash, it is not a root canal irrigants. Now there is- [Jaz]And it doesn’t get rid of necrotic tissue either. [Lucy]Yeah. Now that is some literature that would support the use of 2% chlorhexidine as a root canal irrigant. Now that is 10 times stronger than chlorhexidine mouthwash, and you can buy 2% chlorhexidine for use as a root canal irrigant from endodontic suppliers. So, that bottle of corsodyl mouthwash is not the same as that bottle from the endodontic supplier. One is 10 times stronger than the other, one will not kill anything in the root canal on one. Maybe will but you should probably still use hypochlorite. [Jaz]Very true. I mean, if you saw this, I’d Sanj Bhanderi on a few weeks ago on the podcast, we talked about acute pulpitis. And how to manage extirpation quickly and we talked little bit about this and he says that, ‘You know what, most dentists that do use chlorhexidine. They don’t even use the good stuff. They don’t use the 2%, they just using any old mouthwash.’ And like you said that’s not going to do anything. And I just want to take this moment to say guys, unfortunately, Sanj felt a little bit unwell. He’s okay for me to tell you this. He has been very acutely unwell. We wish him all the best. He is stable. He is doing more positive. I’m not going to post group function 017 on post op pain with him until I get the all clear that he’s absolutely fine and doing well. So, from the Protruserati, we wish Sanj a speedy recovery. We love you mate. We hope you’re doing okay. And a good recovery. So yes, absolutely any other points on not using chlorhexidine as your irrigant? [Lucy]Yeah, a very interesting point here, which ties into my last point. I think the reason that people use corsodyl mouthwash often as the irrigant is because they’re worried about hypochlorite injuries. So, I’ve just been talking about how you can potentially, although I wouldn’t use 2% chlorhexidine as a root canal irrigant. But if you’re going to do that, you should know that if you do use the 2% chlorhexidine, and you have a perforation and you inject that through a perforation, you will cause an injury that is identical to an hypochlorite injury. [Jaz]I had no idea. I had no idea. [Lucy]Absolutely. I have seen it. In a cases that’s come across my desk. And I’ve seen it in the literature as well when working on the case, I’ve had to go back and look at the literature. So yeah, absolutely looks identical in the photos. You can’t tell the difference. So- [Jaz]If you’re a dentist who’s afraid of using hypochlorite because you’re not going to injury and you’re using 2% then there’s no point. [Lucy]Yeah, exactly. You might as well just use the hypochlorite- [Jaz]The good stuff. Use the good stuff. [Lucy]Because it’s gonna be better anyway, so just use hypochlorite, use it sensibly. Use it carefully. Don’t cause perforations, you know, be careful with what you’re doing. [Jaz]Well out on the St. Lucy, from speaking to lots of dentists, some dentists just don’t use rubber dam, you know, they don’t have rubber dam in the practice, they just don’t do it. Okay, and fine. It’s the elephant the room, you know. And so I think the reason why some people might use the mouthwash is because they’re not using rubber dam. And they just want to, they want to irrigate with something. So, what can I use that’s safe, pulling around the mouth, and not having to just irrigate the canals of saliva. They’re thinking, let me use chlorhexidine. But we all know, we don’t need to labor this point. It’s not good enough. [Lucy]It’s not good enough, and it doesn’t work. And to be honest, I don’t think that the hypochlorite, if you’re not using rubberdam, I don’t think that’s a reason not to use hypochlorite anyway. I mean I’ve, hypochlorite when certainly when it’s happened to me, when it’s leaked through a breach and the rubber underneath the rubber dam, that the patient’s got, ‘Ugh, I can taste something.’ You have to lift up the rubber dam, wash it out underneath and suction it up, and then make sure you’ve got your seal on your rubberdam. There’s not causing any kind of injury because it’s on the surface of the tissues. So when you inject it, and it’s going, you’re injecting it into the bone- [Jaz]In the planes of the tissues. [Lucy]Basically, into the tissues, that’s when it causes a problem. So, if you’re not using rubberdam, I mean, obviously, you shouldn’t be but that’s not a reason not to, it doesn’t stop you using hypochlorite, I would say. [Jaz]Absolutely. All right, number seven, please. [Lucy]Okay, number seven, ‘Thou shalt do further charting, when you have 3s and 4s on your BPE.’ [Jaz]Yes, okay. [Lucy]So many, many, many people out there. Do their BPEs, they write the 3s and the 4s and then don’t do anything more. [Jaz]Lucy, I’m gonna pause you for one second. It’s so important to mention for the international audience and in the States, correct me if I’m wrong, Lucy if you know this, but the colleagues I speak to the states and also when I was in Singapore, speaking with dentists from the States, there’s no such thing as BP, like there’s no basic periodontal exam, they actually do six point charting, or they assess the gingiva. They look the radiographs, but there’s no a basic screening tool like that. So, for those internationally, BP is a basic periodontal examination. It’s got code from zero all the way to four, we’re not, it’s not going to be a tutorial on the BPE as a screening tool. So, once you found through your screening tool that this patient has got a screened positive for potential periodontitis because you can’t confirm that as a diagnosis without doing further investigations, radiograph, etc. But yeah, we don’t just screen it’s like screening someone of high risk of anything, and then just leaving them to it, you got to then probe further. [Lucy]Absolutely. Yeah, yeah. So you know, if they’ve got threes and fours, they’ve basically got pocketing every 3.5 millimeters. So, when somebody has 3 and 4 you don’t have to do a six point pocket chart where you write in everything, and you write all the ones and the twos, you don’t have to do that the guidance actually says you don’t have to do that, you have to write the fours and the fives and the, you know, the sixes that the ones that are over three, and you have to write where they are. So personally, in my practice, we have SOE, so you go into the six point pocket chart, you open a new chart, and you just have to put it in those isolated sites. And you know, most patients, it’s just a few sites, it’s not everywhere, you know, maybe sometimes with new patients who’ve not been to the dentist for a long time, and they’ve got really widespread perio, you know, you might have quite a lot to do. But for a lot of your regular patients, it’s just going to be a limited number of sites, and you just need to record where they are. So, you just put in those limited number of sites and it really shouldn’t take very long at all. So again, I am very aware that I work in private practice, and that time is a real issue for people who are working in NHS practice. But if you are just putting in those isolated types, it’s really very quick to do. And- [Jaz]Amazing. That’s a very good top tip there. So that if you’re a dentist who thinks that ‘Okay, 3 means I need to now do the entire sextant.’ It’s not gonna say the case, get find those deep pockets, and then label them where they are and what number they are. And so then you can repeat that in the future. And it doesn’t add to extra time to the equation. [Lucy]Exactly. And you might have a couple of code 3s, and it might literally be two teeth, one on the upper left, one in the upper right, that have got a four millimeter pocket. And, you know, if you don’t want to open up a chart, I mean, this isn’t particularly guidance, this is just my personal opinion, you could just write in the notes, you know, for millimeter pocket, and B for mesio-buccal upper left six, for example. And same for upper right six, that if you’ve written that descriptively in the notes, you’re essentially recording exactly the same information that you would do on a perio chart. But for a very limited number of sites like that, because it’s showing somebody who’s going to look at that, that there’s a code three here, because of that one pocket at that particular site on that particular tooth. And that’s how deep it was. And that that’s the information they need to know. Because otherwise, if you’ve got a code three there could be pockets all over that sextants. So, if you at least when there’s just a couple of slides just just right where they are and how deep they are. And if there’s a few more just pop them in a chart, but you don’t have to do the whole chart. [Jaz]That’s very good real world advice and obviously it make sense do it in the official chart, because in the future, two years down the line, it’s so much easier to find than digging through notes. But it’s a valid point that you know, if you just had to, there’s just one pocket and you had to not do a chart for it. Make a note. Be descriptive where it is. And that’s good. Now we’ve got a question from Osama. Hi, Osama. hope you do well buddy. If the patient seeing hygienist for perio can we write it in the instructions to the hygienist? Now, I’m thinking here Lucy, immediately that ideally, a practice needs to have a policy or protocol for managing their perio patients, who does the pocket charting? How often do you guys do it? How do the dentist and the hygienist work together? That’s the thing is kind of going through my mind. But how would you answer Osama’s question in terms of, can we just write the, can we just delegate it to the hygienist? So, you found let’s make it really tangible. You found a code for upper right, instead of doing the chart, can you now, can you medical legally covered if say, ‘Code four found, informed patient. Andrew, the hygienist, can you please do the six month charting next week when you see them?’ [Lucy]I mean, I think lots of people do that. Lots of people will, particularly if they’ve got a hygienist that’s working with nursing support, then they’ll put them back to have a full charting done by the hygienist. And I think that’s okay. But I think if you are going to then send your patient off to the hygienist to have that full charting done, then you’re actually going to need to look at that charting, because it’s still on you then to do the treatment plan of exactly what their need is. So, you need to see the charting, look at it together with the X-rays, and then make your plan. Personally I do my six point charting to myself, I want to know exactly what and record where all the pockets are myself for that my own peace of mind. So yes, you can delegate some of this to the hygienist. But you’ve got to remember the bugs always going to stick with you. And if they are going to do that pocket charting, you’re still going to have to be looking at it because you’re going to have to be deciding on exactly what that treatment plan is going to be. [Jaz]Good. So you can delegate but that doesn’t mean that you’re now not involved in the care anymore, you need to then go for the next step. So, that’s absolutely reasonable. Number eight, please Lucy. [Lucy]Okay, so I kind of do my fingers that. Okay, number eight. Number eight, ‘Thou shalt not rely on only a single visit scaling without local anesthetic on patients with increased pocketing.’ So, if you’ve got a patient who’s got widespread pocketing, then no one is going to be convinced that a single visit was sufficient. So, even if you write in the notes that you’ve done perio debridement, if it’s been done, if you’ve done your perio debridement in one visit, everybody knows that basically means you just did a scale and polish or maybe just the scale and not a polish- [Jaz]A gross scale. [Lucy]A gross scale. I mean, a lot of it depends on time. It depends on how much time you spent and exactly how many pockets there are, it might be actually that you had quite a bit of time that day. And the number of pockets wasn’t loads. And you were able to go round really thoroughly with the ultrasonic then go around with hand scalars as well. And you’ve done a thorough job as was needed and could have been done in the time. But if that’s the case, you’re going to have to document that very clearly. But on the whole when you see you know, and I see a lot of these cases with patients with codes, threes and fours, when they’ve just had a single visit where it’s you know, they’ve just had a scan, it might be called a scaling, it might be called a periodontal debridement, fit they might have written root planing, I mean there’s root surface debridement that this of course now- [Jaz]A deep clean. [Lucy]A deep, deep, clean, deeply this and of course now we have the new term don’t we? PMPR, Professional Mechanical Plaque Removal. This is not my favorite term. I don’t know what you think of it. [Jaz]It just mumbo jumbo. [Lucy]I mean, okay, so to me that term just says you’re going to remove the plaque and leave the calculus behind really. I mean really on some of those patients that come in with all that calculus cakes every way you’re just going to remove the plaque and leave the calculus is that what they mean? I don’t know. [Jaz]Surely not. But you’re right it’s confusing term. [Lucy]That’s a bit of a strange term I think it’s a strange term. I don’t like it. I think I quite like perio debridement myself. [Jaz]Yep, same route service debridement right what I like perio debridement. Now, it’s so many times I’ve seen patients with code force and I can see that the history of code four has been continuous, ask them have you ever had local anesthetic before to have a deep clean whatnot? I never haven’t had a local anesthetic? For instance, last time I had a feeling 15 years ago, kind of thing. And in my perception of the world the moment if they haven’t had la. Have they really had a thorough debridement? That’s how I see it. Maybe I’m wrong. And Lucy I’m happy for you to say no, actuallyJaz you can do a deep. Good, good job without LA. Where do you stand on that? [Lucy]Okay, well, I would say it does sometimes surprise me. How much you can get away with cleaning deep pockets without local anesthetic and the patient doesn’t seem to flinch. And you know, so yeah, that does surprise me. Having said that, one of the things that I’ve noticed as I’ve become more experienced in my career, maybe I just get frustrated with damn perio and it not getting better that I become pretty brutal. Yeah, my period is brutal. I mean, I, I want them to be really numb, because I’m going to be really brutal and I feel that that’s the best way to get a good result. So, I wouldn’t want to do what I do. When I do, when I see patients, we’ve got quite a lot of pockets and I get them back for to visit perio debridement and I do you know, within the same week I’ll do right side and one day and left side and the other day and I’ll you know, numb them up on one side, go with it and be pretty brutal and then do the same on the other side. So, that’s how I usually manage it. [Jaz]It’s not a practice bill that unfortunately. It reminds your practices to work in Oxford. Now, I used work with these wonderful hygienists. Shout out to Morgan and Lou for listening. Absolutely brilliant what they do, you know really, really good forward thinking hyginiests and then when they’d have to refer to a periodontist for the tough patients. The patients come back saying they just did the exact same thing you did, except they scale me to within the inch of my life like they literally the periodontist, the only thing the periodontist did different was extremely thorough. Now, thorough is not the right word. Aggressive and brutal is the right term. [Lucy]Yeah. ] [Jaz]So yes, I think I completely agree with you. I think that’s the difference. [Lucy]Yeah. The other thing that I think really helps me with perio is my loupes. I think my now 5.5 or 5 magnification and the light as well. I blow what I’ve been scaling, then I blow air down to the pocket and it kind of blows it open. And I can see right down the pocket. It’s amazing. [Jaz]Yeah, it’s amazing how much sub gingival calculus you can spot. [Lucy]Yeah, but I mean, years back when I was nearly qualified, and I wasn’t working with loupes. I had no idea I was working in the dark, really. Whereas now I can see right down the pocket. It’s brilliant. [Jaz]Yeah, definitely agree. Almost coming to 10, guys. Number nine, please. [Lucy]Okay, number nine, ‘Thou shalt not underestimate ID nerve injuries.’ [Jaz]Okay, interesting. [Lucy]We’ll know about ID nerve injuries. So, what we probably know about them is that when you take wisdom teeth out, the patient might end up with a numb lip, and it probably will be temporary, but it could be permanent. And I’m not sure that most people know a lot beyond that. So, one of the things that I’ve learned from doing the dental legal work is I have seen a lot of patients give their accounts to me in person, or I’ve read their accounts- [Jaz]Like you’ve interviewed them. [Lucy]Yeah, when they’ve come to see me for examinations. And I’ve seen their accounts with them that have the impact that an ID nerve injury has had on them. So, of course, it’s not necessarily that they ended up with a numb lip, they might have paraesthesia. So, they might have disturbed nerve sensation. They might have dysesthesia that’s a difficult one so, isn’t it? So, they might have a painful disturbed nerve sensation. So, can you imagine if you have damaged your ID nerve, and you’re getting continuous severe shooting nerve pains? I mean, how do you live with that? It’s just awful. [Jaz]Yeah, I mean, I don’t even know Doc Koray Feran, a fantastic dentist, someone I really admire he, he was lecturing once. And he described these patients from what he’d seen. And he says that it’s like pinching your lower lip, and really just pinching it for a minute. And then feeling what that feels like. And this is how some patients will describe how they’re living constantly, as if there’s a pressure on their lip bases, from his account of the patients you’ve spoken to. So, absolutely agree this is really a big, big issue for the patients that suffer with this nasty complication. [Lucy]So, the other things that they say almost always say is that they don’t eat out anymore, because they can’t tell if they’ve got food on their chin. And that’s quite sad. I mean, that’s a big part of their social life. It’s too embarrassing for them, because they just can’t tell when they’ve got food around their mouth or on their chin. So, they’re just too embarrassed. [Jaz]I have the same issue but with my moustache. I’ve learned to deal with it. [Lucy]Yeah. [Jaz]And I’ve got close, close friends that will just say, Jaz, just over here.’ But yeah, if you’re not on your face, and you don’t have a beard like me, is that that’s a nightmare. [Lucy]Yeah, yes. And so another thing that I’ve seen come up a lot as well is that they don’t want to kiss their partner anymore because it feels weird and uncomfortable, and they don’t like it. And they consistently report that it puts a strain on their relationship. So- [Jaz]Absolutely. [Lucy]Who would have thought that? You don’t think about these things, but it’s, you know, impacts people’s lives so much. I can’t under you know, underestimate how big the impact of these injuries is on people’s lives. I’ve actually come across somewhere where an ID nerve injury was referred to as the suicide injury. Now, I can’t remember where that came from. And I don’t know whether there are documented cases of people actually committing suicide because they couldn’t cope with this injury. But, I think that the takeaway from that is that it is a pretty horrendous injury to have so don’t underestimate it so the take home there is just don’t go anywhere near the ID nerve. Avoid ID blocks if possible, because I have seen a lot- [Jaz]I was just gonna ask you about that because Tara Renton is obviously quite begin saying that ‘Okay, we got to be really careful with ID blocks are they’re a big source of problems.’ [Lucy]Yeah, I’ve seen loads of them. [Jaz]I probably do- Yes. I was gonna ask you in terms of the injuries that you’ve seen, were they what percentage? Well, from like the standard culprit is like tricky wisdom teeth, tricky surgery, orthognathic surgery, and what percentage of the of them were the harmless ID block? [Lucy]I would say probably at least a third would be ID blocks. [Jaz]Wow. [Lucy]Rather than surgeries, I think. Yeah. So yeah, I mean, just just avoid ID blocks where you can. [Jaz]Do you do any ID blocks at the moment? [Lucy]Yeah, I do. I don’t use articaine. I know that the literature is a bit up and down about the significance of that, I use citanest for my ID blocks. Actually,I find that works better than Lignospan. Yeah. And I’m not sure but from the literature, whether that’s better, but it certainly doesn’t seem to be worse. I mean, maybe if we use it for ID blocks less but I haven’t really seen cases where using citanest has being associated with ID nerve injuries. [Jaz]You know, when it comes to ad blocks I’m probably doing around about and I’m working four and a half days, I’m very wet fingered, I’m probably doing about one a month at the moment. I do a fair few extractions, wisdom teeth, I’m doing a lot with infiltrations of articaine. Shout out to Janice Boyd from Canada, who motivated me to take the step to do like, you know, lower second molars were just articaine, buccal, and lingual and I’m getting fantastic results of that. So, that’s working well in my hands at the moment. So, I’m doing less and less than this ID block. So- [Lucy]I was trying to avoid them. But I’m still doing a lot more than you. So obviously, I need to work on that. [Jaz]You know, when I just heard what Janice was doing in Canada, and she really gave me the confidence that she’s doing second molar extractions under just infiltrations of articaine. So, that really gave me the step like, ‘Hey, you know what, let me test the limits here.’ And so far, I’ve only had once wear I just had to top it up with an ID block. But most cases, especially for like cracked teeth, I’ve been doing a lot of second molars quite commonly get cracked, I’ve been dealing with all exclusively with articaine infiltrations, making sure I go into the attached gingiva making sure I see it sort of- [Lucy]Launching. [Jaz]Spread up like a Wrangler, basically, bucally to sort of the collection of the anesthetic, so it’s kind of like subperiosteal, and sometimes going lingually as well. And that really has worked well on my hands. So, that’s a very good one. So, I’m gonna summarize in number 6-9. If we do the big reveal of the last one, it may or may not have any significance of being the last one. But hey, so we left off number five with how to deal with the hypochlorite injury and how debilitating they can be. Six was stop using corsodyl mouthwash as your endodontic irrigant. Come on, guys, we know that already. And number seven was if you’ve screened for periodontal disease, and you found an issue, ie got code 3s and 4s in the BPE which we saw in there in the UK, don’t just ignore that follow up, do some pocket depths. And the big, big takeaway there was, you know, you can do isolated pockets, which is very good. And number eight is if someone just had a scale and polish or single appointment for their full blown periodontal disease, is that really sufficient? Probably not. So, you know, let’s get the full therapy for them. And don’t underestimate ID nerve damage. And Lucy described that about a third of the injuries anecdotally that she’s seen were from just the quote unquote, “harmless ID block.” So, something very good to note there. So- [Lucy]Well, just one more little point, just before we move on to number 10 that I was going to share that the ID blocks is that you know, obviously don’t go correcting the base of a socket when it’s close to the nerve. But another one that I think it’s not so obvious is that when you take a PA of a tooth before you’re going to maybe do an endo, often on the PA you might see the upper border of the ID canal but not the lower border and because you’re not seeing the double tramline, the upper border on its own might not be quite so obvious. So, sometimes you might end up doing an endo with the tooth with roots. And actually people think it’s the eights that are sitting on the ID now but there’s plenty of seven and sixes and even fives that have the apex basically look in the nerve canal on the radiograph. So, you can end up doing endos on those teeth and you can cause ID nerve damage on those teeth as well. So, you’re gonna have to be very, very careful with your endo files when you are working on those teeth. And obviously with implants, I mean just have a massive, massive safety zone. [Jaz]Yep, yep, yep, and with the periapical radiographs that we take for endodontics so make sure that you can see sufficiently beyond the apex to make that sort of assessment on a first molar, on a second molar now on the chat, our good friend Andrew Miles from Trinidad and Tobago, I think it’s Tobago? One of them. Hello, Andrew. He says there are rare cases of emphysema in the neck and mediastinum due to forceful air aspiration around low teeth so puffing air and pockets should be done with that awareness. So, just be careful guys, when you do that for our point. Marks again hello again. Mark says how many ID blocks have done in the UK per year? Probably shit load. Trinidad. But probably less than less. I’m guessing we’re turning more towards articaine infiltrations. So, number 10, Lucy. [Lucy]Okay, so number 10, ‘Thou shalt always palpate for canines at age 10.’ So- [Jaz]Preach! [Lucy]And you know, if they’re not there, just refer don’t keep seeing them till they’re 15. And they’ve still got their C’s, by which time the impacted canines are like this over the roots of the ones and twos and have resolved half the roots of the ones and the twos. Yes, unfortunately, that seems to be another thing that people aren’t that hot on. They’re not palpating for canines. [Jaz]The basic thing to do, I think the big takeaway here guys is start implementing it tomorrow. But how will you implement it in your examination template for child exam? Is it even there? Is that even entry? If it’s not an entry, it’s never going to happen? So, just a simple tangible next step, the logical next step is make sure canines palpated, question mark, why stroke n and then delete the one as appropriate. And do that for every patient at age 10 and above. And I’ve got a few stories here. Like I thought that if I find any concern at around about age 11, 12, because the first time I’ve seen that child, and I’m thinking, ‘Oh, by time I refer them to orthodontist, they’ll see them for a year.’ But actually it doesn’t have to be like that. If you email your orthodontic practice, your NHS orthodontic practice, actually very sympathetic towards this. And they will reply back saying, ‘Okay, we’ll make an urgent arrangement for them.’ So, I think pursue that avenue to get it assessed by the orthodontist, where it’s a good idea to do so. And the other one is a story is I used to treat this fairly well-known international celebrity in Oxford, and I saw his daughter come in and oh, my goodness, it was just, they weren’t threes. They were C’s and previously had all these teeth charted as permanent canines all these years. So, I have to break the news that actually the there’s a big buldge in the palate, and it’s a big issue. So, then it starts a whole fiasco. [Lucy]And how old is she? [Jaz]She was 14. [Lucy]Right. Absolutely. And the thing is with these is that if you get to them quickly, the alignment cannot often spontaneously improve, or if it doesn’t, and they still need to intervene, that you know that they can expose them attach the gold chains, drag them down, the longer you leave it, the less likely it is that’s going to work. [Jaz]And in terms of guidelines, and here’s something that I probably need some advice from you on is I’m always seeking orthodontist guidance on this kind of stuff. Even though I got deployment ortho, I do say, ‘Okay, let me just get the orthodontist opinion. Should we extract the C’s or not?’ And their advice usually, is to do it. Now, should I be making that judgment call myself? So when I see that, okay, they’re 10. I can’t palpate the canines, bucally or palatally. And so should I then be saying to parents, ‘Okay, let’s get a little Tommy in and remove the C’s.’ Should I be making that call? Or should I get that call facilitated by the orthodontist? [Lucy]Personally, I would always check in with the orthodontist in a case like that. It’s peace of mind for me, I feel happier that we’re on the same page. [Jaz]Yeah, yeah, I think so. I think if you’re concerned about the age, and they’re like more 11, 12, and you’re worried, then do an urgent referral and get their opinion. And like I said, just take some photos, and OPG is good, because they can give the orthodontist some more information. So you know, first thing could do is maybe they can OPG attached to that email for the orthodontist, and just get some opinion. And you don’t have to like wait a year for them to get seen about this canine issue, it’s slightly more of a time sensitive issue. Would you agree? [Lucy]Yeah. Yeah. And, and of course, you can use your parallax technique as well. [Jaz]Very true. Very true. So brilliant. So, the last ten there is palpate the canines, the permanent canines at age 10. They should be palpable buccally. If you feel them palatally, you feel a palatal bulge, then yeah, kind of it’s going to be impacted at that stage. So, try to start having that relationship with the orthodontist to discuss these cases. So, that’s been a really good summary of the 10 Commandments. We’ll get them written up and email to everyone as well. And this will come out on the podcast proper. Now guys, if anyone’s got any questions for Lucy has kindly given up her time tonight to discuss all her wisdom for seeing all these cases and all these experiences that she’s had. We’d welcome any last questions that you had. Lucy, any points on any of those 10 Commandments that you feel now that we’ve talked about it that you want to go back and add something to? [Lucy]I’m not sure, really. I mean, I think the biggest ones where I think people just apparently they don’t know that they’re meant to be taking. It sounds bizarre, but they don’t know they’re meant to be taking vitamins on kids. I’m not quite sure how that works. But that seems to be the case. [Jaz]I think they just don’t do it for so long. Because of bad habits and they kind of just forget and dentistry can be very isolated. And if we’re all going on the composite veneer courses, Invisalign courses, no one’s going to the update in radiography guidelines courses, then. [Lucy]Exactly. [Jaz]So these podcasts, sessions like this are very important to remind everyone. [Lucy]Yeah, and the other one is this thing with using corsodyl mouthwash as a root canal irrigant. It seems like somebody must be teaching it because I don’t understand why so many people are doing it but who would be teaching it? So I’m just, I don’t know quite how it got started and how it became so widespread. [Jaz]I was gonna name the parent company of corsodyl but I’m not gonna do that in case this podcast gets sued. So, I’m definitely not teaching it don’t worry. It’s not that indication. I’m not gonna get sued by multimillion corporation. Salomon asked, how did you get involved? This one’s for you actually, Lucy. How’d you get involved in dental legal work? And any tips for those considering exploring it as an additional career avenue please? Thanks, James. [Lucy]Well, funny story, but true is one year, I got my quote through my annual update with dental protection. And yet again, it’s a jumped up again, you know, to some astronomical figure even though I wasn’t making any claims. And I just thought, ‘Wow, it’s so much money that you know, there must be so many claims going on.’ And then I thought, ‘Hmm, maybe that’s a potential avenue for here, avenue here for me.’ Maybe if there’s not much going on there. Maybe it’s something that I can become involved in. And that’s what gave me the idea. And to get involved in it. I just sort of started, I didn’t know nothing about it. Didn’t know what to do, or in what way to get involved. I just started googling. Really lovely guy who’s retired now called Mike Young, who had written a book. [Jaz]Did he also write that book? Managing a Dental Practice: The Genghis Khan Way? [Lucy]Yes, yes. He’s such a lovely guy. So, so helpful and supportive, great, great mentor. Really happy to help anyone out and give advice. [Jaz]Active on Twitter, if I remember. [Lucy]Yes, yes. I mean, he’s completely completely stepped away for a completely completely retired now. But he was really helpful to me a few years ago. And he introduced me to other people who were also really, really helpful. We have a lovely Whatsapp group of people. There’s about 80 of us involved in dental legal stuff now and this Whatsapp group that chat together. And you know, there’s always new people joining and getting a warm welcome from the group, giving each other tips. So- [Jaz]I mean, if someone wants to take the next step in terms of what to Google, or which courses they need to do is you know, a formal degrees or how to get a flavor of it, how can they start? [Lucy]It depends on on exactly what you want to do. Whether you want to work for an indemnity provider as a dental legal adviser, whether he wants to be an expert witness, or whether you want to become doubly qualified, as some people do, and become a solicitor or a barrister, that there’s lots of different routes. There’s the LLM qualification in law that some people do, there are various courses you can go on, there’s a company called Bond Solon that does courses on report writing and cross examination skills. So, you can do certificates and diplomas. There’s lots out there. [Jaz]Brilliant. If anyone wants to send you an email or get support from you, any anything that they could, any way they can reach out to you? [Lucy]Yeah, yeah, sure. I mean, you can look me up- [Jaz]Facebook, Twitter, where’s it? Where’s a quick, easy place? Your Instagram? What do you prefer? [Lucy]Easy to find my emails on my website. You just google me. [Jaz]Yep. Yep, I did Google, you now, saw your website. Very nice. Lucy, thank you so much for giving up your time to talk about these 10. Thanks for preparing it. Thanks for being mindful about it. Thanks for leveling us all up, including me, because there’s a few points that I relearned on as well. And I’m gonna implement straight away because guys, knowledge is nothing without implementation. So, if it’s the fact that you’re not palpating the canines because it’s not in your notes, it’s not in your checklist. Simple thing to do. And now we know how to manage our hypochlorite incidents, or hopefully it never happens where it does, you will remember Lucy and this podcast, Lucy, thanks so much. Guys, I really appreciate you get up by Wednesday evening. Let’s face it, you’d rather be here then the cold murky weather outside. It’s miserable today. So, thanks for joining us and check it out again, when it comes on Spotify, Apple, etc. If you’re on the app this way very much suitable for CPD. So, you’re able to get CPD, just scroll down, click then answer a few question on the type form. And that’d be there with you. Lucy, any final words? [Lucy]No, I just would like to say thank you very much for having me. It’s been a real pleasure to be on. [Jaz]You’ve been very fun to talk to. Thanks so much. Jaz’s Outro:Well, there we have it, guys. Thank you so much for listening all the way to the end. What changes are you going to make tomorrow morning to make sure that we don’t fall foul of these little issues that can become a big medical legal hassle for us in the future? My main takeaway was how I’m going to manage something hopefully that is never going to happen to me. But let’s face it, it could, it probably will happen in my in my career is a hypochlorite incident. Right. And I have more information about how to manage that. But more about dexamethasone and those severe cases that their role, and how am I have a role in those severe cases. So, hope you gained a lot from that. Listen, you’ve got an associate, a principal that you feel should listen to this episode. Please send this to them. Right. Share the love, pay it forward. Once again, don’t forget on the app to answer those questions. Get your CPD right now because let’s face it, you listen all the way to the end. I’m so thankful. You deserve some CPD. Anyway, I’ll catch you in the next episode. Same time, same place.

I am a big believer that the culture of your work place is probably the number one determinant of your fulfilment and joy from clinical Dentistry. https://youtu.be/cGFpxUn6WXw Check out this full episode on Youtube. In this non clinical episode I talk with Dr. Sandy about his past experiences and the reasons he had to make a significant change in order to find fulfillment in his career. We also discuss how to recognize a toxic culture in Dentistry and how to stand up for yourself if you’re in one of those environments. We hope this episode inspires you to take some sort of action, whether it’s small or large, that will improve your enjoyment of work. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 2:13 Dr. Sandy’s Introduction 3:16 Dental Public Health Experience 6:16 Dr. Sandy’s Transition from Public Health to Private Practice 10:11 Taking massive action 14:10 Recognizing a toxic working culture 17:29 Stepping out of the toxic work environment 19:33 Significance of having a plan for your career 24:57 Importance of taking clinical photos 29:26 Improving Dentistry through social media 34:48 Dealing with litigations and patient complaints 41:55 Recognize solutions rather than problems If you enjoyed this episode, you will also like Being Unstoppable with Ferhan Ahmed Click below for full episode transcript: Jaz's Introduction: Hello Protruserati, I'm Jaz Gulati and welcome to this interference cast, where we explore a NON-CLINICAL INTERRUPTION. And this one is huge. This one is so big picture. There's a lot of clinical themes in here. But this is very much bigger picture LIFE DESIGN stuff. Jaz’s Introduction:What if you’re in a scenario where you are really struggling in your workplace? Sometimes dentistry can be like super isolated, feel really lonely, it’s just you and your nurse. And it can get a little bit depressing, especially in the winter months I find. So, community and mentorship and the right culture, oh my goodness, the culture at your workplace, the nurse at your workplace, the relationship with your nurse, or your DA is so, so key. So, these are all the themes that we cover with Dr. Sandy. So, Sandy is this dentist, who and you will hear his story in the podcast, but he was not in the happiest of places. And so, we discussed all about that, and how he had to make a major change and move hundreds of miles away to be able to gain fulfillment from his career. And that’s why I wish for everyone I wish every Protruserati gains fulfilment from dentistry, because it’s a truly wonderful profession. But guess what, this wonderful profession can be an absolute stinker, if in the wrong environment or even a toxic culture. So, in this episode, we’ll discuss all about that, how to recognize it. And what can you do, you have to just stand up for yourself, you have to be your biggest advocate. And I hope this episode inspires you to take some sort of change. If you are identifying with all the things that Sandy saying today, I want you to stand up for yourself and make a change. It’s never easy, because comfort zones are very comfortable, they’re very nice to be in. But growth never happens in comfort zones. So, guys, I hope you enjoy this episode with Dr. Sandy. And I’ll catch you in the outro. Main Episode: Dr. Sandy Rupra, welcome to the Protrusive Dental Podcast my friend. How are you? [Sandy]I’m very good. Thank you, Jaz. How are you? You, okay? Thanks for having me. [Jaz]Very good. Thanks. No, no, thanks for making time for this. So, we spoke a long while ago now, you’re very inspiring. And the kinds of things that you’re telling me in terms of helping dentists finding where they want to be in a more thriving environment, a better environment and while they’re working, enjoy themselves. And it was from your own experiences of going through the LOWS, that we can speak about how to attain the HIGHS. So, before we delve into your story, which involves a little bit of self discovery, a little bit of reflection, we talk a little about litigation and how that can affect someone as well. Tell us about where you are right now, what you work, your little background would be really good to hear. [Sandy]So, I am an Associate Dentist I’m working in the Northwest at the moment. I’ve been there for about a year. I’ve originally qualified in ’07 from Cardiff. Actually, I was a trainee as a technician first. [Jaz]I did not know that. Wow. Okay, cool. [Sandy]That many moons are gonna actually like what- [Jaz]Do you still make your own crowns? I know a buddy called Riz who actually makes his own lab work as well as being a dentist now. [Sandy]You know what if I had time I would. I do my wax ups actually for, so I find it quite therapeutic actually. But I started that in ’98 in Manchester and I finished in 2002. Took a year out and I worked in a prosthetic lab for a year and found that I had a bit of a passion for dentures and all things removable. And then I went on to Cardiff then to do dentistry. So, I finished that in ’07, pretty much since then I wasn’t comfortable going into practice straightaway. So, I went on to do some hospital posts that were there for two years and sort of oral surgery, restorative, bit public health in there. And then 2010, I had landed my first associate job in South Wales. [Jaz]Can I just ask you, Sandy, because you’re on the first few people who said about the dental public health. But I hear colleagues talking about it. What was that like? Is it just lots of reading and lots of signing things? Like, what does that actually involve? Just tell us briefly what you know, if you’re working and you did a bit of work in dental public health, what do you actually do? [Sandy]You know what I can’t answer that question. I don’t know, I don’t know why I did for six months. But I can’t even put it into words actually just literally like putting things into place and regulations. It was mostly a supervisor. You know, I was under a supervisor at the time. And you know, I’ll be talking to over 10 years ago now. [Jaz]Was this just you on a laptop and just like- [Sandy]Pretty much, yeah [Jaz]Sorting things out? [Sandy]Yeah. [Jaz]Just the whole the whole pen pusher thing, but like a keyboard warrior kind of thing. [Sandy]Yeah, working through Excel, you know, trying to work out the formulas in Excel, put things into tabs. But yeah, I mean, it wasn’t one of the most enjoy. For me personally, it wasn’t most, you know- [Jaz]Well, you come from a background of very hands-on, technical, so maybe for those colleagues who decide that they don’t like teeth, and they don’t like people that maybe they want to do dental public health, you think? [Sandy]Absolutely. If you’ve lost your built then yeah, go for it. [Jaz]That’s the beautiful thing about profession, right? You can go into those little avenues. [Sandy]Absolutely. But I mean, those two years were really, really good. I mean, they give me a little quite a bit of insight into dentistry. I was coming out of VT, right. You don’t really know a lot. So you obviously trying to put your skills into place and working straight into practice then. [Jaz]Sandy, one thing I just want to follow up on that is, dental public health. Just touching on that again, and a few other things. Few other sub specialities and training posts that dentists do. Sometimes they do it because they are worried or afraid of going into practice. And I know mainly my colleagues have been affected by this. Do you think, you kind of mentioned a little bit that you weren’t quite you didn’t feel that you were ready for practices yet. Do you think that you might have done these posts at the beginning because you weren’t quite ready for practice? [Sandy]Absolutely. I think for me personally, I think confidence is a big, it’s a massive thing. And I think at the time, you know, I learned a lot from VT, you know, we were talking over 10, 12, 13, 14, many moons ago. But I think the essence of VT is to obviously, learn as much as you can, but you got to be in the right setting, you’ve gotta be in the right place. You’ve got to have that infrastructure, you know, with your principal, your mentor to support you through all these things in order to sort of develop yourself in your skill set, be competent, coming out treatments, but for me, personally, I wasn’t at that stage with at that point, in my time, in my career, where I felt that I was, I don’t wanna use the word good enough, but maybe, yeah, maybe I wasn’t good enough. [Jaz]Maybe it’s just how you felt at the time in yourself, right? [Sandy]Absolutely. And I think that for me, personally, give me a little bit more insight into treatment planning, talking to the patient, your bedside manner, you know, just those little gems like that to try and help you to sort of move forwards with the working in general practice and dealing with patients on a day-to-day basis. I think that’s really important. And I think, you know, for me, personally, that was probably one of the best things that I’ve done. I do think it’s important. [Jaz]And then when you started to work in practice, how did that go for you? And then was it good from day one? Or did it start off in a shaky ground and have that evolve? [Sandy]So, I worked in a practice in South Wales, mixed practice. And yeah, it was good. In the beginning, it was good. I had a good four months there. However, as I found when I was working, the treadmill started to kick in, you know, in terms of I know you’ve touched on certain points in other podcasts where you talked about the financial aspect of associates, how much money is enough? And so I think, you know, as you start sort of working you say, ‘Oh great! you know, I was in VT I was earning 30k, or now I’m an associate and I’ve doubled or tripled, or whatever.’ So, I think, based on that, you know, it’s difficult because I think at the time UDF system, as it is now, it’s difficult to provide that level of care for patients, you know, when you’re hitting that treadmill, you’re seeing how many 20, 30, 40 patients or whatever it is a day, to keep that consistency- [Jaz]Exhausting stuff. [Sandy]Absolutely. [Jaz]Mentally, physically backbreaking. [Sandy]Absolutely, I must have come home absolutely shattered. You know, just- [Jaz]You five days a week? Six days a week, what were you? [Sandy]I was five days a week, full time. Absolutely knackered. And then there was a little bit of a turning point where the practice had a bit of a change in infrastructure and dynamic changed, where more than responsibility was put onto my shoulders as the associate. So, as I found I was doing more and more pressure. And I almost forgot myself, you know, I almost forgot what kind of person I was. Because I was so tired to think about what do I want to do? Or where do I want to go? Or what do I want to do? It just became so monotonous, moving forwards and thinking each day was just boring. Like, for me personally, there was no joy. You know, it sounds a bit morbid saying that. And it’s sad, but you know, it is one of those things, unfortunately after- [Jaz]Sandy, you know, you mentioned already that you did the whole technician training and you know, very much hands-on and try and do things as you were trained and how you enjoyed rural prosthetics, and then to go to a public health and various post that you did, and then the pace jump into high volume dentistry where now, you say you do your wax ups. Now, you probably didn’t have time to do your wax ups before and then you probably were this creative side of you. Am I right in saying that you felt lost that you weren’t be able to express your creative side in dentistry? [Sandy]Absolutely. I thought I felt totally boxed in, you know, literally boxed in, that I couldn’t do the things I wanted to do. But I don’t want to say couldn’t, I wasn’t able to because maybe I wasn’t pushing myself to that point. Or I was saying, wasn’t saying no, I can’t do more. You know, and I think once you get into that trap, I think it’s hard to break out of it. Because we all have these ideas of what we want to do you know, sort of career what kind of things that we’re passionate about? Do I like bonding? Do I like ceramic work? Do I like prosthetics? You know, implant dentistry, but it’s getting the traction to go out there and say, right, I’m gonna go on a course now. I had no time to go on a course, because I felt worried taking time off work. Am I going to be able to catch up? Or am I gonna be able to, you know, finish my contract? And all these worries are going through my head, you know, in terms of back then. And I think- [Jaz]Have you heard the analogy of the frog? The boiling frog? Have you heard the analogy? [Sandy]No. [Jaz]The story. So, it’s like, frogs are really clever. And they’re all just adaptable biologically in the sense that if you put a frog in some hot water, it raises his body temperature so that it doesn’t feel the effects of the hot water anymore. And then as you turn up the gas and you make the water hotter towards boiling, again, it adapts, okay. And then eventually, when it gets to a boiling point, and now the frog can’t survive, it doesn’t have the energy anymore to actually jump because he spent so much energy trying to adapt to a temperature. When he got to boiling point, it didn’t have the energy to jump anymore. So, a lot of my colleagues over the years have described the scenarios where they just felt exhausted, boxed in, trapped in just like you said, and it reminds you of that frog analogy. Frog story that you’re just exhausted and you don’t have the energy to jump anymore. So, it sounds like you did jump eventually. So, tell us what events took place that made you realize, okay, you got to now take massive action, again, a theme I’ve spoken up before in that episode with Laura, Laura Bailey, where she took massive action as a therapist to really take her bonding and composite veneers and stuff to the next level, which is really inspirational. So, when did you end up taking massive action? And have that actually come to be? And what can we learn from that as people who may be listening now and thinking, whoa, Sandy is describing me? [Sandy]Yeah, I mean, when you work Monday to Friday, and you do a heavy contract, something’s gonna slip. Okay? So, it’s inevitable, something is going to happen, it’s going to slip, maybe you missed something or misdiagnosed, or you haven’t written your notes or something’s going to happen. Because- [Jaz]Absolutely. [Sandy]You can’t keep that traction going. So, for me personally, it was an issue that I had, you know, because I fell into that pot. And it was a difficult time. Because, you know, I had to look back and reflect and say, well, look, was it me? Or was I working too hard? Or? Yes, I was working hard. And I’ve obviously missed something, you know, so we’re only human. Right? So, you know, however, we have to be able to say no, to a certain point, you know, that enough is enough. You know, I can’t do any more, you know, you don’t have a stone. You can’t squeeze me any more than I morally squeezed, you know. [Jaz]And so what made you put your foot down? [Sandy]Well, I think for me, personally, it became quite toxic where I was working. So, I think I had to remove myself from that environment. And that took a lot because, you know, I had rapport with the patients. I’ve been there for six years, you know. [Jaz]Financial security, and I know you’re working hard, but there is, you know, mortgages and stuff, and you have security in any job that you’ve had for so long, and to do the big change and to jump ship is a huge risk financially. [Sandy]Absolutely. And I think I had tied myself. You see, because when you work for somebody, your risk is mitigated by someone else. So, when you’re working for somebody, they are, not must have every principal is like this, this is some amazing principals out there who look after the associates. And that is absolutely, if you’re in a position, or in a space like that, keep that. And learn the best you can, you know, keep moving forward to keep growing. But I first unfortunately, was in the opposite position. So, I had to leave where I was because I had to make a decision to say, ‘Look, do I still want to be here or continue with this?’ Because it wasn’t doing very good for me for mentally, you know, I was so passionate about my job, you know, I wanted to be a dentist since I was young, you know, we have this drive and this passion. And I think I lost that. I almost forgot about how hard I used to think about dentistry all the time, you know, when I was younger thinking, right, I’m gonna make it, I’m gonna do it. And I think I almost lost that drive. And I almost had to go back to the beginning, right back to the roots. And I think we’ll look when I left that practice, I thought that was the pinnacle moment, when I thought I came home, and I literally broke down. I thought, you know, what, why is this happening to me? What have I done wrong? I was lucky because my wife’s a practice manager, so we could bounce off each other, you know, that she was a big driving force in to get me back on track. And I think it’s important to have a good support network. You know, at the time- [Jaz]Massively [Sandy]I was so lost and so isolated. You know the fear of talking to colleagues as well, you know, you want to ask someone for this- [Jaz]Stigma is attached to it, right? People will think, ‘Oh, he’s not doing very well’, or that kind of stuff. And that’s why we see so many anonymous posts nowadays on Facebook, right? Because people are afraid to attach their name. And I totally get that, man, I totally get that. [Sandy]Absolutely. I mean, to me, personally, I think I’ve seen about three or four last week, and I think it’s heartbreaking. Some of these younger dentists are working, I think, you know what, I can relate to this, you know, we can all pick up little points, I think, you know, I was there, or I can understand where you’re coming from. And you almost want to reach out to them and say, ‘Look, don’t worry, there’s always things that you can do to come out of it and actually make your situation better.’ So, I think it’s important to understand oneself. I think if you look back and you think, right, well, look, I need to change, how am I going to do that? So- [Jaz]How did you do that? I mean you left, which is a huge step. And we had the support network, and your partner was up, which is amazing. But then where do you go from there? And then also, we will rewind a bit as well. How do you identify a toxic working culture? For me, it’s always been for the most number one determine for me has been my nurse actually. Believe it or not, like if I had a solid nurse, it makes a huge difference to your career to your daily work. If you have a relationship with a nurse, which is got too much friction, or it’s an attitude clash or culture clash, that, it has a huge impact. Not just one person, right? Can determine your data. What kind of things happened to you that led you to deem your workplace as toxic culture at the time? [Sandy]Yeah, I mean, if you go into a practice where you can sense that this is just a bit toxic or you know, whatever word you want to use, you know, stop doesn’t feel right. You are going to find it quite hard to change that dynamic in that practice. As a single person, you’ve got standards and you’ve got a way of treating your patients, you’ve got high standards, and you want to carry out high end treatment and whatever you want to do. It’s hard to try and then push that forward to you or your colleagues or your team members. So that in itself, isolate you. We don’t want to be going from job to job, we want to stay stable. But however, sometimes, you know, the biggest thing is taking responsibility. I had a really good quote a years ago, Spider Man, Peter Parker, his uncle said to him, ‘With great power comes responsibility.’ Yeah, but if you flip that, ‘With great responsibility comes power.’ Now, I felt that I had to be responsible for everything that I do. So I had to be responsible for my destiny, my path or journey, you want to call it? You know, so I had to be responsible. [Jaz]You are the captain of your ship. [Sandy]Absolutely. So, I had to make decisions, which were hard, uncomfortable. [Jaz]Do you mean like clinical decisions or like just give us an example? [Sandy]Examples, the things like i had to sits into a situation where look, do I stay? Or do I go? If it’s an environment, which I’m uncomfortable with? I’m coming home stressed, I’m coming home, you know, mentally exhausted. Do I need to take myself out of that space and go somewhere else? You know, I might take a paper, I might take up stuff in the beginning again, those things are hard, right? You know, being comfortable is easy, isn’t it? But being uncomfortable with something which is difficult. And I think that’s where we have to dissect it and say, look, what do I want to achieve? Look at the long game. Look, what do I want to achieve? What do I want to do? Move forward? What things do I left? And that wasn’t for me, so I had to move. I mean, I had, I was out of work for good four months. You know, when I left that practice, I had no opportunity whatsoever. You know, I had to come home and literally do nothing. It was hard. It was difficult. [Jaz]Did you feel like as the months were going by that you felt, did you explore other career options? Just asking you? Did you wonder? Did you think about it? [Sandy]Absolutely. Those thoughts crept into my mind pretty much every day. But then something was overpowering me, and something was telling me no, subconsciously, something was saying to me, no, just stick it up, hang in there. And you know, things will get better. And I kept telling myself that every day. And eventually, I made the bold move to move. I just moved, and I relocated up to the Northwest. And I started again, it was almost for me Jaz, it was like, going back to VT, you know, starting afresh, and that journey for me was amazing. You know, if that never- [Jaz]Liberating? [Sandy]Yeah, if that never happened to me, I don’t think I’ll be thinking the way that I have been, you know, in terms of- [Jaz]You’re in a much better place now. And it’s because you took that massive action. Now here, here’s an interesting question, did you wait for the right job to come up and then decide to relocate? Or did you, because I’m just thinking about that there might be someone listening who’s in your similar scenario. And then did you decide, Okay, put your finger on the map? Okay, I want to move here, and then look for jobs there. How did you do it? [Sandy]I had a good opportunity. I had a friend who had a practice, who offered me a job, essentially, that’s how my house snowballed into, you know, in South Wales, I knew a lot of people, you know, in terms of dentists, clinicians and nurses, and, you know, just, it’s a small area, right. So in the northwest, I had nobody, you know, in terms of my networking was pretty much zilch, zero. And I think, for me, personally, I had to develop myself. See, I wasn’t really a confident person, you know, so when you’re not confident, you don’t feel that you can execute certain decisions. And you’re always trying to find problems rather than solutions. So, you probably- [Jaz]You doubt yourself, don’t you? [Sandy]Absolutely. Always second guessing always, is that good? Or, you know, my wife does all the time, don’t, you know, you got to think differently. So, my wiring now is a lot different. And I feel better without knowing it. And that sounds silly, but subconsciously, I feel better. But I think for dentists who are in a position where they are not in a good environment, sometimes it’s hard to say to somebody to go and get another job. Just go and find somewhere else. You know, it’s easy to sell it to somebody, but it’s quite hard to execute and actually do, you’re going to have to- [Jaz]Actually, to do that to actually do the action, implementation and listen and heed that advice and actually do something is the main reason and I come from a position of someone who’s worked in the NHS, and I still have a contract where I see children in NHS and I think is great, what NHS dentists can do. And dentists will, actually NHS dentists, as long-term dentists to serve the contract. But a lot of our colleagues, yeah, they’re happy and makes contract and they love it. And they’re doing, they get to have their funds as well. But there are those dentists who are on this treadmill, exhausted and whatnot. And for them, this is a security blanket, and it’s too difficult to actually give up that contract and face the consequences of leaving that behind. [Sandy]Absolutely. I mean, you hit the nail on the head there. I mean, you know, in terms of my associates’ point of view, and a principal is probably there’s two different viewpoints that you see. So, I think it’s very difficult because I think you need to be in a position where you always are having to map out what you want to do. You know, I’m constantly mapping out things, you know, in terms of what I want to do. I plan my journey because I think I had to; I had no choice. You know, I didn’t want to leave the profession. Being on that treadmill is difficult. Sometimes you could, you’ve got to just look back at it, look, if I’m on this treadmill, fine. As long as I can isolate certain things in my career and say, look, I’m working nine to five, I’m doing my ups. I’ve got a bit of private in there, what kind of private work do I like doing, I like bonding, I like ceramics, I like you know, implant dentistry. Try to map out your journey into that and try to sort of network with people that are going to help you support you. Because without support is difficult. You know, you got to knock on the right door as well. You know, you’ve got to be able to contact people who you who think well, look, you know what I can learn from this person. And don’t be afraid to do that. Even if it’s asking for help, you know, even if you need to- [Jaz]Yes. [Sandy]To help. I used to, I mean, coming up, contacted lots of dentists to ask for help, you know, and sometimes you don’t get a response, that’s fine. You know, you don’t- [Jaz]That’s okay. [Sandy]That’s fine. You know, it’s not an issue, you just keep going, keep going and keep moving forwards. I had one dentist a couple of weeks ago asked me about some advice. And, you know, it was nice to be asked, rather than the OSCE. You know, that’s really nice to be asked. And, you know, it’s one of those things, I think things happen, Jaz, you know, this is life, right. And I think when it comes to our careers, you know, there are going to be external factors which affect that. But I think in terms of career development and moving forwards, we need to be able to always keep saying this, but come back to self, you know, what responsibility have I taken to action certain things that are going to help improve me mentally, reduce the stress, you’re never gonna get rid of it just completely, but you can mitigate this risk Yeah. So, I think it’s important to be able to have that strategy in place, you’d have a plan in place and try and execute it, which is what I’ve done the last two years. [Jaz]So, your plan essentially was because I’m thinking already. I’m thinking about how to title this episode. And it’s how to recognize a toxic working culture and how to take massive action or something like that, basically, right? So, I’m thinking, let’s make it very tangible, you recognized it, you felt the effects of it, it was laying heavy on you. And then you took massive action, which is a huge step, and very difficult. So, kudos to you to do that. You’ve got a little bit of luck. But I don’t believe in that. I always think you make your own luck; you had that network. And then you took a big plunge, you took a huge risk move to a brand-new place where you didn’t have a network, didn’t know anyone, except this, obviously, this friend who owns a practice, and you went for it. And so, tell me now how that’s worked out. What kind of working environment it is, and how it’s different to where you were before? And what’s going well, for you and what you’d like to pass on to those listening? [Sandy]Well, I’m in a mixed practice right now in Northwest, and it’s going really well, I’m really happy. I’m in a good place. Got a lovely profile of patients, I started to then look at different courses, what kind of things do I like doing? What kind of was my interests? What was I thinking back then? And I can actually remember what I like doing back then 10 years ago, you know, six, seven years ago. I started thinking, I think it will look like a bit of bonding, like ceramics. And I started to think, look, this journey is going to be quite a long journey, it’s not going to happen quick, you’re not going to happen overnight, you need to graft in you need to, you know, sort of sit down and actually plan out what you’re going to do. So I decided to go over sort, of course, of the dominant castle in Birmingham. So, I think, you know, after I did that, I learned so much from that course. And, you know, I’m going to implant dentistry. Now, I’m doing a bit of bonding. You know, I’m actually- [Jaz]But more importantly, you learn all that stuff, but you are in an environment, correct me if I’m wrong, you were in an environment where you could implement. [Sandy]Absolutely, you have to be in a position where you’re going to spend money on courses, you’re going to spend your time and effort, you know, learning. If you can’t execute those treatments, or you can’t, you know, every patient base where you know, you can do your bonding, or you can do ceramic work or it’s not going to work. If you want to be, if you’re in a position where you’re not happy in your work, and you want to move forwards, and you know you have to do that. You have to almost cut it off and move forward. I know it sounds quite harsh to think like that. But I think I had to tell myself that I had to do that. And right now, what I taught myself back then I told myself back then, I’m glad I did because right now things are working the way that I wanted them to work, because I’ve put them systems in place to do that. But it’s so hard to get that first initial momentum. That first step is the most difficult part. You know, it’s so difficult, but I think you need to keep the faith that things are gonna get better. Whatever it is, you know, whatever issue is in litigation, if it’s toxic environment, if you don’t love your job, you know, you just come home, and you’re stressed. Try and find something that you know, try and map everything out, you know, get piece of paper map-out things where you think look. [Jaz]And don’t be afraid to try things, right? Because, you know, the famous quote, as I say all the time, ‘Sometimes you have to kiss many frogs before you find your Prince Charming.’ You know, it may not go right, you know, imagine you relocated, and things didn’t work out for whatever reason. And then you just have to have that commitment and determination to do it again until you find where you are able to live your best life, work life balance, and try and practice dentistry that you want to and just on that note, here’s an interesting question. Are you taking photos, chemical photos at the moment? [Sandy]Right. So, this is one thing that I wanted to learn about photography. Okay. Now what I do is without fail, I take two photographs minimum every day, because I wanted to learn about photography. So, I spent about six months going through a camera, settings, lighting, I could have got on a course, absolutely, could have gone on the course and had done for me and then going into practice the next day, and it’s done. But I wanted to learn for myself, I wanted to have a photography that was set from me personally. I wanted to have a picture that was my identity in terms of I know, it sounds a bit terms of my style of photography, and it’s amazing photography courses out there. Absolutely amazing. [Jaz]Yeah. [Sandy]You can tell when someone did on a course because of the photography they’ve done. Yeah. So, I think it’s great. [Jaz]Yeah, for sure. [Sandy]My photography, you know, I had to learn. Took me six months, but now I’ve not perfected it. But I’m more confident. This is an example of something which, you know, just to show that sometimes putting the effort in and learning takes time, but when you get there, it’s great. I mean, photography is fantastic. [Jaz]But Sandy in your previous working environment, am I right in saying that you weren’t taking photos? [Sandy]Absolutely not. [Jaz]Okay. So, here’s my opinion. I truly believe that dentists who take photos are happier dentist. Okay, let me explain why I think this okay, A) you get to document your growth. And we look back you think, ‘Wow, I’ve grown I’ve grown and grown.’ And you don’t know you’ve grown unless you’re taking photos, in my opinion and documented it. B) you get to have the opportunity to fall in love with the detail. You fall in love with little details. You enter the flow state. I think I’m a big believer in that. And I know it in myself, like the days where I’m just so busy and stressed that I think you know what if I just pick up a camera, now my nurse will lose her shit. Because we’re running late. Those days, I don’t enjoy as much. But those days like literally there’s a correlation between the number of photos I took that day, number of occlusal shots and quadrant shots I took that day and my happiness as a dentist, I guarantee it. And I know lots of dentists who feel the same way. So, if anyone’s listening and you feel stuck clinically, I guarantee it if you start taking the time and energy to take the photos, not only will you grow as a fastest way to grow, right, and if you’re gonna grow even faster, you start sharing those photos to your colleagues, and that will make you really grow faster. It”ll make your preps instantly improved. And then I just find that as a great way to just enjoy dentistry again. Imagine going through your whole career Sandy, without taking any photos of the work they put people’s mouth, can you imagine? [Sandy]What I think? I mean, what you just said there. I met a good example last week I left my camera on, okay, in the bag. So, I took it out the next day. Dead, completely dead. I was so upset the whole day. I haven’t got a spare battery. My chargers at home, I can’t take any photographs today. My nurse will be through our thank God you know, but I think you’re absolutely hit the spot. Photography for me is an essential kit. Essential for me to do, you know what I mean work. [Jaz]And even if you don’t want to post on Instagram, it doesn’t matter, stop. We don’t need compare and stuff. It’s more for your own growth, your own journey and just like I said just fall in love with something. Even if though if you don’t like your preps, whatever, I still hate my preps and look at them people I couldn’t stop. I don’t like you know, how you’re always critical of your own work, right. But I like to document, and it just gives you another focus. And you know the thing I love clinical dentistry; this is the byproduct. This is the proof. This is the evidence that I look back on one day, you know, people look at photos of their kids and stuff growing up. I like to look at my birth preps and six years and I think yeah, you know what, I’ve got a nail that margin. I’m improving. [Sandy]I think it’s great. I think you’re definitely right. It’s definitely a confidence builder. I think it definitely helps to improve yourself. And I think it’s something to focus on as well. [Jaz]Focus, very true. [Sandy]You need to have that sweet spot, you come into anything like the cameras. And my cameras, so first thing, my routine is in the AC on, uniform, my burs ready, camera on the bracket. And we’re good to go. Yes, take a shot, put up on the screen. Some of them staring at the screen. I’m thinking, oh, this looks great.’ And the patient is sitting, you know, you think, I love it. You know, I think maybe a bit too much. But you know, I think I don’t think it’s wrong with that. But yeah. [Jaz]Nothing wrong with that. [Sandy]I think it’s great. I think you know, when I say critical learning from a photograph, say look, how come I’ve improved that, you know, I constantly look at things when I’m you know, if I see a patient six months ago in a filling, or whatever the crown, how could I improve that? What could I have done? I never had that before. I never had that thought process before. You know, and I think it’s definitely changed me subconsciously, understood without thinking about it. You know, I think it’s really important. I mean, how do you feel about you know, in terms of looking at social media now in terms of how that’s completely blown? You know, I’ve grown up in dentistry right now. [Jaz]I think social media is a good one in the sense that I think I truly believe there’s never been a better time to be a dentist because you get exposed to so much like before the only way you can get exposure on something is actually you have to go travel thousands of miles to go on courses. Or to observe someone over the shoulder or get textbooks and then only get half the story. Now people are posting videos and even YouTube. Man, I learned wisdom teeth surgery initially through YouTube, believe it or not, and it’s the truth, right? People learn from my videos and images and whatnot. So that’s the beautiful side of dentistry, right? It’s made the dental world smaller. And it’s made the access to information and sharing of knowledge is great. So younger dentists, now, younger age, are able to upskill and get access to this information that you’ve had previously very difficult to find. But the dark side of social media is comparing yourself to others and feeling like you’re inadequate, and that kind of stuff. So it’s really, really important to never do that. And always just compare yourself to where you were a few years ago. And it’s nice to be inspired. It’s beautiful to be inspired by other people’s work. But don’t let that be like, ‘Oh man, that work, that patients doing, that dentists doing so much of this work, and I like it, and my own work doesn’t look like that.’ Well map the journey to how you’re going to get work to look like that DM that person. [Sandy]Yeah, I mean, that’s pretty much what I, you know, had a, there’s always pros and cons. Social media is great. I can network with somebody over in Australia, if I wanted to do a course online, from the comfort of my home, you know, I can do a crown prep with, you know, Ripe Global living courses where it’s online, you know, that’s all great, fantastic, absolutely brilliant, I can find somebody that across the world, you know, and talk to them like I am with you now. But I think when it comes to the validation, that’s where I have a bit of an issue with, in terms of, you know, I don’t want dentists to feel like, well, look, I’m validated by this six-inch screen that I’m seeing a photograph of brilliant composite bonding, or a brilliant crown prep, or, you know, yes, it’s great. How, like you said, how do we get to that point where we could emulate this, this treatment, or this bonding or crown prep, or whatever it is, learning is great. [Jaz]But that shouldn’t be our measure, right? That shouldn’t be a measure, our NorthStar should be happiness. So, that’s it, in our lives and also how we make our patients who are ultimately happy and pain free. And those two should be the primary measures. Now, yes, your followers and your quality of your work, that’s good, because not so much the fall is more about the quality of your work. If you can improve that, that gives you a focus, just like we spoke about earlier, that’s wonderful. But your NorthStar should always be happiness, happiness, happiness, and if you could just work on that, if you just work on your own happiness, you will have a great grip. [Sandy]Absolutely. You have to work on self that come you know, you are feeling good about yourself, you feel confident, that’s going to shine through, right? When you go into your surgery, the work you see your patients, ultimately Jaz, if a patient is happy with what work you provided for them, if they’re happy with your bonding, okay, and you post that on social media, and you don’t get much of a response from it. And you think that I haven’t had a response from there because it must not be good. But is the patient happy? Does it matter? In the grand scheme of things, who are you trying to get validation of? Your colleagues or your patient, I just find it difficult. I mean, obviously, I’m on social media myself. So I think I’m still trying to get to grips with how these things are and trying to find my sweet spot in terms of how I want to sort of be portrayed on social media in terms of my patients, or they can have a look at my page and say, look, this is where you kind of want to work that he does and get an example of it. But I think there’s some amazing dentists out there to do some amazing work like yourself, you know, so I think, you know, we just have to kind of sort of work with these people and just try to say, look, I’m gonna learn from this group of people and try to not worry about what happening around here, you know, and just try to focus on that. [Jaz]Just another word on social media is nowadays social media and people’s Instagram and whatnot and Facebook profiles. It’s almost becoming like a portfolio of their work. And I know some dentists, as associates have been hired and actually been headhunted via their social media. You know what your work, it may not have all these bounces and beautiful photography, but I see that you’re very consistent. And I liked the fact that you rubber dam or whatever, are you looking for a job? And this just happen to load of colleagues. So, if anything, if you just post up your work, even if you feel as though you have something to learn and post them reflection, that’s a great way to post reflections. Essentially growing this community of dentists online, whereby you’re critiquing each other in a good way and in helping improving each other’s workflows and protocols. So, there’s lot to learn for social media, if you use it as a portfolio as a young dentist, I think there’s a- [Sandy]Digital CV right there in front of you, you know, here’s my page, you don’t always have to give a CV these days, you just say, here’s my handle, it’s my social media handle. Go ahead, have a look. I think that’s fantastic. I love seeing you know, dentists too, you look at a post and you think, right, this dentist been active for four or five years, but you look at the first post, and then you look at the what, I love that journey. That is- [Jaz]I love that as well. It’s one of my advice just go back and look at the first few photos. They weren’t as epic as they are now, but you see the growth and you’ve got to you’ve got to give love to the growth. [Sandy]I think it’s fantastic. I mean, you see, the photography wasn’t great, but now it’s like, you know, see, that’s the journey. You know, there’s gonna be peaks and troughs along the way. But you just got to try to be the best version of yourself and just try to move forward with the times you know, move forwards, keep pushing forwards. [Jaz]Sandy how difficult was that though? Thinking forwards and thinking positive is many dentists have had litigation experience or whatnot. I know we spoke about it briefly as well. What advice could you give to someone who may be going through a complaint or having an issue? And that itself, imagine your working environment is good. Imagine you’re working in an environment, which is not toxic, it’s quite the opposite. It’s quite good. But even just having a complaint over your head, that can really turn your life upside down, I believe. So, what advice could you give to someone who may be going through this tough? [Sandy]I mean, how are the complaint is all for me? I think it just ruins everything, doesn’t it? I mean, we’ve all been there, when the page is not happy. The letter comes through the post. And this is a, I think, firstly, not to panic. You know, I think if you’re in a good place, and you’ve got good people around you, seek advice, you know, speak to your principal, your colleagues. I think there’s a point where you’re speaking to too many people and obviously getting advice from various angles, which samples can give you situation, I’m a member. [Jaz]Too many chefs. [Sandy]Absolutely. I think you need to obviously, first things first, the indemnity, speak to them. But also, I think, sometimes things you can’t change, you look back and reflect to say, look, how did this happen? What happened? What could I have done better? Or what could I have changed? Or if I didn’t do anything wrong, keep telling yourself that. You know, because I think the worry is, you will think the worst, right? You will think oh, this is gonna happen, or I didn’t do this. I didn’t do that. But I think it’s important to look back and reflect. But I think most important thing is to talk to people, get the support that you get, that’s going to help you push forward through an action of a complaint. I just find it heartbreaking. Sometimes when you know, you have these complaints put through anything, I didn’t do anything wrong. Why is a complete picture compelling about me? Sometimes these things happen. I think we just have to brush that off and say, ‘Look, it isn’t me. I do think right’, I had a situation where a colleague had tweeted it up, right five, and refilled the tooth. Okay, that refilling failed. So, I gave the patient the options. And I saw the patient, then about a year later, and I took the tooth out to give them all the options. Retreatment patient didn’t want that. And then we looked at a situation where the patient was pulling the options denture bridge or implant when a patient decided to go for a resin detain bridge. So, we provided them with resin retained bridge. And to cut the long story short, the patient put a complaint in and said, ‘I want you to provide me with an implant.’ [Jaz]Okay, on the grounds. [Sandy]Basically, this bridge has failed, has come off. So, the bridge can be bonding. So, look back at it. Why is it the bonding? Is it the occlusion? What was going on here? This was about 10 years ago. Now, at that time, I thought myself, was it, did I do anything wrong? Or what’s happened over the complaint? Nothing came of it. But just the action of patients saying I’m going to complain that caused the nervousness in your belly, you think? Oh. [Jaz]Absolutely. Sleepless nights and doubting yourself and the cascade of events. That yeah- [Sandy]It was just literally nothing happened. But I’m just trying to explain that, that just having someone even say, I’m going to complain, or I want your email address, I want the practice just complaints, policy. [Jaz]GDC numbers- [Sandy]These things are, you know, I don’t know, it just really has a negative effect on you, you know, in terms of your whole day is just the whole week. [Jaz]Do you look back now obviously now that that was settled but like in the sense that it nothing came of it. But when you look back now, if you could tell your former self some advice, it sounds like you’d say, why are you panicking and worrying about something that’s most likely not going to turn into anything? Obviously, you catastrophize, you think of the worse, and you spent all that time worrying? You know, worrying does nothing except steal the pizza? [Sandy]I will be more confident now thinking, well, look, you know what, my notes are rock solid. I’ve given the patient, all the options I’ve discussed with them. [Jaz]Yep. [Sandy]Warned them of the risks, and they’ve consented to this treatment, I’m not gonna lose sleep. And that’s my mentality. Now, if I’ve done something which I think you know, okay, I’ve missed that. Or I could have explained this. So, I didn’t put that in my notes record. Fair enough. But I don’t feel, I don’t lose sleep over it. And that, that took me a long time to be in a position to do that. [Jaz]And then Sandy, it’s about not owning I mean I says all the time, like a broken record, but about not owning the patient’s problems. So, recognizing that, hey, this is your problem, the patient is your problem, here are the options, course, or what would you like to do? And if they ask the recommendation, you can give a recommendation because you’re allowed to give a recommendation based on what you think is clinically the most appropriate option, but they can choose the other options that exist. And these are all the suitable options. But then essentially, it’s over to you. And then as long as your notes reflect that, it just makes you much more peaceful, sort of positioning yourself that, hey, you’ve done what you can and now it’s up to the patient is, you know, you don’t need to dwell on this any further. [Sandy]It’s difficult because I think sometimes, you know, as human beings, we do have this sense of, you know, feeling like this when something doesn’t go right. You know, you almost want to be sort of cold to it. But my treatment planning is better now, the last few years than it was then because I was unconfident in what I’m setting in the patient. [Jaz]And that comes from confidence, right? [Sandy]Thanks to myself feeling- [Jaz]And having confidence in yourself. [Sandy]It comes back down to self and monitoring and planning is better, you know, right now, because that way I’m locked up there is minimal risk of a patient saying, ‘Well, look, you didn’t tell me that.’ I mean, I’ve got a sheet, magic sheet up on my wall with marker and I’m talking to the patient, while I’m telling them exactly what’s happening with the pros and cons. You know, what the alternatives, you know, explaining in a diagrammatic form in terms of what a root canal is. So, they walk out with all the information they need, but that comes with me feeling confident about what I’m saying, also to the patient, and really not forwards. You know, I could talk to you about root canals all days, you know, but does the patient understand? So, I think it’s important in that sense, but it all comes back down to everything that we’re discussing, everything that we discuss, it all comes back down to self, you need to have that confidence. And that takes time. It’s not going to come overnight; it takes time to build and treatment planning from going on these courses is really important. You know, start from the basics, start from right from the beginning, learn the foundations, like I said, I feel like I’m doing a second VT right now, in terms of last three years, and it’s great. It’s fantastic, but I think it’s working fine. [Jaz]It’s good to see you smile, as you say that it’s good to see you, you got your mojo back in dentistry you’re doing, and being more creative. And I think if I was to summarize this episode so far, is recognize that toxic environment, have the courage and try and find the courage and the support network to to jump ship, don’t be the boiling frog, jump ship, be the captain of your own ship. Invest in yourself, in your mental health and your physical health and on courses and knowledge because ultimately, that is you. And that will give you more confidence. And the patients can smell that, I know they can smell that. Take more photos and enjoy your dentistry again. Is there anything else you want to add Sandy as part of this, a hopefully a feel-good episode with a happy ending and just sharing struggles with those dentists because I know loads will resonate with what we’re saying today. And it’s a shame. But I’m hoping if even just one dentist will say, ‘You know what, I ended up boiling frog today.’ And this episode has given me the courage and the conviction to take massive action. And I think we’ve succeeded, don’t you? [Sandy]I think I couldn’t agree with you more that, Jaz. I mean, those points were clear, concise, to the point, I think, you know, you need to come back and reflect on everything that you do, you know, always constantly think about what I’m doing, why am I doing it? How I’m going to do it? You know my map everything, you know, write down things that you think even think go right, or just overanalyze, you know, self-analysis is important. You know, I think it’s really, really important. Recognize solutions rather than problems. How am I going to get out of a difficult spot? What do I need to do to get, don’t look at problems and automatically, your brain would just be rewired. And you subconsciously, you won’t even think about the problem. You think about, if you said to me, we have a problem, right now, we’ve got a bit of an issue, right? What we’re gonna do Jaz, just put some points and it’s a must find a solution, automatically that comes out. But you’ve got to train your mind to be able to do that. And it’s difficult to try. And I’ve had lots of dentists over the years talk about things like this. And I think myself, ‘Yeah, but how am I going to do that?’ You know, when you’re in a difficult position when I was in a difficult spot and dark times, I think, how am I going to do this? What am I going to do? But I think you really need to firstly, recognize a problem. Yeah. And then find the solution and then say, right, this is what I’m going to do, I’m going to stick to it. Most important thing for me, my biggest advice would be to keep knocking on the doors, Keep approaching people ask for help. That’s really, really important. And if you get knock on 10, doors, and nine, close the door, new one opens, doesn’t matter is fine. There’ll be someone out there that’s going to help you to guide you through certain things, give you advice when you need it. I mean, your podcasts, there’s support groups out there that can help, you know, my doors always open. I think it’s really important. I do feel sad, and the dentists feel like that, you know, I think you must sort of reach out to them and say, ‘Look, don’t worry, man, it’d be fighting.’ Yeah. [Jaz]Trying to give him a shake and a hug. I mean, ‘That it’s gonna be okay, we can do this.’ [Sandy]I think t’s important. I think these are the people that are going to be our colleagues, you know, we got to stick together. And it’s kind of why the storm together and help each other not trying to put each other under the bus. [Jaz]You know Sandy, people who ski and they go super, super fast, right? And then they go around these trees and stuff, right? Imagine that all they were thinking about was don’t hit the trees, don’t hit the trees, don’t hit the trees, they would be just seeing the trees and hit the trees. But instead, what they do is follow the snow, the snow, follow the snow. And then that’s how they succeed. So that the lesson there, just as you said is, if there are problems in your life, stop finding the solutions. Don’t just moan and dwell on the problems. So, I’m glad we ended on that, because it’s a good sort of summary of everything we talked about. But now it’s time to find the solutions. And maybe DM someone today, email someone today, build that network, strengthen that network that you have. So Sandy, thanks so much for an inspirational episode today. Really appreciate you sharing your journey. Because I’ll be very blunt Sandy, right. The podcast was because I love I love this podcast a lot. I’m very passionate about Protrusive and the fun we have and how much I’m learning and how much people learning from the podcast. But let’s not forget that most people that come on a podcast, they have something to share, which is amazing. They can help us in practice and they’re doing it for free, which is amazing. But also, they generate revenue for their courses and stuff in Coming up my course. And that’s cool. And that’s how it grows. And that’s fine. You’ve come on today you have nothing to sell my friend, right? You have nothing to sell me. Okay? You’ve come because you call me and he said, ‘Jaz, you know what I feel this way. And I’ve been through this, and I want to help other dentists can we have a chat?’ And I said, ‘Yes, absolutely!’ So, thank you from the bottom my heart and from the Protruserati for just being at that dentist that represents so many of us today, and to show us your journey and show us your vulnerabilities. And just a thank you. [Sandy]My pleasure, to be honest with you, I’m just glad that you give me this platform to be able to share that with you. And I think it’s, you know, I’m at the stage now where I’m confident to say what things haven’t gone right on. You know, I think it’s important. And like I said, my doors always open to anyone who wants to talk, or anyone who wants to share anything or any advice I’m not an expert. But I’ve been through those experiences. I’ve been through those feelings, those emotions, so I think it’s important to reach out definitely, definitely, definitely reach out to anyone that you think that be able to help you and guide you through. [Jaz]If someone wants to just give you a virtual hug or high five or an email or a DM what’s the best way for them to contact? [Sandy]My email on sandeep.rupra@gmail.com. Or they can holler at me on their Instagram, or Facebook. [Jaz]What’s your handle? [Sandy]drsandyrupra. Yeah, you can check me out there. [Jaz]I will put that in the show notes. [Sandy] I think we all had for each other. So, but yeah, I mean, I’m pretty appreciated, Jaz. It’s been really good. Really good. Jaz’s Outro: Thank you. It’s been a lot of fun. Thanks so much. We explored a lot of themes and finally now we know what people do during dental public health. And then, there we are. Now, we know. Thank you so much. Well, there we have it guys, this interference cast with Sandy. I hope it’s opened your eyes and your ears and your heart to come up with the next steps. How can you actually gain fulfillment if you’re not already fulfilled in your workplace? Every dentists deserve fulfillment from the workplace. So why don’t take a leaf out of Sandy’s page and figure out, what is your next step? You might not be able to achieve it next month or in a few months, but at least have a plan of change. What is your action plan? What is a massive change you’re going to make in life to head towards where you want to be in your life and in your career? If you found this episode useful, please do consider leaving a review on wherever you’re listening. That could be Spotify Apple, if you’re on the app, head to the community section. Tell me about how you found this episode insightful and we’re always chatting on the community as well as the Telegram group. So, appreciate you guys so much for listening all the way to the end as always. I’ll catch you same time, same place, next week.

Have you ever prepared the last molar for a crown? And just when you check the occlusal reduction, the patient bites down and as if by magic, the reduction has all DISAPPEARED?! It is the phenomenon that we call ‘The Last Tooth in the Arch Syndrome’ This episode with Dr. Mahmoud Ibrahim will give you more confidence in recognizing, screening, and managing such complications in practice. But like I say in the main episode, optimistically, this phenomenon will never happen to you AGAIN if you follow these protocols for screening. https://youtu.be/gs1r5mlefHU Check out this full episode on YouTube Protrusive Dental Pearl:  Watch out for the patient with quite flat teeth as they are more susceptible to the last tooth in the arch syndrome / bite change. They do not have good posterior coupling/stability and therefore more likely to ‘forget’ their bite as the cuspal inclines do not guide the mandible back in to maximum intercuspation. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 2:41 Protrusive Dental Pearl 6:09 Introduction to Dr. Mahmoud Ibrahim 9:34 What is Centric relation? 10:45 Last tooth in the arch syndrome 13:14 Risk assessment for Last Tooth in the Arch Syndrome 15:52 Screening patient’s CRCP and the degree of slide 17:33 Leaf Gauge protocol for screening CRCP 30:23 Communication with High-risk patients 34:35 Case Discussion 44:36 Management of space loss after preparation 46:24 Dr. Mahmoud’s top tips to prevent the ‘Last Tooth in the Arch Syndrome 58:47 Occlusion Basics and Beyond 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! If you loved this episode, you will like If You are Not In Centric Relation, You Will Die Click below for full episode transcript: Opening Snippet: Because it sounds horrible, but if it's happened with all the sequelae of you losing space and bite changing, that is a big deal. I mean, this patient that might be looking at ortho might be looking at a rehab, who's paying for that? Chances are you. So for two minutes screen that you can do. And once you get good at it, it's, it's really, really quick. Just to buy yourself that peace of mind and being able to inform the patient and gain proper consent when you're restoring the terminal tooth or maybe the one in front. That two minutes is worth it in my opinion. Jaz’s Introduction:Have you ever prepared the second molar or the last molar of the patient’s mouth for a crown? And when you’ve checked the occlusal reduction, you get the patient to bite together. And it’s as if you NEVER DID ANY OCCLUSAL REDUCTION. You think what the hell is going on? I swear I just sunk a two millimeter bur into this tooth. And now it’s like there’s hardly any space there. What’s going on? Has that ever happened to you? Has that problem bitten you? Have you had that dreaded phone call from the lab saying, ‘We need a bit more space here, Doc.’ If you experienced this, you probably searched it and spoke to prosthodontics and got some information about LAST TOOTH IN THE ARCH SYNDROME where that space magically disappears. What’s behind that? Why is that happened? Why, if you’re not careful, it could happen to you could happen to anyone I know some great dentists. And it’s happened to them. So no one is immune to this. However, the topics that me and Mahmoud Ibraham, my guest today will make sure that you will a be able to screen when this issue might happen. Have a conversation with your patient ahead of time and sometimes consider a change of treatment plan because you know that as soon as you prep the second molar, you’re likely to lose space and to have that knowledge and screening for assessment is just absolutely fundamental. And of course, we will also talk about what actually, what do you do when that does happen? How do you manage that situation when you’ve lost that space? So yet again, it’s an occlusion based episode with my good buddy Mahmoud Ibrahim, we’re actually working really hard at the moment where we’re creating a huge project called OBAB. It stands for Occlusion Basics and Beyond. And the vision is like really, really bold. Like they say that when you, your dream, if your dreams don’t scare you, then what’s the point? So the dream that’s scaring me and Mahmoud and we’re working really hard behind the scenes like think 4am wake ups and late nights to you know, surrounding our clinical dentistry that we do in family lives is building OBAB. The occlusion course that will start from the very foundation, single tooth stuff think when I place a crown, what should my dots look like? How can I plan to go beyond a single crown? At what point later like modules four and five, raising the OBD. So we’ve got so much plan in terms of the most comprehensive, thorough, tangible and best occlusion course there is in the world in the universe ever. That’s the dream. So it’s a extremely bold claim. So give us a few months as we’re kind of halfway through at the moment. We’ve got the beta testers, you’ve got people like Tif Qureshi giving us advice and coaching us as well to make sure that this course is going to be absolutely sensational. So get a bit of a flavor of that today. But we will go in depth into this. So you will feel much more confident about last tooth in the arch syndrome, recognizing, screening and managing such complications in practice. But hopefully, like I said after this episode, it’s never going to happen to you. So that was a longer introduction. Hello, Protruserati. I’m Jaz Gulati if you’re new to the podcast, welcome. It’s great to have you, to the usual listeners get some onions get ready, it’s gonna be a good one here. The Protrusive Dental Pearl:The Protrusive Dental Pearl I have for you is very much related to this. Any type of dentistry that you do, including full coverage, occlusal appliances, or partial coverage, or anything that you do has a risk of changing the patient’s bite. In fact, sometimes you might have even met a patient who said, ‘You know what my front teeth used to touch together, but now they don’t touch anymore. And when my bite has changed, they didn’t have any restorative dentistry or splint or anything.’ But they had experienced this bite change. So what’s behind that? Why does that happen? Well, there’s loads of things that can be changed at the condylar level, for example. But how do you know who’s at risk? So I always want to look at posterior stability. Now what I mean by that is imagine someone with really well defined cusps, what kind of population have a well defined cusp, young people, right? They don’t have that much wear and young people have got these lovely pre molars and very acute inclines and very cuspy teeth. So think of that term ‘cuspy’. Cuspy teeth on their molars and premolars. Therefore, when they bite together, if their bite was to keep changing, for some reason, actually as the mandible closes into the maxilla, it’s those cusps as well defined cusps that guide the lower jaw and the lower cusps in to the maximum intercuspal position which is their normal bite. So if someone has got that really nice bite ie like a classic class one Andrew’s keys with not that much wear, I’m gonna say that is a very occlusally stable patient. So you’re saying, ‘Okay Jaz where’s the tip though?’ The tip is, watch out for the opposite of that patient. Watch out for the patient that’s got quite flat teeth. And actually, they might not have a well defined bite. When they bite together, you see lots of spaces and abrasions between their back teeth. And there’s only like point contact, and there’s nothing really guiding the lower jaw into the morphology of the upper teeth. This is a population of patients who are more susceptible to the last tooth in the arch syndrome, which we’re discussing today. These are the group of patients that even if we give a full coverage tenor appliance, their bite might change for good, ie take the splint off and their bite has been changed. Because they already have this feature that the teeth don’t mesh together very well. They don’t mate together very well. And therefore they’ve kind of got these multiple bites and because of this lack of occlusal stability, you’re at risk. So the pearl is have a look at your patient have they got good occlusal stability? Or poor occlusal stability? And if you’re carrying out let’s say an occlusal appliance, it’s even though it’s a full coverage occlusal appliance, your bite could still change. So I would go back to splintember series. So go to the podcast old episodes, splintember, around about episode 39, 40 onwards, we covered a whole series about occlusal appliances and watching out for bite changing stuff. You can go to that as well if you want to learn more about these things, but just assess your patient’s occlusal stability, make an entry in the notes. But of course it’s something that you gather from photographs as well. Main Episode:Now let’s join Dr. Mahmoud Ibrahim and talk about last tooth in the arch syndrome. Mahmoud, my brother from another mother, welcome back to the Protrusive Dental Podcast yet again for occlusion. How are you? [Mahmoud]I’m good, man. Thank you very much for having me again. So- [Jaz]We left off last time saying that we need to cover last tooth in the arch. And literally someone the other week messaged me saying, ‘Jaz, you mentioned Mahmoud is going to cover last tooth in the arch. It hasn’t happened yet.’ It was quite a bit of mess around with Mahmoud. Come on, the people out there want it. So let’s make it happen. And so just remind those who maybe for some reason have not listened to basics of occlusion part one and two, it was part two that we did it together, we covered some really cool concepts at that point. You know, just building on the foundations of that part one. Who are you? Where do you work and why do you love occlusion so much, man? [Mahmoud]Well, okay, my name is Mahmoud Ibrahim, and I’m a general dentist, I work in Telford and in Birmingham suit. And I’ve been qualified since 2005. My journey in occlusion kind of started really about five years in once I’ve decided I actually want to stay a dentist. My gonna repeat all that, for occlusion for me really is born out of the fact that I don’t want my stuff to fail. I don’t want the patients coming in with broken restorations. And it fascinated me because of its relation to physics and forces and things like that, which is something I’ve always loved at school. So yeah, it’s it’s always attracted me and it’s a very poorly understood subject because it is a bit abstract. You know, it’s not as easy as step by step 123 bonding or whatever it is. So yeah, it’s- [Jaz]It can get very philosophical and that it’s a double edged sword. It’s annoying thing but it’s also cool just there’s been people from different occlusal religions and camps in here, how do they approach it and how these other guys approach it? I think, me and you what we’re putting together as you have heard of the announcement of the episodes go that Mahmoud and I were putting something together quite comprehensive when it comes to occlusion starting from the very basics, occlusion basics and beyond. And there’s something we’re very excited to put together and so it’s, I’ve been spending a lot more time with you. It’s been great. And discussing these philosophies and having some was shawarma wraps and discussing, you know, canine guidance and stuff, and all that kind of stuff. So we’ve been we’ve been doing all that it’s been great. But today, let’s very much cover last tooth in the arch syndrome. So Mahmoud, just to set the scene, right? Most dentists, they probably learn about this, when it actually happens. So when they prep a second molar, it doesn’t have to be second molar, obviously. But let’s go for the classical scenario, they prep a second molar and they swore that they prepped, you know, two millimeters or whatever, right? And they get the patient to bite together for the bite reg, and wait, all that space, almost that space is now lost. And they’re like, ‘Wait, did I just dream that I prepped for like last, you know, 20,30 minutes to this tooth? Did that actually happened? And then they like, oh, there’s a such thing as a last tooth in the arch syndrome. And then they have to, like, have that very awkward and difficult conversation with the patient when they haven’t understood themselves. What’s happening? So just describe what is this phenomenon? And how did you, I want to know how did you learn about it? And it happened to you first, and then you learned about it? Well, you’re always smart about it from the start. [Mahmoud]I’m not gonna say I was smart about it. But what does what happened to me is for a period of five or six years, I was truly obsessed with occlusion and I read absolutely everything I could. So luckily, for me, I discovered a lot of these pitfalls before actually happened to me. However, saying that I did get caught out anyway, and it will happen. I got caught out by a upper second molar. I was prepping the two teeth, six and seven. I did my screening. And according to my screen, it was on the other side. But and we’ll get to this. Some people actually have centric relation contact points or points of initial contact or prematurity is in the CR on both sides. It can happen. So luckily for me, I lost a little bit of space on the provisional. And I was able to prep a little bit more, but we’ll get to that. To sort of describe what last tooth in the arch syndrome is, I’ll just take you back a step, the loyal Protruserati, it would have listened to basics of occlusion part two. But if you haven’t, or maybe you’ve forgotten, it’s important to describe what centric relation is, because that’s how it started at the last podcast, you said, what are the uses of centric relation, and this topic came up. So this is a quick reminder centric relation, I think Jaz you and I both like the description of the condyle as snug as possible up in the fossa. And really the technical definition is, it’s a jaw relationship, it’s irrespective of the teeth. And it’s where the condyle sits up against the anterior eminence of the anterior wall, in the glenoid fossa. But practically, for me, it’s if the back teeth are out of the way, and the lateral pterygoid muscle is fully relaxed, the elevator muscles contract and they seek the condyle up into the fossa as far as they’ll go. The reason that’s important is because in 90% of the patients, or 90% of people, when that condyle is fully seated, and the patient closes, they’re only going to touch on one or two teeth. Now to get all your teeth together, which is something you need to do to swallow or as many of your teeth as possible together. Usually the lateral pterygoid contracts and it pulls the condyle down the eminence a little bit to be able to get all your teeth together. So essentially that initial contact on those one or two teeth programs the lateral pterygoid to contract and bring the condyle down so that you’re the rest of your teeth meet. Now this becomes a learned response in your lateral pterygoid to automatically. So last tooth in the arch syndrome comes in when you inadvertently not knowingly remove that initial point of contact. And in a way you lose some of that programming of lateral pterygoid. So lateral pterygoid either doesn’t feel the need to or forgets how to pull the condyle down. And essentially, the condyle seats, maybe not fully, maybe just a little bit, but it’ll seat up and back a little bit. But what happens is your condyle’s attached to the rest of your mandible. So as the condyle goes up, the rest of them will goes up a little bit, up and back. And let’s say you’re prepping a lower second molar, that’s gone up a little bit. So what’s happened to your occlusal clearance that you created, you’ve lost some of it, all of it, if you’re lucky. And that’s what this tooth in the arch syndrome is. And like you said, it doesn’t have to be the last tooth, you know, it could be a six, it could be a seven could be a five. But the important thing is there is a wait screen for it. And we’ll get to that. But that’s what it is in a nutshell. [Jaz]Yeah. And I just want to put for those who listened so far. And they’re still you know, these terms can get really confusing. I like the fact that you started off with the definition of centric relation. But just some other terms that people may be familiar with from dental school, maybe RCP, retruded contact position. So we don’t tend to use that term anymore, even though dental schools might do, because it implies that the condyle needs to be shoved all the way back into the cliche era of dentistry, it’s not the case, we know that it’s more anterior superior. And it’s interesting how the definitions have changed over time. So again, go back to that episode, basics occlusion Part Two, to get a more of a sense of that. So RCP, you mentioned the point of initial contact, the centric relation contact point. So whenever the muscles are relaxed, and sort of the condyle, supposedly is a bit of rotation, you know, we can debate all that if you would like to. But it’s that retruded contact position, which you may have heard of before, or me and Mahmoud, like central place and contact position. And at that position where you got to start screening and when to come on to that in terms of your prevention. So we’re going to talk about how to screen for this. But maybe, well I think we should I was gonna say yeah, let’s go with that first, because someone might actually come on to this podcast when this actually has happened to them. And the bit they really want the most is, ‘Wait, crap, what I do now? Mahmoud, Jaz get to the bit where what would I tell my patient?’ Because I don’t want to prep anymore. If I prep anymore, I’m gonna see red. And so how am I going to do this, this crown restoration, if the bites changed and whatnot. So I guess the plate because of that person, maybe just wait a bit, we’ll get to that about what if you act, you know, step up, or you didn’t know about this, and you’ve joined this podcast, welcome to the podcast, by the way. I’m sorry that you’re joining us in distress scenario. But we will all cover that, don’t worry. So, Mahmoud, who is acceptable? Who is at risk? Because just like you said, 90% plus of people have a first point of contact, ie, their normal bite, the MIP, the maximum intercuspal position is when most of their teeth or lots of the teeth touch together, it’s the bite of best fit, which is going to be different to when you put their condyle into centric relation. And that’s a different bite. So 90% of people fit into this category. But who is actually at risk of this happening to? So let’s start off by the fact that you have to be preparing a tooth for this to happen, you know, to you in the context we’re talking about right? [Mahmoud]Yeah, I mean, you have to be altering the tooth somehow. I mean, it could be that you’re, you’re filling it, it could be that you’re extracting it, you know, if the tooth is unrestorable and it’s infected and it’s got to come out. I mean, you’re gonna take it out. But yes, as long as you’re altering the surface that’s contacting in centric relation this could happen. The highest risk is when the difference between the center correlation and the maximum intercostal position is large. Okay. So, essentially, luckily for us, again, most of the people that have a centric correlation to MIP shift, that shift is a millimeter at most, okay, for most people. If you think about it, if the condyle can only really move up a millimeter, even if that’s completely vertically, which you won’t be it’s at an angle, the chances of you losing enough space for it to be a problem are very low. So in my opinion, you want to be screening, whenever you’re prepping a molar, if you want to be really extra, you can check it when it’s a pre molar as well. But last tooth in an arch, definitely check, you know, if it’s second to thin might be worth a check as well. And once you know whether or not they have a big shift, then you can figure out what to do. But I would always screen a last tooth and maybe the one in front and get on to how we do that. [Jaz]Well, I think before we choose to restore that tooth, you know, could be the second last tooth or the last tooth in the arch. And we’re thinking, ‘Okay, I remember listen to that podcast. So I better I better do this check now to make sure it is a patient at risk or not.’ But just like you said, this might be happening to us in the population all the time. But the differences and changes so small, that, you know, we don’t notice it as much. So thankfully, our patients are kind to us. And actually, you know what? This has never happened to me, I actually got way smarter to this before it actually happened to me and I started screening before ever happened to me. So it’s never actually happened to me. And then I’ve used different techniques like the island prep and stuff, which we’ll come to later to prevent it happening. So it’s never happened to me, but I guess it might have happened to me unknowingly. But it’s happened to such a small degree that we don’t actually notice, because the seating is not significant. So let’s say we’re preparing a tooth, how would you check if that tooth is the central patient contact point, and therefore, how can you check to what degree the slide is? [Mahmoud]Okay, so my preference is to use something called a leaf gauge, what I’ll do is I’ll just search for my screen. [Jaz]So we’re going to make it very tangible for those listening at the moment, obviously going to describe everything we’re seeing, because the loyal Protruserati was started out. Started out on Apple and Spotify and whatnot, Stitcher, etc, we’re going to make sure we never forget you. But for those who are watching on YouTube right now, then yeah, you get to see some visuals as well as a commentary. [Mahmoud]So essentially, a leaf gauge is a bunch of sort of plastic leaves, and you can add or take away leaves to make it thicker or thinner, or you put it in between the incisors at the front. And essentially, it creates an anterior jig that separates the back teeth. So you put in enough leaves to completely lose contact at the back. If that, if you put it between the teeth and the patient close on their back teeth and they squeeze, they cannot feel any of the back teeth touch. Now this is essential that you completely clear the posterior contacts. Because if you don’t, then that’s when you don’t really know whether or not you’ve stretched lateral pterygoid as much as possible. So if you only put in a few leaves, and the patient says yep, I only contacted the back here, you check with the paper, and yet, there’s only one tooth that contact. Now, that might be the fully seated position. But it might not be you might find that you can actually add a few more leaves. And they’re still contacting but it’s in a different position on that tooth. So you clearly the context completely, fully stretched lateral pterygoid. And then you start taking leaves down to- [Jaz]I was gonna ask you a question, I would which I actually get a lot right for those beginning start with a leaf gauge. And they’re like, ‘How do I know how many leads to start at the beginning? Is it that second round is what should I start with 15? Should I start with 20?’ So what’s your protocol? How many leaves we’ll just start with? [Mahmoud]I mean, to be honest, I’ll start with 10,11, something like that. If the patient looks like they’ve got a normal overjet, overbite relationship, if they’ve got an anterior open bite, I’ll use half the pack. Yeah, we’ve got a really deep bite, or use maybe five. And then you just take it from there. Once you’ve done it a few times, you’re, you start to sort of see it in your mind, you can eyeball it. But yeah, maybe- [Jaz]And you can get very predictable and consistent results with this, I think. And then the key lesson here, guys, is to make sure that you put enough leaves in, even with just one or two extra that the back teeth cannot touch just like Mahmoud said. So make sure no back teeth can touch. [Mahmoud]Exactly. So once you’ve ensured that none of the back teeth are touching, you’re going to have the patient go forward and back. I let them do this for maybe 30 seconds because it just helps deprogram the lateral pterygoid and I’ll get them go forward. So I learned this from you Jaz, it’s great tip. Ask him to go forward like a bulldog, and then go back as far as it’s comfortable. And I get them to squeeze. Ideally want them to squeeze off half hard as JR one calls it half hard on both sides. ‘Can you feel any of your back teeth touch?’ They say no. Then you ask, ‘Can you feel any tension or tenderness?’ The reason why I ask is because I want to make sure that the lateral pterygoid has relaxed if it hasn’t and it’s a bit tense. They’re gonna say maybe I can feel a little bit of tension. But the other thing you’re checking for is essentially you’re load testing the joint. So you’re compressing that joint a little bit and seeing if there’s any pain, if there is any pain then that joint is unhealthy? Do you really want to start messing around with someone’s occlusion potentially with an unhealthy joint? So, once you’ve done that- [Jaz]Just before you continue Mahmoud, our talk is load testing, I mean, we can speak for an hour just on load testing. But I think it was worth just having this visual and you know, if you’re driving, if you’re chopping onions, wherever you have this visual, if you’re new to this concept, that if you’ve got these plastic leaves in between your front teeth, right, and you bite on these plastic leaves, okay, what’s happening? The central incisors are going to be intruding within their PDL. Okay, but then what about all the rest of the force, where’s that going to, right? Well, if the leaves are contacting your incisors, okay, and your muscles are going for it, the only other thing that can can now move is the condyles. So if the condyles are now going higher, and pressing in to the glenoid fossa, you have now placed load in the TMJs. And this is what load testing basically is, we’re now loading the glenoid fossa, we’re loading the temporomandibular joint. And then just like Mahmud said, if someone’s saying, ‘Whoa, what did you just do Mahmoud that really kills?’ Then maybe this is a complex patient. And you know what, thankfully, these patients are rare. I’ve never had an okay. Like once, maybe. And this is that was a TMD evaluation. So I was expecting it right? Like a severe intracapsular issue that was acute that gave us responses. Thankfully, this is rare. So I actually know some colleagues in our experience colleagues who said, you know, I stopped load testing now, because I realized that it wasn’t adding much, I still think it’s a good thing to do. And good part, the thing to do part of your notes, because you never know when you can get surprised. But definitely that, what I like about what you said, Mahmoud. And for those who might have missed it when you said it is your testing to see if they’re feeling any tension. And that’s the lateral pterygoid stretching, you want a position where when they’re pumping half hard just like Mahmoud said, they don’t feel any tension. And that tells you, okay, lateral pterygoid to stretch, it’s relaxed. It should be a nice and relaxed and comfortable position. It shouldn’t be like aching there. And what do you do Mahmoud? If they say, ‘Ya know what, I just feel strange tightness up here.’ And they’re pointing to a master and lateral pterygoid. What’s your protocol? [Mahmoud]So, the what I’ll do next, if they say that is I’ll get a couple of cotton rolls. So I’ll take a leaf gauge, I’ve got a couple of cotton rolls, put it over the molar area, and I’ll get the patient to squeeze on it for a couple of seconds and let go. Squeeze on it for a couple of seconds and let go do this five to six times [Jaz]Between the molars? [Mahmoud]Between the molars on both sides. The idea there being is you’re getting the elevated muscles to really contract and what they’re doing is they’re trying to seek the condyles up and forward. Because if you consider the vectors of the muscles, that’s the direction they’re gonna pull the condyle in, and they’re just trying to gently stretch that lateral pterygoid. You know, if you get a cramp in your leg and you’re trying to stretch it out, you pull, pull your foot up, same sort of thing. Once you’ve done it a few times, put leaf gauge back in, get them to go forward, back as far as is comfortable squeezed half hard on both sides. Can you feel a tension attendance? Most of the time it’s gone. [Jaz]Yes. Agreed my experience as well. And I just want to say Mahmoud, I’m sorry for interrupting. But really important to mention that when Mahmoud is taking out that leaf gauge, and putting in the cotton roll, and taking out the cotton roll and putting the leaf gauge at no point is a patient able or should be able to bite together make sure the patient does not bite together. Because then the neuro musculature just remembers again and they go into MIP or whatever. And then you have to deprogram all over again. So really important point we haven’t mentioned yet is that make sure their teeth don’t touch together. [Mahmoud]Yeah, so the two keys, really in terms of deprogramming is don’t let theback teeth touch. And make sure that when you are dialing the leaves in, you fully clear the contacts of the back. Don’t get complacent, think out there only touching one. Just get some more leaves in there. Make sure it’s open, get them to deprogram a little bit and then do your load test. Then if you’re happy, then we do the screen. [Jaz]Carry on. I’m liking others going. So yeah, what next? [Mahmoud]‘Cause we are load tested with deprogrammed relatively. And now we feel comfortable that the condyle is seated. Now we’re going to start taking leaves out. So again, patient opens, you stick your finger in there, so close, take one leaf out, put leaf gauge back in, go forwards like a bulldog, back as far as it’s comfortable. Squeeze half hard on both sides. Can you feel any back teeth touch? Now you’ll get to a point where they will say yes. And what I’ll do at that point is I’ll put my articulating paper in with the leaf gauge, again, open up please put the articulating paper in on the side. They said they could feel it. Leaf gauge back in, forward and back and squeeze. Can I feel it sort of grabbing? If I can, I’ll actually now check it on the other side as well. Why? Because I got caught out that time. So it took on the other side. Often, if they can feel it on both sides, I will actually add a leaf back in because it could be that they were touching before but they just needed a little bit more pressure on the PDL at the back there to actually register. So add one more leaf and do it again. And ideally I want to be able to get one tooth to grab shim stock with the leaf gauge in, so leaf gauge in. You know I’ve identified where the contact is with my articulating paper, put the shim stock over there, forward back and squeeze tug. If it’s catching that shim stock where everywhere else isn’t. I know that I’m pretty comfortable that that is their actual centric relation contact point. And the question then becomes is that the tooth that you’re going to prep? [Jaz]If it is? [Mahmoud]Then you need to be careful, then you need to take into account everything we’re going to say next. If it isn’t, fine, you know, document your notes. And you’ll know for next time, you know, you have to do the screening again. So once you found out that it is, then you need to start collecting maybe a little bit more information. [Jaz]So the next thing is probably to see, okay, now you’ve figured out that the upper left second molar is the first point of contact, and hey, guess what you were going to do a cuspal covers restoration for that tooth, and you’ll be altering that contact. And now what your going to be doing is figuring out okay, what am I up against here? Am I up against a patient here? Who the loss of space is gonna be so minimal that I don’t even need to sway anything? Or are we really at risk here of losing everything? And then I better tell the patient upfront, and maybe even this disagreement isn’t even viable. But we’ll come to that those extreme ends, right. One is, it doesn’t matter, I’ll be fine. And the other one is, whoa, you need ortho. You need surgery? We can’t even do this. So we’ll talk about that – yes. [Mahmoud]Yeah. All right. So most of the time, you’re going to find that if the tooth that is centric relation contact point or point of initial contact is the tooth that you’re prepping. Usually, you’ll find that either A) it is the point of initial contact, along with maybe another tooth that puts you in a low risk category, because you know, the other tooth is going to provide the programming for the lateral pterygoid or- [Jaz]For example, a tooth in front or a tooth on the other side? Is that we mean? [Mahmoud]Usually it’s on the other side. Yeah, usually, because if you think about it, when there are leakages in at the front, and both condyles are seated, the condyles are sort of the other two legs of the tripod if you like. And you can imagine that if it’s close enough, there’s actually a little bit of bend in the mandible. So it’s actually possible to get two contacts. In fact, if you think about it, logically, it’s, it may be even more more likely to have to, unless one is really quite far ahead of the other, does that make sense? There’s probably two, or at least close enough to being two. So if it’s one of two contacts in centric relation, then it’s a very low risk. The other thing I like to look at is, you know, if you look at the picture, you can see if the tooth is holding up, you know, the bite, so you’re in centric relation, and that tooth is the only contact in centric relation, but the teeth next door look like they’re almost touching. And they’ve got good sort of Cusp fossa interdigitation. Again, chances are, you’re not going to lose that much space, because those bottom teeth only need to move a tiny bit for them to hit the upper teeth. So really, how much space can you lose? Not a ton. But also, they’re probably close enough together, that that programming for the lateral pterygoid is still going to happen. [Jaz]Yes. [Mahmoud]Okay. And the last thing I look at is the sort of how big the slide is, there’s a few ways of measuring it if you like. Maybe the easiest way is just see how many leaves you’ve had to put in. That gives you an idea, we know that on the leaf gauge are mostly gauges, each leaf is about 0.1, a 10th of a millimeter. So 10 of them is a millimeter. Now, if you remember from middle school, sort of opening the vertical anteriorly three millimeters gives you about one millimeter opening at the back, that three to one ratio you can use. So if you’ve opened them three millimeters at the front, and chances are they’ve only opened a millimeter at the back, which means to close them back to MIP, you need to lose a millimeter off of whatever is holding them up, which are the front of the leaf gauge but the back is your central relation contact point. The other way to do it is you can actually put leakage in, get them into centric relation, get them at the point of initial contact and measure the overjet, then you take a leaf gauge out, get them to bite into MIP, measured the object again. Subtract one from the other, you’ve got the difference between the two. And that’s actually the horizontal component of the shift. So for me, anything that sort of less than two millimeters, or you know, anything less than one and a half, I’m probably not too worried, because it usually means that the shift at the back is actually quite small. [Jaz]Correct. [Mahmoud]Okay, so- [Jaz]But Mahmoud, that means something about that perhaps should have answered earlier. But all these things we’re assessing, like, if the rest of their teeth have got such a good mechanical interlocking, that they fits so well into a jigsaw, even though they have that first point of contact, which you may be altering. Do you subscribe to the theory that actually when they just go searching for their bite of best fit, they will just find it because the rest of it, they just interlock so well. And that perhaps it is because what I believe in please tell me if you don’t is that you’re more susceptible. If you’ve got general tattered occlusion, wear, lots of MOD, flat amalgams and you really don’t have much of a bite to grasp onto. Would you agree that perhaps that patient will be more susceptible? [Mahmoud]Absolutely. I mean, it’s the same things when we discuss to people with a risk of an anterior open bite when you give them an anterior only appliance it’s the same thing. So if they’ve gotten good cusp to fossa contacts at the back, chances are they’re not going to lose MIP when you get rid of one centric correlation compound contact point where they’ll find something that is close enough. So yeah, the risk is pretty low. So really, it’s people with big shifts, or people where when they’re hitting that one contact in centric relation, you know, so what I like to do is I’ve got leaf gauge in there sitting on their centric relation contact point, I’ll, you know things back a little bit, I’ll put my mirror in there, I’ll have a look. If the teeth are really far apart, you know, in front of my tooth that I’m gonna prep this is like a two millimeter gap. And then I’m thinking, okay, I might be in trouble here. And because for those teeth to come back together, again, I know the mandible has to move up about two millimeters. Now chances are, it’s not going to move a full two millimeters up. But if it moves one and a half, and I’ve prepped one and a half, I’ve lost all my clearance. And now I’ve got another one and a half, which means I’ve prepped a total of three, you know, with my eyes, probably four millimeters off the occlusal surface of the stoop. So I hope it’s- [Jaz]And the second molars tend to have small clinical crowns, because you’ve got that, you know, not Gingival overgrowth, but they’re, they quite often they are small, clinical crowns anywhere from either wear or they have altered passive eruption of some sort for the gums. So you’re already dealing with smaller clinical grounds. [Mahmoud]Yeah. So you don’t really want to be adding millimeters to your prep, or at least you need to know about it in advance. So you- [Jaz]So you’ve found this high risk patient, I’m always fascinated by how do you actually seat them up and say, ‘Hey, you have this issue.’ I mean, it’s such a complex thing to explain to dentists, how do you explain to a patient? [Mahmoud]Yeah, so I mean, I think this is so key. And it’s the fact that it’s their problem. So all you need to do really is just sit them up and explain what you see, tell them nobody has ever put a leaf gauge in their mouth. No one’s ever checked this in any way. And they will probably already be feeling by others get really cares, or this guy knows what he’s doing. So I seat them up. And I’ll say, ‘Sorry, Mrs. Jones, my screening has shown that your bite is in such a way that if we do the treatment we’re discussing, and I try and put a crown on that your bite might irreversibly change, to possibly a degree where you can’t find your bite anymore. And in that new bite, there’s no space for the crown.’ Okay, so the crown- [Jaz]And that’s a, you’ve explained that beautifully, but you know, for patients to actually grasp that, it’s tough. [Mahmoud]It is. And, you know, if you’ve got some diagrams, or if you’ve got, you know, a skull, or, you know, I use the diagrams I’m showing on the screen now. Because it shows a series of me prepping the tooth off of the models and showing them that might come back together again, and it is a complex thing to explain. But usually I’ll try your best to explain it in my opinion. And, yeah, I found patients do understand, bite changing. So you know, the fact that it’s just one tooth, and it’s gonna change everything, obviously sounds a bit. Really, that sounds like, that sounds ridiculous. But you just have to have conviction in your, what you’re saying, because it’s true. [Jaz]Yeah, I just like to add the way, the way I would say, the way I do say to patients, is we’re preparing preparing this tooth, which is right next to your joint, it’s like the furthers back tooth, right. And so if you change anything, this tooth actually is so close to a joint, you actually change the joint a bit. And then if you change the hinges of the door, the entire position of the door actually might change, you know, change the hinge of the door, you completed all the angles go off. So basically what this means for you, Mrs. Smith, is that this is just a little bit more complex. And you could have a bite change. And I love the fact that you also agree that bite change, is that is main thing, because that’s what they perceive. And then so therefore, we need to take more care and how we treat you. And then instead of boring them with a whole plethora of further information, just tell them, here’s what I’m gonna do differently to prevent this from happening. But just know that it could happen, that’s essential. You don’t want to over complicate it and you make it a half an hour discussion. [Mahmoud]No, you don’t want to bore the patient to death. But they need to understand that this is something to do with their bite. It’s not something you have done or will do. You know, as the saying goes, if you tell them before it’s a reason you tell them afterwards, it’s an excuse. [Jaz]Absolutely. [Mahmoud]So this is a patient probably I’ll describe it to our listeners, she’s got a massive CR to MIP shift. So her first point of contact is on an upper left seven, you can see the palatal cusp sort of dangling, you’ll see this on a lot of patients. The upper palatal cusp on seven sort of the tooth rotates a little bit buckling, and that palatal cusp hanging down, and it’s hitting against the distal marginal ridge of the opposing six. [Jaz]Hey guys, hope you enjoyed the episode so far. Remember that you can claim CPD for this episode, and all the other 99% or so episodes are eligible to claiming your CPE or CPD certificate. As well as that on the app. You can download it on iOS and Android. There’s a whole load of exclusive content has a lot more plan. Like my biggest thing that I want to do early in 2023 is to Verti Preps for plonkers, right? So it’d be like a complete definitive guide to Verti Preps, I’m not going to post on YouTube. This is like gonna take a lot of extra hard work. It’ll be like a full online course except I’m gonna just make it an extremely good value and just make it available to premium members of the app, so whether it’s just getting CPD, finding the app in one place with all its content, being able to download the episodes and the videos to your device, being able to access the notes that come alongside the new episodes, or you want to get access to exclusive content, my commentary, please do subscribe to the app downloaded on iOS and Android, the download is free, you can actually use Apple free as well, it’s really functional really good. But to get the real juice, if you’re a true onion chopper, then check out Protrusive premium. And I look forward to helping you in your journey of dentistry. [Mahmoud]So yeah, I’ve got this patient here. And when you look at the cast, you’ve got the upper left second molar. And it’s sort of rotated a little bit buckling, which you often see which means the palatal cusp is hanging down quite a bit. That is the centric relation contact point or point of initial contact in centric relation when the patient closes. And it’s the upper second molar palatal cusp against the lower first molar distal marginal ridge. And if you can see the photo, you’ll see that actually, when they are at that CRCP, the space between the other teeth is almost two millimeters. Now, this kind of patient scares me, if I see this, I’m automatically thinking. Worst case scenario is I’m going to lose all of that space, I’m going to lose a hole two millimeters. Now, I usually take about a millimeter and a half off of the occlusal. So, if I do that, and I lose two millimeters, I’m still going to have another sort of two and a half millimeters I need to take off to actually get the clearance I want. So if we cycle through the images, what I’ve got here is, this is how the patient would present to you. So this is her in her MIP. This is the bite she knows. Okay, so she comes in all her teeth touch. Yeah, upper seven is sort of in midair a little bit and it’s fractured. We’re thinking about putting an implant in the bottom where we think I’ll go crown this tooth for now, you do your screening. And I had to put a ton of leaves in at the front because she’s got a little bit of an anterior open bite. And lo and behold, that upper second molar is my centric relation contact point. And if you could look all around the arch, that is the only tooth touching by a mile. None of the other teeth are even close to touching. So that’s why I get these models because I want to know what’s going to happen when I prep that tooth. [Jaz]And so do you get this you know, do your face bow and get this mounted on a semi adjustable articulator? [Mahmoud]Yep, upper and lower impressions, face bow because you want the upper cast related as closely as possible to where the condyle is, and centric relation bite records. And then so once I’ve got the casts, I’ll prep the upper second molar on the cast. So I’ve taken two millimeters off the occlusal. Okay, but these casts are still being held in centric relation. So once I undo the pin, and I close the cast together, you can see the teeth close back into MIP. And look at my clearance, I have zero. So in fact, in fact, the only tooth touching is still that upper second molar. So really the condyle might not see it fully. But even if it goes most of the way there, I’m going to lose all of my clearance. [Jaz]For those listening right now, I mean, Mahmoud’s shown very beautifully here, he’s chopped that molar good to three millimeters, and the patient’s now able to bite together as before, but also still pretty much biting on that mesial of that second molar still. And classic is a great way to show on the models, what you may have experienced. And that’s why you’re listening watching his podcasts. And that’s what happened. That’s a great visual. [Mahmoud]Yeah, so there’s two consequences to the last tooth in the arch syndrome and possibly A) you lose the clearance, which will look something like this. But worst case scenario and patient with big shift is you end up destabilizing MIP, meaning the lateral pterygoid no longer knows what to do, and the patient cannot find their habitual bite anymore. And in this case, once I’ve removed enough off of the second molar, so I had to remove another two millimeters to simulate getting enough occlusal clearance. The patient is only occluding on their first premolar on the other side. [Jaz]But that will be the new centric relation contact point, righr? That new point of contact is now that, yeah, yeah. [Mahmoud]Correct. Now, I’m not saying that’s definitely going to happen. But in order to properly inform the patient, I need to be able to tell them that A) this might happen, meaning I need to take more off the tooth and B) if your bite changes, it could end up looking a bit like this. And they’ll be like, ‘Well, I don’t, I can’t chew on just one tooth.’ Like I know, which means you might require more treatment. What that treatment entails, we’ll discuss. But the important thing is it’s not, you know, it’s not up to us to really decide what to do. It’s up to us to inform the patient of what their teeth and their jaw relationship are presenting us with. And for them to choose what option best suits them. [Jaz]And so what options did you give to this patient? The tooth you know, it’s desirable to restore that tooth, but there’s a higher risk for this last tooth in the art syndrome and you’ve been wise and you’ve done your screening up ahead and even informed the patient and you’ve gone to the trouble of you know, mounted cast and to actually create these beautiful visuals. So in the level of informed consent here is amazing. So how did you actually manage her? [Mahmoud]So with this too, you know, the options in this case are, you know, that tooth itself, luckily, is endo treated. So we don’t, aren’t worried about pulp but we’re going to need to prep more. Now, in this case, I’ve got space, if I didn’t, what are the other options? So I could reduce the opposing? Or I can- [Jaz]So you said you meet, you got space? You mean enough height of tooth? [Mahmoud]Yes. She also by prepping even more for if it’s an old lady, you’ve got enough. [Jaz]Still going up retention form? [Mahmoud]Yeah. And if you’re onlaying it, you’re relying on your adhesion. It depends what you’re doing. [Jaz]So it’s still restorable? Still restore. But despite three millimeters of adjustment, the tooth it was still restorable. [Mahmoud]in this case, because it’s an upper and it’s maybe slightly overreacted. [Jaz]Okay. [Mahmoud]That’s not always going to be the case, if it’s a lower might be a different story. And then you’re having the discussion with the patient of, is this even viable? But ultimately, once you’ve got this information, you need to present the patient with options, and the options are going to be do nothing. Or how can we gain more space for, because you’ve got two problems, remember, you got the losing occlusal clearance, and you’ve got the bite changing. So the options for losing occlusal clearance is prep the tooth more, prep the opposing, do ortho and move the teeth, create more space, or open the vertical and restore more teeth. Those are really the only options. Yeah, apart from- [Jaz]But even then Mahmoud, like just just discussing with you like it’s not written and we’re talking about risks here, it’s not written that it’s not guaranteed that the bite will change. So you know, you do that, you know, your initial 1.5 millimeters, right? And, you know, let’s say you get the patient bite together, you might find that the muscles are able to go back to their usual MIP. And then in this case, you got lucky. But it’s all what this episode is about is identifying that high risk patient, and then having this exactly as conversation and knowing your options ahead of time, and hope that they won’t happen. And then that, you know, just won’t put it out there that okay, it’s not guaranteed that this will happen. It just could happen. [Mahmoud]Yeah. And that’s, even if it does happen, it didn’t happen all the way. So I don’t think that most of the time, you will lose all of that space, the condyle, let’s just see a little bit until it gets to the next point of initial contact, right? And that’s going to procline lateral pterygoid. So the condyles might see a little bit, but not all the way and you haven’t lost all the space. In which case, it’s fine. But the question is, what if it does? So, you prepped. Now, once we discuss the options for the space, or the lack of, then again, you got to just mention the fact that the bite might be completely different. What are the options there? Well, like you said, already, most of the time, the patient will adapt, and most of the time, it will be fine. But if it isn’t, you need to be able to explain to them that I might need to adjust your bite. So you’re looking at equilibration. Alright, so you’re looking at adjusting the contacts until more teeth meet in that centric relation position. [Jaz]And please don’t do this if you have no experienced, you know, don’t go around chasing blue dots, please. Right? Basically, as you listen to two guys on a podcast, telling that there’s an option, okay, this is something that you need some sort of training and experience with. So, Mahmoud, you’re stating, calibration is an option to manage the funky bite that the patient may have. [Mahmoud]Yeah. The other two options being ortho, or again, opening the vertical and reorganizing occlusion. Now, we have a few things working in our favor, that usually mean this. This is why we don’t see this every day, you don’t see it every month is A) like we said 90% of people that have a shift, that shift is under a millimeter. The other people that have maybe a slightly more elevated risk, still have enough context around where that centric relation contact point is to pick up the slack, essentially, and re-establish a new MIP or the same MIP just with a slightly different slide. But also, I haven’t really sort of you know, I don’t have any proof of this. But in my head, I’m thinking, especially us here, we tend to do indirect restorations on teeth that have broken quite severely in a way. Now we generally don’t tend to, you know, put indirect restorations on teeth that haven’t had a cuspal fracture. Now, what are the chances that the cusp has fractured because it used to be the centric relation contact point? And that patient whenever they hit and slide have overloaded that cusp and then that cusp fractured. So in fact, what’s happened is that patient has lost that central relation contact point before they even walked in. And you pick up leaf gauge, you put it in centric relation somewhere else because well, they broke the cuspal used to be the centric relation contact point then you’re going to crown the tooth, and you haven’t changed anything because it all happened once that tooth broke. So I think that’s partly why we maybe don’t see this as often as we do. So this sounds like okay, well, this is not really going to happen to me or maybe it’ll happen once or twice in my career. [Jaz]But when it does happen, it’s a big deal. It’s a big deal because usually you haven’t preempted it. Yeah. [Mahmoud]Yeah. And that’s why it’s called Last Tooth in the Arch Syndrome like making it sound like really dramatic. It sounds horrible, but if it’s happened with all this sequelae of you losing space and bite changing it’s, that is a big deal. I mean, this patient that might be looking at ortho might be looking at a rehab, who’s paying for that? Chances are you. So for two minutes screen that you can do. And once you get good at it, it’s really, really quick, just by yourself that peace of mind and being able to inform the patient and gain proper consent, when you’re restoring the terminal tooth, or maybe the one in front, that two minutes is worth it, in my opinion. [Jaz]Well, before we talk about some strategies of prevention of this happening in those high risk patients, let’s address that poor guy or gal who’s joined this podcast now and then thinking, ‘Oh my god, I just discovered this thing called Last Tooth in the Arch Syndrome.’ Mrs. Smith is like totally pissed off at me, what the hell do I do now? And they send the patient home, they just put some composite on like, some bond or something just to seal the tubules maybe. And they’re like, ‘Okay, I have no idea what to do now.’ You, I know you went over the options, but any advice you can give to that dentists has joined us? [Mahmoud]Okay, so if you’ve already had the condyle seat, and as long as when you put your whatever it is you put on your bone, your composite, you haven’t re-established a new centric relation contact point. So you haven’t put it in high, I would wait and see if that patient develops or, you know, adapts to the existing new occlusion if you like, all right? And then assess from there. If I would do the screening again, once they come back after a few weeks, do the screening again. Chances are you’ll find that their centric relation contact point is on a different tooth now, because you’ve prepped the old one off. And if it is on a different tooth, and they are comfortable, and they have a stable MIP, then you’re back to square one. They need to assess whether you can still prep the tooth or not. Is there enough space? If there isn’t? What are you gonna do about it? Again, it’s a discussion with the patient, explain what’s happened. You tell them what the situation is. And then the options are kind of like what we discussed, because you need space. So either you’re going to prep the tooth more, you get to prep the opposing, or it’s ortho. [Jaz]Or I mean theoretically speaking, Crown Lengthening to actually give yourself more retention form, whatever, but it’s very difficult to cram everything and applications and stuff. So may not be a real world option. So yeah, fine, that’s good. But let’s say we have found the high risk patient, but in the real world, we’re not all as meticulous as you Mahmoud. We’re not going to get our face bow out and do bounded cards and stuff. You’re too good with that. So what are the strategies, the top hacks, the sort of top secret hacks that we’re going to share with everyone, watching, listening to prevent this being an issue, even those high risk scenarios? [Mahmoud]Okay, so I’ll come to this bur, just caveat that a little bit, I want to differentiate between sort of the low to medium and the medium to high risk, I think someone with the scenario we saw were, when they were sitting on the centric relation contact point that the vertical changes almost two millimeters. I don’t know that I would use a hack because I would still be scared. I think it’s the ones that are sort of in between where the you know, you can see a little bit of space you know, millimeter and you know, a millimeter between the teeth and you think okay, there is a good risk, they might, you know, shift a little bit. There’s two things I would you know, consider my personal favorite is before I numb the patient before I do anything, I’ll get a triple tray. For people that don’t know, a triple tray is like a quarter inch tray and it’s flattened, it’s got a metal handle and like a mesh on it. And the idea is you put your putty on the top and bottom of it, then you squirt your wash over the prep and you actually put it in the patient bites on it. So there is a called triple trace because you’re capturing your prep the opposing and the bite all in one go. Now what I do with it is I put bite registration material on both sides, put it in I get the patient to bite together in MIP. Right? And it’s critical that once you’ve done that, let it set, take it out, and put it up to the light. And you want to see pinpoint holes where the light is coming through where the patient bites into MIP. The reason is if there aren’t there then they haven’t bitten improperly and maybe the bit of metal going around the back is in the way or something like that. [Jaz]Okay, but Mahmoud, why use a triple tray, why not just squirt in bite reg material on its own? Because essentially just capturing half side bite. [Mahmoud]It’s just easier to handle because I’m going to be taken in and out just fine like just a piece of bite reg is maybe a little bit more. [Jaz]Easy to hold. A bit more nurse proof, I get it. [Mahmoud]So once I’ve done that, and I’ve got this bite. The key with that is that bite needs to stay in the mouth at any point that the patient might bring their teeth together. So it’s in while I’m prepping and it only comes out when I’m doing my, so, it’s in when I checked my clearance. Alright, it comes out when I’m doing my scan or my impression because one point I think we haven’t mentioned, if when you’re dealing with last teeth in the arch, always take full arch impression. I know in scanning you might get away with it a little bit more but you know paranoid so full arch scan or full arch impression. The bite goes back in afterwards. The bite is there. One, I’m doing my temporary the I want I’m checking the conclusion on the temporary. And the reason this can work is basically it’s preserving or trying to preserve the programming of the lateral pterygoid. So those engrams that are telling us to ptreygoid to pull the condyles down a little bit, that to be able to get into that bite that programming has to remain. But also, all centric relation shifts into MIP. While at least most of them are not like straightforward, okay, there’s usually a lateral component to it as well, meaning that bite can hold the mandible for and stop it moving laterally, which again, hopefully means you don’t lose the shift. Yes, I learned this trick from lino chi a while ago, he’s got a very interesting name for it, if you if you look it up, [Jaz]You could say girlfriends. [Mahmoud]And he calls it you save your ass bite. [Jaz]I told my nurses, ‘Can I get an SYA, please? And they know that, they know I need my bite reg for one side. So that’s, that’s a good way of doing it. The other way, which I do digitally is in that in that low to medium risk patient is you scan the both arches in a preprep. So you do the preprep scan, so you get the unprepped teeth, both opposing and the working. And then you scan the bite from the beginning and said, and then that way the lab get the pre-operative anatomy and that anatomy is okay. It’s acceptable, Then they can copy the features into the final crown and hopefully not disturb the balance. But also we’re getting the bite array. So at no point will the patient be encouraged to bite onto their prepared tooth, you can actually just get them to bite when they got the temporary in place. And hopefully you’ve minimized the risk. And so the more primitive version of that, you know, 10 years ago would have been just make sure the patient doesn’t bite together, just make sure the patient doesn’t bite together at all, keep the patient’s mouth apart at all times, basically. And then that was the other way of doing that. What do you think about those ways? [Mahmoud]Yeah, I mean, it does come down to whether or not you sort of want to preserve MIP, or are you trying to preserve the slide? So the island prep the, you know, scan the tooth prior and sort of copy the anatomy, or things that are trying to copy the or reincorporate the slide. And, you know, in a patient who doesn’t show a ton of wear, or you know, as well, we’ll cover certain things in hopefully on the course, in terms of identifying patterns of wear. You know, someone who shows excessive wear on the second molars, but virtually nowhere else may be someone who slides into their centric relation, and grinds. Now, if they do that, and you see evidence of that, and then you replicate what was there before, you might find that your restorations are being overloaded. And whatever broke the tooth, might well break a restoration. So I haven’t been brave enough to try the island prep, which is, I believe you’ve tried it. [Jaz]Yeah. And so just to briefly describe it, you mock up that contact, the slide, the centric relation contact point or point of initial contact. And then because when you wash the tooth, you prep the tooth, that red marker, blue mark is going to go wash away. So you put a tiny bit of bond on it to preserve that marking the colored mark, you prep the tooth as normal, but you preserve that contact area on the tooth. And then you do your impressions and bite reg as normal and it’s over to a lab. And what the lab will do is a lab will actually prep it away. And they’ll make a little Duralay coping, and then they’ll send the crown the properly made crown and the coping to you. And so then I just put the coping back on the tooth, I prep away that little sticky outy bit which was the slide if you’d like and then my crown is now going to seat. The interesting thing that happened, Mahmoud, when I did this technique is the patient came back a few weeks later, with a hole in their zirconia crown. I’ve never seen this. Can you imagine a hole in the middle? There’s a chronograph. So what had happened is that I must have prepped a little bit too much on the island. Okay? So now where the crown was had the, you know, 40 microns of cement space everywhere, in that one area, there was maybe, let’s say arbitrarily 120 microns of cement space in that one area, right? And then I didn’t put enough cement either. So, you know, when mistakes happen is compounding of errors, not just one error, right? So I must have not put enough cement. So there was cement, cement cement everywhere. And underneath that a Zirconia where the island was, was air. So it was Zirconia-Air-Prep wherever else was Zirconia-Cement-Prep. And so that’s what how my technician and I came up with a conclusion. So you had to hear again and make her a new crown. Interestingly. So that was my experience. So just thought I’d share that with you. [Mahmoud]Oh, that’s, it happens right? That’s the thing you know, you try your best and stuff will still come back to bite you. [Jaz]The last tooth in the arch did not bite me at that time. So yeah, that’s the another way of doing it. Anything we’ve missed you think? [Mahmoud]I think the most important takeaway messages are screen for it. It takes two minutes. Have the conversation with your patient. And, you know, this may have sounded like a really depressing lecture where, okay, I’m never going to put up second molars again, because your bite’s gonna change the patient’s gonna sue me 95% of the patients are 95% of time, this is not a problem You’ve probably been in this situation and just crap the next half of the it because he thought, okay, maybe that bur fit or thought or, or whatever. And chances are this is, you know, this has happened time and time again, you haven’t noticed. So I wouldn’t be too worried about it. But now that you know, it’s easier to describe and then have the conversation with the patient. Because if you don’t, and then you do get caught out, you’re going to be feeling really silly that you listen to podcasts and certain do it. [Jaz]That very true. And I think just want to wrap up by saying that even those, you know, we start screening and get start getting good at the leaf gauges, you know, gives you it opens up so much in the world of occlusion and treating more teeth and moving out of single tooth dentistry makes you think whole mouth, right, and then that’s when dentistry becomes more fun. So, you know, start screening your patients anyway, every time you’re doing suspect restorations where you know, this, this could be a phenomenon, even though it’s gonna be rare, it gets you into good habits of screening. And then you know, sometimes it’ll be like a low risk or medium risk. And you know that, ‘Hey, from my risk assessment, I might lose a half a millimeter space here.’ So you know that the worst case scenario here is you can just prep half a millimeter more, and if your tooth can can take it, then you’re at peace. But if you find a really challenging dental scenario, but more importantly, that dental scenario is on a not challenging tooth, but a challenging person, a challenging human, that having come in or just you dread conversating with this patient, then the best thing about being a GDP is the ability to cherry pick. Now, because you’ve been smart, and you’ve done your assessment, and you know that, okay, there’s gonna be a full mouth case here, I don’t want to just deal with this angst with this patient, I can’t be bothered with this, say that you’re really complex pace, your bite is really screwed up. Here’s a prosthodontist I don’t like and ship them there. Right? So, you know, I’m just saying screening is a wonderful thing. So if there’s anything you take away from this episode is screen. And then you can choose way on treat that case, and most of the time, things will just sort out. [Mahmoud]Absolutely. The flip side of that is if you are comfortable treating more complex cases. And now you’ve discovered how to screen for this. This also opens up the area of you having the discussion with the patient of you know the other way to do this, because you’ve got plenty of other teeth that need restoration, should we start thinking about maybe long term comprehensive treatment? So that opens the door to have that discussion. And maybe you’re able to stabilize that patient, and treat more teeth, do more comprehensive fun denstistry on someone who needs it. And it’s all come about because of this one broken molar. And you’re doing your best, you know, to try and treat the patient, you know, as best as you can. And you’ve discovered this issue and it just opens the door for a natural conversation to flow. [Jaz]Very well said and that patient who you are treating that compromised upper left second molar to use that example again. And you’re right, they’ve got like these MOD amalgams and leaking composites for mouth they got significant wear, multiple cracks, and they will actually benefit from cuspal coverage. And by maybe increasing the OED you can actually do quite conservative restorations that you don’t have to even drill so much, and give them a really aesthetic result as well, then it really opens up a lot of opportunities for you to start, you know, to do comprehensive dentistry. To do it, you first need to think it and communicate it. So by doing this, the more you practice communicating, it might be your 30th or 40th patient that you can you get slick at talking about it. And then you say actually, ‘Miss Smith, you know, your crown on this side was done in 1970, your crown, your MOD amalgam here was done in 1980, the dispelling was done five years ago, and you just got like a patchwork one tooth at a time. And your bites not very stable. And so you told me Miss Smith that, you know, your main thing for you is that you want to smile, you want to improve your smile, you want the teeth to look withstand time and minimize how much dental care you’ll need in the future.’ And therefore this might be a good time, if it fits in your life to consider something a bit more comprehensive, just like you said, Mahmoud, would you like me to assess you with those eyes? And if they give you permission, then do your full occlusal examination and give them some options. [Mahmoud]Exactly. And, you know, once it comes from them presenting with an issue and you relating everything to their long term goals. It’s a very natural, comfortable conversation. That’s exactly the kind of conversation I like to have in order to progress on to complex denstistry. [Jaz]Okay, so Mahmoud, thanks for giving up your time to talk about this very geeky topic. I know I mean, you’re super into it. Not everyone’s into it. But I think what me and you are on a mission is to make occlusion really practical. And one of the things that we’re setting up in our course is one of my aims is not to say the word McKenna receptor even once. That’s my aim, okay, because I want to show people videos and photos of teeth of dots and lines and say ‘Hey, do this, do that don’t do this, prep this and refer that.’ And that’s really the angle that we’re coming from. But who is the ideal dentist out there that are course OBAB occlusion basics and beyond is gonna benefit? [Mahmoud]I know it’s such a cheesy answer but really we are aiming for it to appeal or serve as many that’s it for but if you are interested in sort of taking on more what are you’re interested and taking on more complex cases or whether you choose to do the simple cases, but do them really well and really predictably. And you’ve always thought that the occlusion just sounds a bit too confusing. It sounds a bit too abstract. It’s, you know, it’s not, it’s not something I can visualize, it’s not something I can, I can really see in my mind. My aim, even though I’ve said my kind of receptors, maybe twice, sorry, lectures, but it comes with pictures. And, genuinely, for me, personally, I’m a very visual person, I need to see how things work. And once I can see them, I can extrapolate. So that’s the idea behind how I’ve sort of we’ve structured the courses, making it really tangible making it really something you can see how it works and understand it and then apply it to all the different situations. [Jaz]Because Mahmoud’s made some really cool videos and photos series of you know, articulators step by step by step by step. And if for those of you join us for the video part of this, if you actually saw when he prepped that tooth and how it seated, we look on YouTube stuff, you will only find cartoons of that, you know, he’s actually done models, and this kind of visuals that Mahmoud’s got throughout the entire course. So we kind of split it in half, I’ve covered half, Mahmoud covered half. Mahmoud you’re into more your tools and stuff in terms of articulaters and vice versa stuff you love that I try and do as much as I can, without relying on articulates faceless I try and just eyeball it. And so we’ve got two different approaches, but we marry it together in terms of okay, fine, this is how we do it. But what we cover is why, when, okay, and when not. And that’s why I’m super excited to launch this. So guys, when we’re ready for OBAB, I will email you and you’ll hear about in the podcast. But if you haven’t listened already to basics of collusion, part one and two check it out to get a little flavor, but very exciting times ahead. And we look forward to getting this out to you. [Mahmoud]Yeah, really, really excited about it. I think it’s gonna be something that’s really, really different to what’s out there. I really think so. And it will take you from the basics. Although it’s beyond, you know, talking about, like, you know, pictures and series and stuff like that, I’ll take you through a rare case that shows every type of wear you can imagine, and I’m waxing in the contacts one by one and you’ll see step by step and I’ll give you the reasoning of why we do certain things and how were, is all about force management. Then once you see it, and once it’s there in your head, you will you will understand the concepts and then you’ll be able to apply it to whether you’re doing you know you got just a class four or you’re doing for composite veneers or you’re doing it full mouth rehab, the concepts are the same. That’s that’s the aim really is for you to be able to do from A to Z, knowing that you ticked all the all the boxes, knowing that you understand why certain things need to be done, and not just blindly following an occlusal religion as we like to call them. [Jaz]Yeah, I think me and you, I wouldn’t say we’re atheists, I think we’ve had lots of influences in different religions. And I don’t want to say we’re starting our own religion or anything. We’re just we’re gonna pick okay, we like this from Kois. And we like this from Dawson. And and here’s how we do is with a mishmash, and you know, why don’t you try implementing this and seeing that actually, we found that this works better in our hands in day to day, general care, me and you busy practitioners, and when the real world weapon dentistry, so that’s what we hope to share. So thanks so much, guys for for listening all the way to the end here. And we look forward to see you on OBAB. [Mahmoud]Thank you very much, Jaz. And thanks, everyone for listening. Jaz’s Outro:Well, there we have it guys, for those who are listening and some of the visuals that were amazing. Honestly, that second molar visuals that Mahmoud created, I will just go back to YouTube or the app ideally, and go back to those points. Those are absolutely golden. So hope you enjoy that. I just want to say thank you to April Whitlock and Narni Fulford. These two ladies, lovely ladies and fantastic dentists who on the app, the protrusive app in the community section actually asked for this episode. This episode was supposed to come out much later, but because I couldn’t say no to them, and they posted it in the community section of the app. I was like okay, we’re gonna do it for you. This does this episode was dedicated to you, April Whitlock and Narni Fulford.. For thank you so much for supporting the podcast in the way you do. I’ll catch you guys in the next episode, same time, same place.

From the entire Protrusive Community – we wish Sanj a speedy recovery – keep smiling Sanj and stay strong! In the previous episode with Sanj Bhanderi on ‘how to extirpate properly and efficiently‘, we briefly touched on postoperative pain control. In this episode, we’re focusing more on postoperative pain and the dreaded severe pain after the obturation appointment (or in-between visits). https://youtu.be/RJzQZNhBup0 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Highlight of this episode: 2:27 Post-op pain after endodontic treatment 7:43 Flare-ups 9:46 Guidelines in antibiotic microbial management 11:03 Flare up in between visits (RCT has not been finished yet)  13:40 Crown Down approach Dr Finlay Sutton is coming down South for his one-day signature RPD Masterclass on Saturday 14th of January 2023!  Limited to 12 delegates, reserve your seat now! If you enjoyed this, you might also like my episode with another talented Endodontist, Dr Ammar Al-Hourani, on Is Single Point Obturation Acceptable?  Click below for full episode transcript: Opening Snippet: I wanted to start this podcast with a get well soon message for our guest, Dr. Sanj Bhanderi who did such a brilliant job with our last group function on how to extirpate quickly and properly. Now, unfortunately, after we recorded that episode, and after we recorded this one, Sanj felt acutely unwell. It was actually scary hearing the news of him being ill. But I'm getting some positive updates. And so we the Protrusive Dental Community, and then all dentists around the world. We wish Sanj a speedy recovery. We hope you get well soon. We're so glad you're okay and on the mend. And we want to pass on these wishes to you. It's been quite clear on social media, what a likable guy you are, and how much we all want you to make a speedy recovery mate. So wishing you all the best and get well soon from Team protrusive. Jaz’s Introduction:I bet this scenario sounds very familiar to you imagine you’re on a course you having a great time. I personally love courses, I think you all know that. You’re on your fifth coffee, and everything’s going great. And suddenly your pocket starts vibrating. You’ve got a call from the practice or text message informing receptionist saying that, ‘Mrs. Smith, you know, the root canal that you saw yesterday, she’s in absolute agony.’ And you curse because you think wow, you know, that was a completely straightforward root canal procedure. The patient was asymptomatic before you even started. Why is this happening for me? Look, post-op pain after endodontics is an absolute bitch. It’s one of those annoying things ever actually puts me off doing root canal treatment because of the one in harmony of a chance that post op pain instance is going to happen. And I’m going to discuss with Sanj Bhanderi who does such a brilliant job in that GF016, where we talk about how to extirpate properly and efficiently. So if you haven’t listened to that one, oh my goodness, you are in for a treat. Go back and listen to that one. But in this episode, we’re focusing more on post op pain like how do you manage that kind of scenario? What do you say to the patient? How can you prevent this from even happening in the first place? You know, it’s funny I’ve actually had four root canals on my own self and before you think, ‘Oh, Jaz is disgusting, you got caries, etc.’ No, it’s actually trauma from orthodontics. Can you believe it? Orthodontics devitalize, my lower four incisors, and I’ve had all sorts of issues and root canals and fractures, etc, etc. And now have a resin bonded zirconia bridge, hence why I’m so passionate about those bridges. Anyway, I experienced post op pain myself, it was a nasty thing. It was lots of inflammation. And so I’ve been there and I totally empathize with my patients. Before we joined the main episode I want to say yesterday I released new tickets to Finlay Sutton’s mass class. So Finlay Sutton, he travels all around the world. He’s in USA last week. He goes Scandinavia a lot. He teaches us everywhere. If you think removable prosthetics you think Finlay Sutton. He’s just a phenomenal educator and the best in the space when it comes to removal pros. Now he came on for episode 56. How to make Chrome dentures easier. So check that one out if you haven’t already either. But he’s doing a live one day partial dentures maths class on Saturday, the 14th of January 2023. So if you’d like to join us go to protrusive.co.uk/finlay, that’s F-I-N-L-A-Y. It’s limited to just 12 delegates only. And it’s very rare chance to see him down south usually have to go to practice up north, or you have to go abroad. So this is very rarely comes south. And so if you’d like to join us, including the dinner, the night before, it’d be great to have you. So once again, the link is protrusive.co.uk/finlay. And there’s also a payment plan to split your payment into three if you need that. [Jaz]Anyway, let’s join the main episode. Main Episode: I recently created a gentleman I talked about this gentleman on the podcast necrotic canine very strange, severe bruxists, I think I suspect some airway issues we’re investigating at the moment, like to the extent that 50% of his canine is just shot. That canine was dark in color. My dentist who I inherited his list has been putting his, he’s had a couple of bouts of antibiotics in the past for this tooth, and he just felt he’s too young. He’s late 20s To have a root canal on a canine and he just couldn’t figure out why it went necrotic but it did. I tested everything. It was necrotic I went inside his canine. It was necrotic, it was infected. So I confirmed that, and then I did a root filling. And my goodness, and I’d followed all the right protocols hypochloride, gutta-percha, everything was done, took a high standard radiograph look good. There was no extrusion of the GP or anything. But my goodness was this chap in so much pain, and he ended up in a&e. They did some bloods on them. They didn’t find any sepsis, but they found high inflammatory markers in his blood is actually interesting enough. So that was my one really bad experience about four months ago. Otherwise, I don’t tend to get significant post op pain. But I’ve been with dentists at conferences and we’ve been at a conference on a course and the dentist nips at 11am because there was a root canal heated yesterday, the patient’s now in agony after finishing the root canal. What do we know in terms of Iiterature? You’re probably there lecturing and speaking your phone were vibrating. Mrs. Smith from yesterday? What is behind that? What causes that? Even in your expert hands, is it just bad luck? Or do you, do we know what causes it and then therefore, what steps can we take to minimize its occurrence? [Sanj]I think it’s quite multifactorial, some of it is, it is unpredictable. There are certain conditions that seem to predispose patients having what’s called a flare up of flare up by definition, the endodontic definition of flare up is this is in between treatment after treatment of treatments been performed, and the patient gets acute pain that requires treatments they have to attend to. That’s the definition of a flare up. There are a few things that I suppose we break down to patient factors, which are we told the anxiety levels we’re talking about. There are some certain genetic factors, some patients are more predisposed to pain, period. And definitely there’s a- [Jaz]yes, yes, absolutely. We know that from TMD, chronic back pain, the study of pain itself is we know that people are much more susceptible pain than others. Yeah, yeah. [Sanj]So on those physicals patients, and also talked about this symptomology, it’s patient management, if you pre-warm them, it doesn’t mean that there’s not gonna be out of pain, but they can handle it, it’s when they’re not expecting their pain. That’s when it the problem started in the, you know, just increases anxiety. And so it’s been a patient management and those patients who you’re going to kind of arm bells, these patients are a bit tricky. Or if you’ve seen patients before previous treatment, they’ve always taken the two second ages to settle down or even root. So that’s the first thing in terms of the actual tooth itself. It’s the inflammatory state of the two. So pre existing lesions, if there’s an apical lesion, radiographic lesion, those teeth are more susceptible for post operative or interrupted pain. Okay, so for me, the before the endodontic treatments, we always preload our patients with anti inflammatories, not just emergencies, but routine root canals, and especially retreatment. And especially if there’s a lesion already on the tooth. We know that they’re more predisposed to flare up. So, just preload them anyway, with anti inflammatories or painkillers. And then during the procedure, you’re going to do utmost to follow what we now call is everyone knows a crown down protocol, you do not want an necrotic case, the whole majority of that canal space is going to be infected. Often, it’s actually not the apical tissues are actually not infected. Just because there’s an apical lesion that apical lesion unless there’s an abscess, or separation, it’s not infected. It’s just the inflammatory process, we need to remember that. Because the last thing you want to do is put bugs into the apical area or even worse through and it can happen easily, I do. I’m sure one of the main reasons you get a flare up is because we’ve inadvertently push biofilms through, it happened some time. So we’re just gonna do our utmost to go down, Crown down. And so as you as you do that, part of the reason for that approach is you’re flushing out bacteria progressively without with minimal risk of pushing it ahead of the instruments. This is one reason going back to emergency treatment, you don’t fish around the root canals because if the canal happens to be necrotic, in that module, two of them are flying the other one and he shoved bacteria further down, you’re going to inoculate areas which weren’t actually infected. So that’s another reason not to fish around the root canal going back to the emergent situation. So this, in this situation, when it’s necrotic, that canine, you do your utmost just to work your way down. Now some endodontists, traditional endodontist, say you should be dressing all those cases, you don’t do those in one visit. That’s another area just decrease the bacterial load because calcium hydroxide. That’s the evidence suggests it’s probably doesn’t matter. He can do those in one visit. But there is the evidence for one visit. [Jaz]That reminds me actually that yeah, I think we’re coming to the same point. I believe there was a systematic review comparing one visit, two visit, and they found that they’re both equally successful, but you might get more flare ups and one was it is that where you’re gonna come to the [Sanj]Post-operative pain may flare up beat the patient, they will get more post operative pain that is [Jaz]post op pain. Yeah, that’s what I mean. So yeah. [Sanj]Flare ups a different situation. There’s also the patient factors in terms of their immune response. Everyone’s different, we’re dealing with immune responses, which are we can’t control apart from maybe anti inflammatories. And I think the body, when this happens, again, this happens in, they’ve got lesions, apical lesions, there’s an inflammatory process been going on for a long, long time, the patient has been asymptomatic. The body’s kind of, in simple terms, the way I explained to the patients, the body’s got to use to having an infection in the tooth, and it’s reacting slowly. Sometimes when we go in, it may not being that we’ve pushed every through, we’ve changed the balance, whether it’s pressure, whether it’s something else has changed. And we just disrupt that. And it’s a short term reaction they’re going to get I gotta warn them, when there’s a big you know, radiolucent area. You think these, these are cases they’re gonna kick off with doesn’t matter what how well you do the endo is going to kick off. I pre warn those patients. There’s a chance this is going to kick off. Okay? So it’s patient management, and if it does kick off, then you can deal with that. But it’s the fact that they know about it, they often won’t bother contacting you. They’ll say I just took anti inflammatories you see them on the second visit, visit to visit and thing was fine. It was settled down. So there are those situations you are- [Jaz]Now, Sanj you speak to your patients afterwards. You warn them big time, you document it, and you still have that you know you’re teaching at a conference and your your phone is buzzing. And you speak to Miss Smith from yesterday who had that feeling finally finished, and then she’s experiencing post op pain. Now, the temptation, oh my goodness, the temptation is so much for her to come in and then to do something and use that something is his amoxicillin 500 mg, or something like that. And that temptation is there and I don’t cave in. And that time he ended up in hospital and the hospital doctors gave him antibiotics. He got better, eventually. Okay, but do I honestly think it was due to antibiotics? I think he would have got better anyway due to inflammation is what because they found no microbials in his body. They found a high inflammatory marker in this particular instance, how should we manage it? Is it okay just to say ‘Look, don’t worry, you’ll be fine. Give it time’. Or is there ever a situation where antibiotics is justified? [Sanj]I think in antibiotic- [Jaz]and post op pain. [Jaz]Yeah, I mean, with the current guidelines and antibiotic microbial management, whether it’s nice or whether it’s endodontic European whatever. I think, if you start with a systemic involvement, now it’s again you got to be practical about this. If they’ve got, there’s an abscess like you say, fluctuation swelling can be cellulitis kind of symptoms. You know, this is not just localized. An apical periodontitis kicking off there’s definitely soft tissue involvement. Then I think, in the short term, even a short course of an antibiotic with anti inflammatories dosed up, I think that’s justified. If there’s no obvious signs of an abscess, cellulitis spreading infection, then you know, it is high dose and painkillers with or without codeine, if you know if it’s affecting the sleep, something like dihydrocodeine, DF 118, something like that, just to get them through that pain. And hopefully it’ll calm down. It is a tricky one, though, because it’s a nice, there’s a theory [Jaz]It’s so tricky. [Sanj]When you’re in practice, and you’ve got the patient there, but you shouldn’t really throw them antibiotics, you’ve got to have good justification for doing it. If there’s a fluctuation swelling, incise it, free the area, incise it. If you haven’t finished the endo open the tooth up. In terms of leaving open drainage 24 to 48 hours, you can leave on open drainage just to relieve that pressure, but you’ve got to go back and get them back in. Okay, go back and try and get some drains, so it’s back to surgical. [Jaz]Now in those scenarios, let’s say we we are in between visits. And let’s say we’ve done our crown down protocol where we’ve got the canals as clean as we can and we aim to obturate at the next visit. And it’s in between that initial cleaning of the canals and actually obturating the patient comes up with a flare up in between those two visits. So you’re not quite ready to obturate because you haven’t got that diary time to obturate. But the patient’s now sat there. If we were to go back into that tooth, let’s remove our a Cavit or Kalzinol and go back in, in this instance, would you recommend taking the file all the way to the apex? Or how would you manage that scenario? [Sanj]If you’ve got the working length, and yeah, just go back in and kind of semi re-prep getting just get the calcium hydroxide out. It may be the fact that you haven’t got the dressing material later length. One thing that actually worth mentioning between appointments always dress the tooth, never leave it dry and empty. Never. Always put something in it, a calcium hydroxide, the thing to do. The difficult thing is getting a calcium hydroxide in volume to length. You can be only squirt at the top end of the crown. So it’s going to have any effect apically, you don’t get the benefit of the properties. So open it up. The fact you open the system up you relieve pressure, because it’s usually apical pressure that’s causing the pain. Whether you get separation, it doesn’t really matter. I think you just opening up the pressure, some endodontists would say you go you got your work length, go a little bit patent, you’re not gonna do any harm. If anything, you might release or relieve any microbes that sits down there. And then wash out again hypochlorite redress and close up. And then your, your chemotherapeutics your anti inflammatories and things like that. Painkillers and things like that after that. [Jaz]Well, this was a tough question compared to an emergency one because it’s a scenario we hate, you know, as dentists and as an endodontist as well. We hate this scenario of finishing an endo and then they have that initial acute inflammatory reaction what we believe and they just, you know, just kind of wait it out and eventually it will get better. We know that. Okay. But it’s that, that patient at the end of the chair who’s suffering and we feel bad for it, I felt devastated sounds when that happened to to my patient, but I really do in my heart of hearts believe it wasn’t my fault. And I do think perhaps I shouldn’t have been so heavy handed, maybe. I was using rotary instruments for a canine and maybe some extrusion of the debris or dentin on debris could have happened. Exacerbating that inflammation. I put my hand up there that could, that could have been it. But in those scenarios, I think the lesson is, let’s not be too hard on ourselves. Let’s promote anti inflammatories. Let’s warn them that this could happen. And they can then self manage and not expected. But if it happens, they’re not like completely in shock. And then only if justified with swellings and cellulitis. Consider antibiotics and then I guess during the treatment, the Crown down approac. Now just for any students listening, last thing we’ll ask you is just describe, make it tangible, an example of a crown down approach for a molar inside a molar root canal, for example. [Sanj]Okay, I’m glad you asked this question because I think this is quite important from a technical point of view, but also from an antibacterial preventing a flare up. Because I think maybe majority of flare ups are due to back to stuff being pushed to the end, debris infected material. I think that’s the most common reason why. So the protocol is, you found the orifices this is when you got to time. Okay, so going back to the emergency dressing, the golden rule is just to recap the emergency dressing unless you’re going to you’ve got time to go down to full working length and confirm it. Don’t go into root canal space. Okay, that said, see your second appointment you can got the time. You booked into the root canal, you find the orifices and the only thing you’re going to do now is you’re going to confirm the orifice and we what we call the endodontist called scouting and here’s a 10 to 15 size file just to confirm that there is a patent canals there and what I mean patents, I mean patent coronal not to patency we’re talking about the end. Once you canal is there, then you go on to most people using rotary systems or reciprocating. I’ve got slight reservation about reciprocating systems, they’re not as efficient as removing debris. So if you prefer a reciprocating system, way one reciproc, or whichever one, just be careful you wash out more frequently, you clean the files more frequently, because they get clogged up because of the nature of the mechanism the way they think through its work. With rotary, you’re going to use the system in its sequence. Okay. My role is, and this is this, this goes against a lot of what the manufacturers suggest, once you’ve found the orifice, they often say ‘Get down, get a working length’. And then you go through the system. That goes against the principles of of disinfection, because you you could shove coronal bacteria, majority in necrotic teeth, majority of bacteria is at the top end. It’s not actually the apex, which I mentioned. So the last thing want to do is shove biofilm further down. So you’ve got to get rid of that. So the coronal preparation, the mid third is really important before you worry about working length, I do the majority of the preparation up to the estimated working length and knock off a quarter of that, I’ll do that blindly. Without an apex locator reading. How do I know that estimated length? I’ve got a decent pre op radiograph, and knock out a quarter, I’m safe. I know I’m gonna be well short. And I’ll go through the whole preparation sequence to that point. So that all I then got to do once I’ve prepared the canal to three quarters is confirmed the working length, I know everything’s clear, because apically, there’s gonna be no virtually no bad biofilm bacteria. And there’s less chance of me pushing any rubbish through. And also, because I’ve opened the system up, your working length determination is more predictable, it doesn’t change, because working length changes from the start of the preparation to the end, it gets shorter. So another reason if you do your working length at the beginning, by the time you’ve finished, you fled that, you prep, you’re probably going through the apex. If you keep that working length, as do the geometry in the curve canal. So I do the coronal three quarters prep without working, without worrying about the working length. And then I’ll confirm the work and then all it’s doing is finishing off. And you know you’ve disinfect every point with less risk of pushing debris through. So I think that’s really important, which goes slightly against a lot of manufacturers and some endodontic teachers teach. And I’ve stuck by that. [Jaz]Biologically, it makes so much sense to me, I think because otherwise in practice, it’s like a race to the apex which it shouldn’t be. It should be clearing just like you said the coronal portions first to allow you to get better access to the apex. So it’s very much. I listen to your lectures Sanj. Listen. I listen to your lectures. Sanj, listen, thank you so much for for giving up this afternoon to speak to me. We’ve made two episodes out of this space you so called group functions where we are answer one key pressing theme. So we talked about extra patients. So if you haven’t listened to that one, go back and listen to that one. It was it was brilliant. And now he’s covered his post op pain and flare up at the end you covered really beautifully. Just a good description of a crown down approach for young dentists and students to really connect and even just the oldies, I know what I should probably go back to doing that rather than going straight to the apex. So Sanj, please tell us about, I know you teach at the moment with institutions, but what kind of private courses do you do? Where do you do them? Is it all in Manchester? Tell us more. [Sanj]Yeah, so at the moment, I do, we do a good friend of mine, Ammar Al-Hourani was my post grad student. He’s now established in London. So we both run courses two and four day courses in London and Manchester, for convenience because I’m in Manchester and he comes out and I go down to London. it’s quite good, quite good fun. So we do four day courses and we’re going to be doing a longer program next year. We’ve got plans for doing a longer, summer like a diploma course next year. So we’re looking forward to that. And also do a, it’s a microsurgical course. We did our second one a few weeks ago and it’s the only, it’s a human cadaver course. It’s the only endodontic course that I’m aware of in Europe and that’s been going really well in Coventry so West Midlands we’ve got another one coming up in March I think is gonna be fully booked so that’s quite good and microsurgery is another little area of mine pet subject of mine so and a lot of people live with with interest in endo or specialists don’t come across good surgical training. So that’s something I think it’s really needs to be shared and then- [Jaz]Any website you can recommend for us to check out these courses? [Sanj]Now, most of the things, when once we’ve got days we wish you on social media and the usual dental forums and instant things like that. I’m very old fashioned like that. I’m getting into that or that sort of thing. But so yeah, that we put posts out we haven’t got a website as such yet so that’s that’s an ongoing thing. So should we getting any website for the practice all the courses will be there but essentially keep a lookout on social media. [Jaz]When you do give it to me, so I’ll put it on the on the YouTube and on the podcast in the summary. Because people want to know, you know people people enjoy the content let you know identify with this educator. I like the way he thinks. I like the way he or she speaks. And so therefore, I wanna be able to connect people who want knowledge to person who can help them upskill so please do send me those links when you can. And it’s no surprise that you work with Ammar Al-Hourani . He came on as a guest actually in the podcast some time ago. And we talked about, ‘Is single point arbitration adequate?’ Is it okay for dentists to do? And you know, he gave such a lovely just like you did a very real world, very diplomatic, very sympathetic to the plight of the GDP. So hats off to both of you. I love clinicians like this who don’t have that ivory towers there has to be this way. I hate dogmatic approaches. And so Sanj and Ammar if you’re listening to this, thank you so much, guys. It’s obviously great to have you as the endo buds on this podcast. Thank you so much, Sanj. [Sanj]Thank you as well. Jaz’s Outro:There we have it guys. The joys of post op pain now covered by Dr. Sanj Bhandari. Sanj, thanks so much for creating these two amazing episodes. And thank you protruserati for listening all the way to the end. Now you come this far, why not answer a few questions to claim CPD for listening to this. I think of all the different memberships that you have or the online memberships. And think when was the last time you logged in? When was the last time you used it? Well, you just listened to a podcast episode and you’ve learned something, hopefully. So once you actually test your knowledge, get the CPD certificate, and actually get some reflections as well. So if you’re on the app, you can do that. Now as a premium member, you get CPD certificates, a whole lot of exclusive content. So if you haven’t already, do check it out. Otherwise, I’ll catch you same time, same place. Bye for now.