Protrusive Dental Podcast

Have you ever been planning a smile (this could be a complete denture or some veneers!) and thought ‘where do I begin’? Planning aesthetic dentistry involves more than just the teeth. A great smile is ‘facially driven’ – where do the teeth sit in relation to the face?Today we are joined by Dr. Josh Rowley to share the four rules of planning Aesthetic Dentistry (you will love them). https://youtu.be/2jbfK2WU1e4 The Protrusive Dental Pearl: Don’t start complex/comprehensive treatment on someone who is not sure or not motivated. Need to Read it? Check out the Full Episode Transcript below! Highlights in this episode: 2:58 The Protrusive Dental Pearl – Communication Tip 14:49 Screening for the first point of contact for Orthodontic patients 16:36 Four rules of planning Aesthetic Dentistry 35:10 SureSmile Aligners 39:35 Low trim height 41:24 High trim height 44:03 Support system for Sure Smile Check out the courses that Dr. Josh teaches through IAS Academy and SureSmile Aligners 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:The first rule of planning Aesthetic Dentistry is so key that everything about the smile just falls into place from this very first rule. I’ve got Dr. Josh Rowley today to share the four rules of planning Aesthetic Dentistry. Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. It’s been a crazy few weeks for Team protrusive. Just few weeks ago, we hosted Lincoln Harris live in London for his famous destress dental lecture. And let me tell you, this was a MASTERCLASS in theatrics, comedy, dental comedy, and public speaking. It was just a PHENOMENAL lecture. And I’ve actually got his slides on my desktop, and for eight hours that we spoke for seven hours, right. And he only had like 38 slides. This is a sign of a phenomenal speaker. He barely looked at slides, yes, so much conviction in his message. And the lessons he shared was so real, well, a lot of big, bigger picture communication type stuff to reduce our stress in dentistry and a few slides here and there and then delving deeper into it. It was just, such an engaging lecture. There’s very few people I think, can hold and captivate an audience for six hours during the day and you learn so much at the same time. It’s just absolutely brilliant. So, hats off to you Linc for that. And I met so many of you for the first time it was great to connect with the Protruserati. Safina came all the way from Northern Ireland. She’s a dental student, it was great that you made that trip. She’s part of our telegram group. So Safina, a personal thank you for, for coming out that way on a day where there were so many train strikes from around the UK. So, thank you so much. And a shout out I mean, I can’t shout out all of you. There’s like so many I met for the first time. It was to privilege but a shout out Sagar Patel. Sagar is someone who told me a story. When he met me, he said that the influence that protrusive had on him was so big. And the protrusive dental community Facebook group helped him to connect with his now principal. And he’s in a good place and happy environment. And that just made me feel so warm and fuzzy and happy. And in fact, we’ve been connecting and exchanging messages on Facebook. And then we had this photo that we took together, and he said, ‘May I owe my whole inspiration of dentistry back to you, became very demotivated during COVID and DST, but your passion kept me going to where I am now.’ So, this was just an amazing thing to hear from a Protruserati like him. And these messages really keep me going. And so many of you came with love and kindness. So, thank you to all the people who came to my event. And it was just lovely to see you. Main Episode: Now let’s join the four rules of planning Aesthetic Dentistry with Dr. Josh Rowley. Josh Rowley, welcome to the purchase of dental podcast, my friend, how are you? [Josh]Very well. Thank you, Jaz. Thanks for having me on. [Jaz] It’s an absolute privilege and a pleasure to have you on Josh. I’ve seen you grow and grow as a clinician, the stuff you’re doing an ortho restorative is amazing. I don’t know if you remember a few years ago, I asked him some help with the case and you helped me nail it. Do you remember that? Yeah. [Josh]Yeah. Try my best. [Jaz]Josh, when I asked you for help on that case, on Facebook all those years ago. So thank you again, I feel like you’ve switched aligner companies, you’re batting for the other team now. So what, what led you to change a liner sort of modality from one company to another company? Because I see you doing a lot of work with Suresmile now [Josh]Yeah, absolutely. Yeah, I teach and mentor anyone who needs help with any aligner brands are out there. But the main reason for me why I made the switch a few years ago now to suresmile was because of patient preference. You know, patients want a discrete nature treatment, one that maybe their friends, even relatives may not even know that they’re even doing and yeah, it really comes down to the material that they’re made from actually. And I had a friend actually who I’m doing his treatment for who just finished his braces treatment. And there’s a couple of little tweaks to do. And we’ve now just made him a couple of suresmile aligners just to finish his case, as opposed to the fine tuning. And he was like, ‘Wow, why didn’t, why didn’t I start with these aligners in the first place?’ And he’s and he’s a dentist, as well, as a dentist and a colleague of mine, and he’s honestly converted, and I’m gradually getting one by one people turning over thinking, ‘Why are people not using these?’ But yeah, the clarity is one, the ability to be able to give the patients what they’ve asked for, which is a discrete nature treatment. Something that fits in with their lifestyle, something that they can eat and chew what they want, you know, it maintains its clarity throughout the treatment as well. You know, one of the things which was a bit of a bugbear for me was after some aligners have been worn for a few days or a week or so. And they do tend to tarnish and then it makes it a bit difficult if you have to go back a couple of aligners to kind of pick teeth up and then go forward again. And so it’s again opened up a whole new arm of aligner treatment for me where I can ask the patients to go back in time, as well as go forward. So and because they’re happy to go back and wear them because they maintain their integrity. [Jaz] Well, I think we’re going to talk about I mean, I’d like to know a bit more about that system, because there’s something about trim heights and stuff, which seems really like voodoo science, but it seems really clever. But I want to, I want to say that towards the end. Let’s talk more about the four principles that make the four rules of aesthetic planning, which obviously with your background in ortho restorative, I think you’d be perfect for.Just to set the scene and context, the first time we met was a part of the dental Chivas trip to love and to see it to see the GC group we learnt about Junior composites. And from then I knew, ‘Okay, this guy’s really switched on guy he knows what he wants.’ And to see the dent you’ve made in the ortho restorative world has been absolutely amazing. So it’s great to have you on Josh. For those that don’t know you, Josh, please tell us a little bit about you, your journey, how you fell into orthodontics, and I actually want to know for myself, are you limited to orthodontics? I just feel like that’s that’d be a real shame if you’re not doing restorative dentistry as well. [Josh] How long have we got? [Jaz] You got 60 seconds for this intro. [Josh]60 seconds, well, my name is Dr. Josh Rowley, I’m a specialist orthodontist in Edinburgh in Scotland. I work in two dental practices, one which is purely focused at the orthodontics. I do a combination of NHS and private orthodontics. And the other practice is very much a general practice. I see patients for checkups, I do restorative work, limited restorative work. I tend to not do that many endodontic treatments or nothing with too much blood and guts, no surgery kind of thing. [Jaz]Typical orthodontist? [Josh]Yeah, absolutely. I mean doing a lot of teaching as well just pretty much since lockdown actually. Quite enjoying that. Just kind of sharing the past experiences, sharing the knowledge that I can. Train to help younger dentists and dentists that want to get into orthodontics later on in their career. Just to try not make the mistakes that I made as such trying to get them the quicker path. But ya know, I’m thoroughly enjoying what I do. Can I imagine myself doing anything else? [Jaz]Well, I would have thought when I saw you all those years ago that you were going to be fully down the restorative path. What made you pivot into specializing in orthodontics, right? [Josh] Yeah, absolutely. So I kind of went a little bit of a niche way into orthodontics, whereby I was working in a quite a high end practice in Edinburgh at the time, I had very good mentors around me. And as a general practitioner, I was doing a lot of aligner treatments. And I really enjoyed doing it. But I definitely found that there was that little black box of knowledge that I just didn’t know. And I thought about doing postgraduate courses privately funded, and then looked into maybe going back and doing specialty training. And it was because I then went into the hospital, and I just inquired about it. That actually, it was just a complete chance that at the time, the consultant in charge actually offered me a position the following year, in fact, starting in about two months. [Jaz] Wow. [Josh] And so yeah, it was really quite a curveball. And it wasn’t a specialist training, I have to say it was a privately funded doctorate, whereby I entered into the world of orthodontics, just wanting to know more. I didn’t have any interest really becoming a specialist. I just knew that if I want to know what’s inside this box, I’ve got to go in and do this gotta treat the patients, but of over the shoulder mentoring. And yeah, and it kind of went on from there, really. And like I said, it’s, I’ve got an engineering kind of brain. And orthodontic is all about the kind of the engineering and the planning and the cases, which I’m sure we’ll talk a lot about today. [Jaz] Well, you know, the education that you do, and I watch your stuff, so I know that you’re involved in planning smiles and you don’t work with DSD. And you do all that kind of stuff, which is great. So do you still do like composite bonding, veneers as an adjunct to your ortho or what? Give me a percentage breakdown. I would like to know what Josh Rowley is doing today. So in terms of your percentage of aligners, your percentage or fixed appliances for ortho. So tell me about that. And then also tell me ortho in general versus your restorative, I would just just I mean nosey, [Josh] That’s obviously fine. And so I would say in both practices, now, I’m 50/50 with braces and aligners. And the reason why that number might be higher than you might think, is because I do NHS orthodontics, and an NHS orthodontics is really the bread and butter of an orthodontist work. It’s the growing individuals, it’s where you can really you know, do your, see, the see, the biggest changes sometimes I suppose with functional appliances, even surgery as well. But yes, NHS leads into the private side, in the sense that you’ll get a lot of kids whose parents might ask, ‘Ah, you know, I see, you know, the results I’ve seen with my son or daughter, fantastic, you know, what do you think?. You could do with me, and they’re sitting in the chair, you know, just like the dental chair, and they just go like this, ‘You know, what can you do with this?’ You know? I’m sure you get the same. I know and only to the other. I’m doing more and more treatments with aligners now because I’m becoming more confident in what they can do. But I’m very aware of the limitations that aligners have as well. And so, as I’ll probably talk a little bit about later, aligners are really a tool for the job, just like braces are a tool. And really it’s about knowing that limitations and knowing what was best for the job, really. But in terms of ortho restorative, you’re absolutely right. I tend to focus my restorative work on the post orthodontic kind of treatments like incisal edge bonding, could even be veneers. I’m putting together a lecture for a course I’m doing next week where you know, I’m, you know, just like when you’re writing lectures, you’re traveling through your cases, and I’m thinking, ‘I better do a lot more porcelain that made me think, actually.’ It is just the tweaking at the end and reshaping the teeth and sizably to turn a good case into a great one really. [Jaz] So this episode what I want to extract for your mind onto Protruserati is, where do you even begin? So the rules of aesthetic planning and who better than you someone who is, you know, done all your training in ortho formal training ortho, but I know your heart is as a restorative dentist so I think someone like you is perfectly suited now. Before we cover the main thing., you know what I’m like when it comes to occlusion. I can’t I can’t possibly continue without asking you a very interesting curveball question. This is completely unscripted for everyone. I was at a lecture yesterday by Korey Feran and Moira Wong and they were talking about the orthodontic restorative interface in terms of the joint position. And what I mean by that is, the starting point for most rehabs in traditional sort of school thinking not neuromuscular but centric relation. But then it got Koray asked the audience. Okay, now orthodontist. Where do they start? Which joint position did they started? And everyone sort of said, ‘Well, they just kind of work around MIP usually, because that’s what you’re taught.’ Now for you as someone who is trained in restorative dentist, I would I’m just being nosy again, do you screen for the first point of contact in your young kids or your adults and then plan from that joint position for your orthodontics? [Josh] Yeah, absolutely. You know, at leaf gauges, one of the most useful tools in the armory of a dentist in my opinion. So you want to make sure that the patient is comfortable in reaching a CR position. And really, you know that leaf gauge should be a diagnostic tool. It’s a way of us deciding, is this joint healthy enough to be able to kind of like Humpty Dumpty versus patient off the wall to then put them back together again, with orthodontics? Or you know, is the joint maybe in a position that’s going to cause problems or cause potential pain when you’re doing this as well? So, for a lot of adult patients, certainly, if there are symptoms of TMD, whether that’d be muscular or intracapsular problems, so it was good to diagnose first. And they can be as simple as making a B splint or a little Lucia jig, just to get them to wear for the interim time before they get their braces on or aligners started and is a general rule of thumb for me. If that pain or problems had been having go away with that anterior or deprogrammer, then you’re good to go. Whereas if they sometimes make the problem worse, or they really can’t wear it, it might be an indication for further diagnostic records that could even be you would refer them to oral medicine clinic just to see for a second opinion as well. It has to see it’s not an area that I’m you know, a specialist in not like yourself, but certainly I know the boxes to tick to know when I’m being safe or not. [Jaz] Good man. Good man. It’s good to hear about orthodontist as yourself looking at the joint position in terms of their final orthodontic outcome. But anyway, that’s digressing into occlusion. Where do you start to, Okay? You got a patient in the chair, and they want a lovely smile and with your eyes, how do you begin planning aesthetic? So if you were to boil it down to four rules, as I kindly ask you to do, what are the first rule of making this, helping this patient to achieve a beautiful smile? [Josh] Well, we’re off. The four rules of planning Aesthetic Dentistry, and I’ve been the first really. It all starts with the face, because you got to know you know, where, what’s going to look good for the patient? Or where, what is the face asking of the teeth is what, is what we normally see. So first, it all starts with a facial photograph. And then we start what we would do as a smile design. And so the real starting position of a smile is really the incisal edge of the upper central incisors. So we’re taking our photograph, the first bit that you do when you’re doing a smile design as you oriented a photograph to the horizontal. So you’re making sure that patients face is perfectly in line. And then we- [Jaz]Do you use any tools for this? Like don’t like you know, sometimes people do like go a bit lopsided. So do you use like blinds behind you? Exactly. So, how do you gauge that as, as a young dentist, try and take photos, portrait photographs, how can you be sure to help you? [Josh] So usually natural head position, just asking the patient just to relax, shrug their shoulders, usually just before they take the photographs. Try and get the patient to look directly into the camera and just being aware and the patient might kind of just move their head left to right. So we’re getting a really nice parallel picture with the patient’s face. The software that I would use is just keynote, you can use Keynote, you can use PowerPoint, you can use paint, you know any, any software that allows you to draw lines on a page. It’s really not that simple. You could even print off a picture of the patient’s face for a smiling picture, for example, and literally draw with pen and paper. And really, you’re looking to draw that midline wires, the facial midline. And then we’re looking at two photographs that I take for every single patient walks in the door. And that is an M position photograph and an E position photograph. E position being the maximum smile that that patient can give you, you know, really exaggerating the lip movements. You want to see how high that lip moves up, or the tablet moves up, I should say. And position a bit more difficult actually. But there’s generally a relaxed position where there is no muscle activity and the upper lip. And what we’re really looking for with between these two photographs is where does the incisal edge sit. So the end position, you’re looking at maybe two to three millimeters of incisal display and maybe a slightly older patient, whereas that number will do and usually increase to maybe six or even seven millimeters for someone who’s very young. And so really, that’s our starting point. So the end position photograph- [Jaz] Just, so I can make it, yeah, I think we’re gonna come to it now exactly what the dentist should say to the patient to get them to make those smiles that we want. [Josh] Well to be honest, I just get the patient to lick their lips. So for the end position, I say, ‘Let your lips and just let your lips at rest.’ And a lot of the time for adult patients, you know, they might not show any insight or display arrest. And don’t worry if that’s the case, because that means you’ve probably got an additive case where you want to move the teeth down or maybe add length to teeth. So they then have display of incisal display at rest. And then with the E position, it is literally, just imagine I’ve told you the funniest joke and you’ve got this belly laugh. How high can you get your upper lip to go up when you’re smiling at your maximum? And that’s really what I say. And it’s important to get the diagnosis right because I do get you know, shy individuals that come in and they’re guarded, you know, you want to try and get this e&m position out of them. You got to try and make them laugh, anything you can because you can get your diagnosis wrong if you get these photographs wrong. And it’s important that you kind of are aware that is as much as the look and move. [Jaz] When I used to Josh, get my patients do the Emma and say Emma, but I found out that people for some reason found it funny to say Emma, and then and then I take it they start smiling. So I got I kind of got a little bit of a rest one but then I got a smile. And then and then my usual question is, ‘Did you have an Emma and your life?’ And then they really smile, okay? And they they stop getting really awkward if their partner is also in the room. So I stopped doing that one. I like your one licking lips. Exactly, exactly. [Josh] Yeah. And then from there, you know, you’ve got your vertical reference point, you’ve also got your horizontal reference point. And do you know where the facial midline is, and that is where you build your smile from that kind of mid dot all the way around in the back. And I suppose going back a little bit to the main title, which was the four rules of planning, you know, the next one for me is really getting the diagnosis right. You know, without the diagnosis being correct, you’re off to a bad start. And, you know, you might not be able to deliver the best for that patient. And so really just understanding where the patient has come from, when I teach certainly, you know, younger dentists, you know, what questions they should be asking of the patient. I always start with the five W’s and an H. So it’s kind of like the what, where, when, why, and how or who sometimes as well. And it’s really asking, you know, where’s the patient come from? Why’s that wear seen here? Asking yourself all these questions like if you’re in like a job interview, or something like that, you know. And it’s kind of really just getting a detailed background of why the patient is presenting in this way, but it’s only once you understand why their teeth and dentition or malocclusion is like this you can then start to treat it. So really important that we get the diagnosis right. And that just covers all dentistry, not necessarily just aesthetic dentistry, because Aesthetic Dentistry really is an umbrella term for all the specialties. Really. [Jaz] I guess the best example of that Josh, I’m sure you agree, is when deciding whether to lengthen the teeth downwards or push the gum go upwards or a crown lengthening. And that’s as a young dentist, I struggle in this case, but it’s all it comes down to diagnosis. And then again, your photos, just like the ones you described become so powerful, and helping you decide should you lengthen or actually this is one for the periodontist or yourself with some experience to actually make the gums go higher up a gum lift. [Josh] That’s it. Yeah, you can. I mean, what a smile design is, is basically a blueprint. It’s like if you’re building a house, you don’t just start laying bricks, and that’s where dentists go wrong sometimes. You got to know where you’re going. And so therefore, what do you do? Well, you bring in an architect, you work out what shape, what room size, where’s the Garrett’s going, and then you know, after that, then you ask the engineer, you know, is this actually going to work? And what I mean by the engineer and dentistry is you do trial smiles you, you might simulate the orthodontic tooth movement with orthodontic simulations. And only once you’ve actually got that you’ve got your blueprint, you’ve asked the engineer, they’re pretty happy with it, then you start building the bricks. And I always say that smile design should really be part of every special diagnosis, just like taking your X rays or taking photographs. You know, it should form part of your special investigation. Sorry, is what I meant to say. And then I suppose going on to the third kind of- [Jaz]Before we get to the third one, Josh, so you know, you made me think of this question now is, you know, you’re someone who I respect as a restorative dentist and then you went this formal orthodontic training, which is awesome. But when you did that orthodontic training, compared to perhaps some of the other trainees or orthodontics you’re probably a bit more experienced in the restorative side? Did you find that the orthodontic program covered these aspects of smile design in a same or different or better or worse way than what the restorative dentists teach restorative dentists? [Josh] That’s a very good question. Actually, it’s not one I’ve actually thought of before, but I have to say that a lot of the postgraduate orthodontic programs out there, as opposed they’re maybe more traditional in the way that they would approach the planning of cases where it’s very much study models on a bench, if I’m perfectly honest. And it’s not difficult, it might be difficult for some, but for some cases, it can be quite difficult to get the smile to the good within the face, you can get the models lovely in class one that’s not a problem, you’re taking teeth, moving teeth around, it’s just a big boy’s mechano. Really, you know, it’s just, it’s just pulling teeth here, there and everywhere. But it’s actually getting it to look good within the face. And that can depend on the canting, the sagittal cant take if there’s a transverse count how much inside of display they have, you know, things like that you’re looking at all the planes of space to fit those models in that nice class when occlusion ideally. [Jaz] So it’s safe to say that while whilst people were doing their study models planning, you were keeping that further to pass the exams, but you were looking at the photos more than- [Josh] Always having that facial picture there. And always really just having references, you don’t always have to do a full smile design. But as long as you know, your references, your starting points, you can work from there. But I like to work in a way that I’m trying, I’m gathering all the diagnostic information I can, and then kind of using that when I’m formulating a plan. And I suppose that then it’s very well I was gonna say into the thirds rule, which is- [Jaz] But I just want to summarize, so far. So just want to summarize rule one was begin with the upper incisal edges and plan from there. [Josh] Yeah. [Jaz]And then rule two was nail your diagnosis. [Josh] Absolutely. [Jaz] The all the W’s and H is to figure out the story and then to help you forward so that’s where we’re up to so far. So here’s what the rule three my friend. [Josh] So rule three, really and it’s one that I kind of follow every single day and it’s going to talk to me about dentists called Dr. Miguel Stanley. So you’ve heard before we’re in a mass- [Jaz] Dentist. [Josh] I think so yeah, you’re right. And he really kind of hit home to me it was about giving ideal a chance. And what that means is that every patient that comes in the front door, you know, they have come to you for a diagnosis. They’ve come to you, for a way presented to them, what is the best thing for them? They might come in saying, ‘Josh, my operate central incisors rotated, that’s all I want to treat.’ But I don’t ignore that. Don’t get me wrong, but I kind of put that to one side. Because I would still take the same records, photographs, scans, X rays, maybe even a cone beam CT if I needed it. And I would treat that patient, you know, as if they’ve asked me, ‘Josh, what can I do here?’ Time and money were no object, what would you love to do? Because just because they’ve come in asking for an upper central incisor rotated, doesn’t excuse the fact that might have quite bad wear in their teeth, their canines have worn down their gums are in the best condition, you know, we’ve got a duty of care for the patients and in the way I do treatment very much is that we give ideal a chance and we work back from there. So it might involve a lot of work, it might involve doing orthodontics may involve some porcelain work or composite work, it might involve very heavy work with the periodontal specialists if there’s any problems. And it might even involve orthognathic surgery because they have an underlying skeletal problem. But it’s important that the patient is aware of all that could be and then working back from there. You know, it’s there’s absolutely no harm in doing compromising for your treatment, as long as the patient is aware that, you know, that is the gold standard of what we could have in ideal world. And we can work back from there. So for me, rule three is giving ideal a chance. [Jaz] I love that rule, Josh, I mean, rule one is so fundamental. And when I started to actually look at smiles. Rule two is great in terms of making sure we get the bigger picture. But rule three in terms of a real communication skill to have with your patients. Because put it this way, if you never present the ideal, you never get to do the ideal if you never present comprehensive guess what you’d never get to do comprehensive. So that’s such a key one. And then recently, I was at a lecture by Lincoln Harris, who came over to London and did an amazing like performance. It was an actual performance. He was one of the best performances of his because I’ve seen him live before but he was just on fire. And it reminded me of a great thing he taught that day is that he’ll says to patients, and I’m definitely going to use this my patients is I’m going to present you the ideal plan. If it’s too expensive, and you can he says you can use what expensive, it’s okay, don’t be shy. If it’s too expensive. Let me know, we can make some compromises and find a solution that best suits you overall, but I’m gonna still plan ideally, because everyone deserves ideal. So I’m gonna plan ideally, but if it’s too expensive, let me know I have other options. And that gives you the license. [Josh] Yeah, it really does. And I suppose compromises can be in materials, it can be in accepting certain things of a malocclusion, for instance, and overjet- [Jaz] Like a slightly increased, I was just gonna say overjet. Yeah. [Josh] Or a crossbite, that you might not want to train a treat. And there might be limitations. And it might be that surgery is the only option. I’m sure we’ve seen. I think I saw on your stories recently that I think it was your it was your oldest son had his adenoids taken out recently, is that right? [Jaz] Right. [Josh] Yeah, we get patients that unfortunately, don’t get that done. And then they have, you know, skeletal problems that manifests throughout their adult life, and narrowing of the upper jaw, for example. And they want, they come in asking for a wider smile. And it’s something that’s orthodontics alone, it’s something that we can give them because we’d be moving those teeth out the bone. And so really their options are, you know, accepting that fact that orthodontically that’s whether you’d have to be or restoratively it can be a bit wider, you know, it can have veneers composite to widen the teeth artificially as such, or they’re moving the bones, you know, they’re moving the surgical expansion, I wouldn’t, I wouldn’t dream anyone or wish anyone to have it. But certainly it is an option. And these are the things that it’s important that anyone who’s providing orthodontics really, in my opinion knows about, you know, always plan towards the ideal. And you can always compromise from there. As long as the patient is aware of what these compromises mean long term. [Jaz] And medically, legally, that it just makes sense to write your note in that way as well so that they know exactly what the ideal was. And sometimes, you know, as I say, treat children idealistically treat adults, realistically, that’s a mantra drilled into me, but it doesn’t mean that we can’t present the ideal plan to adults. [Josh] Absolutely. Yeah. The good thing is, you know, in a lot of the patients I treat are kind of younger teenagers. And I guess they come with a bit less baggage in the sense that they normally have really nice shapes of teeth on worn, you know, good oral hygiene, ideally. And really, it’s a case of really just moving the teeth, you know, to where their face is asking. But I’d also as you know, they come with some more problems, gum problems, wear, missing teeth, things like that. So there’s a lot more to plan. And I have to say that I have no problems with saying to my patients, I don’t know. Because in reality, you know, you were thrown with so much information, first consultation situation that you can certainly let the patients know, you know what a rough idea could be. I think your teeth are at a position maybe we can think about some orthodontics here. I think the shape of your teeth could be adjusted, maybe even the color adjusted here. So you’ve got a couple of ideas. You’re planting the seed, but I’m not always telling the patient at day one that we need to do this, this and this. You know, I say, I don’t know yet. The honest answer is I’m gonna invite you back when I’m going to gather some more information. And I’m going to get you back in. And we’re going to present a couple of options for you, you know, and if one of those options fits your your budget and fits what you’re wanting, then great, we can go ahead. And I suppose the fourth kind of rule, bring me right into that really nicely, there is simulations. Because during a second consultation appointment, simulating the treatment plan for the patient and really allowing them to visualize it before they begin, it is crucial, in my opinion. And that can be as simple as doing an orthodontic setup, such as an aligner setup to show the patient the beginning and end result of what orthodontist. [Jaz] Different aligner companies have got different software’s and stuff. So that’s what you mean by the simulation? Right? [Josh] Absolutely. Yes, so the suresmile aligners, which is the company that I have been working with for a very long time, and I really, you know, enjoying using the software and really enjoying using the aligners, as I’m sure we’ll talk about it later on as well. I can even share my screen and show you, you know what the software looks like. So we’ve got an example here. [Jaz] And just described for those listening in the car driving on the train, chopping onions, etc. Just also describe what we’re seeing here as well. [Josh] So what we’re seeing here is an orthodontic simulation, it’s showing us the plan, from the start to the finish of where the teeth need to move to. Start and then the finish. And what we’re also getting here is the staging here. So the stage models of going from day one, or aligner one, all the way up to, in this case, aligner number 28. It’s showing us where the attachments need to go to provide that extra grip to the teeth that need it, as well as any space creation by the form of any IPR or interproximal reduction that’s between the teeth that allows us to get the room to align the teeth, and showing us when that’s being performed, and at what stage is being performed. And so this is something which I use a lot to just demonstrate to patients just how their treatment will play out from start to finish. And so they get that kind of a crystal ball moment of what their treatment will look like, once they’re done [Jaz] That when this is brilliant, but the Josh, there’s a another aligner company that I use at the moment. And they are very well known. And they have their own version of software. And I want to I want to know from you, someone who’s used both systems, is there anything different or interesting about the short smile software, because I heard yesterday at the Congress, that something about the envelope of function outlines is that they will show you the cross section of the envelope function? [Josh] It does indeed. So this software is really the most powerful software I’ve ever seen. It’s got so much in it. And the one of the biggest things for me are the quality control tools. So these are the tools that allow you to see the contact points tooth, the marginal ridges, tooth access and things as well. [Jaz] Wow. [Josh] As well as being able to actually kind of see and measure, you know, between the teeth, let me get the kind of measuring tool here, you can kind of clip the frame as well. So you can see the envelope of function right there, you can then move between the to see where the contact points are. It is really quite, sometimes daunting, I’m not gonna lie, the amount of buttons, but to be honest with you, you know, it’s you can use it for as much or as little as you want, really. [Jaz] You get out what you want what you put in. So if you want to see all that extra detail, you can reveal it if you want to. But if you want to do the usual stuff, you can do that as well I can see that. I mean, [Josh] The software really came from traditional orthodontic planning with brackets and wires. And it’s really kind of developed from there. And so there’s so much diagnostic information that can be you know, at your fingertips here, as well as really looking really closely into your cases to look at where they come from and where you want to get to. And that’s, you know, that’s just the software that’s not even talking about the actual aligners themselves. So yeah, you can see I’m passionate about it, because I honestly don’t know why more people aren’t using it. Because it’s like, wow. [Jaz]Okay well, let’s talk about that Josh. Rule one was incisal edge. Rule two was ask the questions to get the diagnosis, or the W’s and H. Rule three, which I love was give ideal a chance. And rule four was the rule of aesthetic planning is use simulation, which just makes so much sense to your patient. And also to you as you’re planning the case, oh, my God, you just overlaid the face over it. This is awesome. So, so this is cool. So that makes complete sense. And I’ll let you just tell me any other things you want to tell me about Rule Four. Before we then talk about suresmile and Why perhaps we’re using suresmile, not some of the other competitor aligners out there. [Josh] Yeah, I mean, for me, really, as I told you in Rule one, you know, it starts with the face, it starts with the smell design. And really with the software, you can overlay the exact teeth, both the starting model and the end model into the patient’s face. So you can see kind of what it’s going to look like in the end like a try before you buy, you wouldn’t buy a car or that taken it for a test drive first, and that’s exactly the same. So this is really the simplest version of the simulation where you can just show the patient what it would look like, you know, it’s a little bit of a cartoon here because obviously the teeth are your scans that you’ve taken in the mouth, but it really does give the patient a really nice idea of what- [Jaz] I’m sorry to stop you there, Josh. You said scans are, I have to ask you this right? So with certain aligner companies, you have to get a certain scanner to send. So would I need to densify? So I would have, I would have to have a prime scan to send to get suresmile aligners? [Josh] No, you don’t actually the suresmile aligner system is very much an open access platform, accepts scans from any brand of scanner that’s out there. [Jaz] Okay. [Josh] That’s part of the reason why I really like working with densify is that they have always been and always will be an open access software where you’re not limited by a brand as well as that you can also export things. So without jumping too far ahead here, you know, it really does give you know, the freedom and the versatility to ask for all of your aligners to be made. And that’s by suresmile itself, which comes in a very nice kind of branded packaging, just like you would with other aligner brands as well, the patients will recognize. But it does also allow you to export. So if you have a local dental lab or you have a lab in house, you can ask for them to print the models for you. For you to make your aligners or even if you want to do everything, you know, yourself, you could export each STL file, or each scan file of every stage or every aligner in that treatment. And you can make them yourself. So it’s a bit like strangers in the past about going into a restaurant, you know, you can go in and you can order from the set menu, which is like what you would do with other aligner brands where you’re limited to maybe 12, or for your 24 liners, you know, or you can have as many layers as you want, you can eat as much as you want in the buffet. Or, you know, you can choose from the ala carte menu, you can decide you don’t want to start today, but you will want to remain in the desert, and that’s fine. So you can export the STL files and make dierct yourself. Or if you really want to go to town, you can even go walk into the kitchen, and you can make your own food, you know, you can actually go in there, you’re not relying on a technician if you really want to. And I would say I’m stressed that I keep this myself for more milder cases where I can take control and be my own technician, where I can actually move the teeth myself, plan the movements, which the software allows and then actually explore or ask suresmile to make my aligners for me. So there is a- [Jaz]What would be the benefit to you, Josh, why would you do that step of making it in house? Is it ultimately a financial benefit of you cooking in house compared to eating out? [Josh] It is really the financial benefit, but also for the patient. Yeah, I mean, at the end of the day, I’m not having to pay for the chef. So yeah. [Jaz] Yeah. But that’s really good that dentists buy insurance might allow you to that I’m kind of surprised in a way and shocked and it’s pretty impressive that they’re pretty open with that. That’s pretty to be admired. [Josh] I guess you can use it for as much or as little as you wish, just like the quality control tools and the diagnostic tools in the sense that if you do have a more mild case, perhaps just a relapse, that patient has lost the retainer for a few weeks, and they said, ‘Oh, my tooth has moved a little bit.’ You know, you could literally take a scan of the mouth, upload it, move that tooth back, it will tell you just how many stages you might need. And then you know you make those aligners and it saves the cost for you since the cost for the patient, everyone wins. [Jaz] Is that something that you get taught by suresmile? Because I guess there are lots of courses teaching you how to do your aligners orthodontic base. So just suresmile actually teach you the methods involved. Or hey, if you want to come to the kitchen cook itself? Well, you know, here’s utensils like how’s it work? [Josh] The main focus for suresmile you know, as a mentor, and as a teacher myself, really, it is using the software and it is about kind of using the technicians communicating with technicians for more complex cases or cases that you want the help, basically. But it did allows you to open the doors to do that yourself. And that is something that over the years I have, I have learned myself, you know, I haven’t had much guidance other than some of my peers. But and in a sense, there is an element of trial and error here as well. You know, you are moving the tooth, mild movements, I would say I wouldn’t tackle anything above say, eight or 10 aligners and myself, but certainly the- [Jaz]But with that with their full package. You can do elastic tabs like the full whack? [Josh] Absolutely, yeah, there is no limitation. Again, you can add elastics if you need to. In fact, I’ve just listened to your one of the podcasts from Straightpril actually about elastics. And I was a bit kind of like, oh, wow, don’t use that. I don’t have to say I’m glad I listened to that lecture because it kind of are their podcasts because it really did kind of confirm that I’m doing things okay. You know, I’m not doing it for the sake of I’m doing because I’m moving individual teeth and yeah, you know, if you want, it allows you to be creative. You can add bite ramps, if you want to yourself, you can actually ask for a variable trim height. And this is one of the most underrated things and aligners at the moment is asking for a variable trim height. [Jaz] So first explain what that actually? What you were just about to do. I’m sorry, but also like why were no when you would ask for a lower trim height? Because I seem to have talked about this. And I’m like, firstly, okay, it’s pretty cool how you can customize something but at the moment with my lack of knowledge, I wouldn’t know when to prescribe which one and what benefits would you get? So tell us teach us enlighten us. [Josh] So yeah, as you said, I actually again, just listen to a podcast that Tif did I think it was the teeth and tails podcast. There’s just going on recently, actually, and he described this perfectly actually. So I’m probably going to repeat a little bit what he said if I’m honest and that is the with scalloped trim line like you might be more accustomed to using some other brands of aligners that has a degree of flexibility, okay for correcting rotated teeth for example where you want the plastic to be able to bend and almost stretch into an embrasure or into an area where that’s the plastic is quite difficult to reach. Because with aligners, you’re gonna think like the plastic how does that tooth or aligner grip that tooth, you know. I think I also liked the analogy on one of the podcasts I listened to recently where it’s like a slippery watermelon seed. I love that. For lateral incisors like slippery watermelon seeds. [Jaz] That’s it. [Josh] And, and yeah, you know, more flexible aligner trim height, like the skeleton might for rotations. But also being aware that the higher up or the more rigid the tree is. So if you’re asking for a straight trim line more associated with something like a retainer, for example, that becomes a lot more rigid. And so if the patient is needing a lot of attachments, because of control, you want to keep more control over certain tooth movements. Then again, you might choose a scalloped trim line, because you want that flexibility, so the patient can comfortably get in and out. And I haven’t cut out in the past where I thought yeah, all the attachments really high trim line, and the patient goes. And you’re like, oh, wow, that incoming out easy. So yeah, is there a degree that you know, is a bit of a learning curve as well, when you start with this other option, essentially, Maybe haven’t been had the chance to use before. [Jaz]So if you go for a higher trendline, ie, straights or not scallop straight, that means that you need to use less attachments that I get that right? [Josh] Yeah, you’re spot on, so with a more rigid, because this, the aligner is trimmed a bit higher, you can apply I suppose slightly heavier forces to the teeth just ever so slightly, and it does mean you get more control, you know. So it will mean less attachments, which is amazing, because patients generally request aligner treatment for the discrete nature of the treatment. And so when you can offer the patient a higher trim line, which keeps the plastic above the smile line, so they don’t actually see any of the plastic at all, or the edge of the plastic, I should say, which is something very visible, and you’re having less attachments, because attachments are they reflect the light at different angles, and they can be very visible. And one of the things which was one of the main reasons why I moved away from other aligner brands and, you know, years and years ago, was because actually during that fitting appointment, where you hand the patient the mirror and say here is your first aligner you know, I used to dread that because the honest truth was it didn’t like it, you know that the aligners weren’t maybe as clear as they were hoping for. And also there was a lot of attachments which just drew away from that discrete nature. And so now it is a complete cheat reversal whereby, you know, I am looking forward to given the patient the mirror and say, ‘Look how clear these are.’ The actual aligner material themselves, and look how, you know, discrete this can be free. So, you know, there’s this is a topic I speak a lot on and it’s fantastic. I’m hoping I’m bringing forward my enthusiasm for it. [Jaz]Absolutely, no it shines through and I do want you to spend best part of 4000 pounds to learn how to give these aligners. [Josh] No, no, it’s maybe not my area to say. But certainly if you’re a keen to get involved with another aligner brand is such you know, I’d always say don’t say put all your eggs in one basket, you know, look around, see what other options are available. And suresmile being one of the major competitors in the aligner market at the moment. And if you wanted to start using sure smile is a case of reaching out to one of the representatives and going out on the website and expressing your interest. There isn’t so much a course that you would pay to go on as such that you’re almost paying to have access to the software because it is such a powerful software. And with that access, then comes the case for you to do for your first case for free. So really, there’s an investment to make to start using suresmile, but if you do your first case, it balances out. So that’s really the best way I can describe it. [Jaz] Brilliant, brilliant. So you obviously teach for suresmile. Are you also like a mentor like on the end of a phone? If someone needs advice in planning case? Oh, how does it I guess my next question is how does support lend itself to the system. [Josh] So at the moment, I’m sure smile and IS Academy, myself and Tiff and Ross Hobson and many other mentors that are out there, can’t name them all. And we actually have a kind of a handshake agreement I suppose with Dentsply and suresmile to provide a lot of the teaching and also the mentoring. So if there are cases that you would like to ask questions that would photographs or get any help with then there are many mentors all over the world to help with that. There is also the communication kind of customer support line as well for simple more software related things as well. So there will be an answer to your question somewhere. [Jaz] Is this on like the IAS or website where you got like the room and stuff? Oh, that’s brilliant. I mean, I haven’t used on the past. I can definitely vouch for that. You know, I have so much faith in IAS, Tif, Prav Prof. So some some great people there. So IAS is very trustworthy. So that’s a really good thing to have. So that’s amazing. [Josh] You know, and you can again use as much or a little of the support network that’s there as you wish, you know, even things like Whatsapp group chats, if you just want a quick answer to a question as well, you know, we’re trying to keep it in the 21st century and keep everyone kind of in contact with one another. [Jaz]Very cool. Well, Josh, you’ve answered my main thing about the four key rules in planning, aesthetic dentistry, and it’s great coming from you so passionate about ortho restorative, and I’m sure you’ll agree that the best orthodontics might be done with from someone who’s got a restorative eye as you do. And I truly believe that. So it’s great to learn these polls from you. And thanks for sharing some extra bits about why other aligner companies might do things differently and what benefits that may present. So, you know, shout out to suresmile for that. And so it’s great to learn about that. And I trust people like you, and Tif. Tif is a huge inspiration in my carrer and I know that yours as well. So, hat tip to Tif as well. Josh, tell us how we can follow you and find out more from you on social media and also any courses that you run that kind of stuff. [Josh] I wish I was better at social media, if I’m honest with you, I just it’s a matter of time. It really is. I am a busy man, what can I say you know, treating, treating patients doing what I enjoy doing the most, which is actually achieving the smiles that we do. But yeah, happy for anyone to contact me via social media, things like that, if you want to, I’m on Instagram and Facebook, I would strongly encourage, you know, anyone who’s listening today to if you have any questions just to reach out to me. And yeah, you know, see what’s out there. I would say to any young dentists or dentists really wanting to get into this kind of work, whether it’s with orthodontics or smile design, do your research, you know, see what courses might be out there. I don’t particularly run any courses myself, I do a lot of the teaching through suresmile and through IS Academy. So again, you know, seek these courses out if you want to learn more. There is so much with aligners, you know, it’s not something that can be taught in a day, you know, like when you go on our course, you know, in our hotel room for one day, yes, they can teach you how to do the fundamentals, which is your IPR, your polishing your teeth, you can teach how to put attachments on but there is that black box I was talking about before that really separates the you know how to do it. But how to really can understand it really is a passionate driving test. You don’t really know how to drive and your flash drive and test. [Jaz] Absolutely no, you’re always done afterwards, I said the same thing about BDS. And it’s great to have mentorship, which is a recurring theme of the podcast, hence why I was able to lean on your knowledge as a mentor, a few years back on a case. So thank you, again, Josh for helping me out that time and again, helping me out this time to help these dentists better plan their aesthetics. And just you know that rule one is just so key in knowing where to begin. And I really, really, really love that rule three, that communication one. So those my two of them my favorite of the four, but I think you gave great value there. So Josh, thank you so much for for spending time with us today. [Josh] Thanks so much Jaz. Thanks for everyone who was listening. And yeah, everyone enjoy the rest of your weekend. Jaz’s Outro:So there we have it, guys, as a summary rule number one that I said right at the beginning, is to start with the upper incisal edges. Once you plan where the upper incisal edge will go into face, and your or the proposed future position of that central incisor. Everything else falls into place. That rule two was to find out what the diagnosis is diagnose, diagnose, diagnose the why the what the how, where do you want the different teeth to be. So the example I gave was whether you should lengthen the teeth or in that specific patient, would you get a better result in the face by crown lengthening. Another example would be if someone’s with the proportions of their teeth that got very small, lateral incisors, that’s really important as part of the diagnosis. So diagnose in every way possible. So you can get a better treat and plan because the diagnosis always informs your treatment plan. Rule number three was my personal favorite, give ideal a chance give the ideal treatment plan a chance, communicate it with your patient. Yes, you can make compromises. It is not a sin, it is not dirty to compromise. But if you are compromising the patient should know there’s a compromise being made. It really helps with your consent, and number four simulations. So if you aren’t using aligner therapy, then you can use the software of your line and company. Yeah, sure. Smile look like very snazzy. So thanks to Josh for sharing the screen share. But those who are listening, were able to follow along in terms of what makes this software unique. And if you’ve watched or if you’ve listened on the Protrusive premium app, you can now answer the simple questions to claim your CPD for this episode, which is really quick and easy. within 72 hours, we send you a certificate with your reflective log inside as well. One of the example questions for this episode is ‘What are the two main photos used for deciding the central incisor position?’ Is it a the D and N smile? Is it B the E and M smile? Is it C? The E and M smile? Or is it D? The D and M smiles? So if you know the answer to that one and the other ones, why don’t you join protrusive premium? Answer a few questions and get rewarded for your CPD hour for listening to the entire way and also validate your learning and reflect on it. This will be really good at the end of the year to have all your reflections and the lessons you learned from protrusive in one place. So if you’ve got a few minutes, get on the app and just answer those questions and you’re well on your way to getting CPD. Anyway, I’ll catch you in the next episode. Same time, same place. Thank you for listening all the way to the end.

When you Extirpate a Hot Pulp – do you need to find ALL the canals? Do you need to file to the apex? Which is the sedative of choice? In this episode, we’ve got specialist Endodontist Dr Sanj Bhanderi to talk us through the CORRECT way to extirpate teeth in acute pain WITHOUT wasting time or making things worse for future treatment. It’s packed full of gems for pain relief, diagnosis and isolation. So, what is your protocol for extirpation? This episode is all about how to get the job done right and minimize discomfort for your patient. https://youtu.be/SjYWxr1sSDc Click Here to watch this episode on YouTube. For the full notes check out the Protrusive App on iOS and Android. “I call it Ninja endodontics – get in and GET OUT – Stealth!” Dr. Sanj Bhanderi Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 2:38 Dr. Sanj’s journey to Endodontics 6:30 Emergency extirpations 8:42 Diagnosis Protocol Irreversible Pulpitis 11:57 Anaesthetic for Hot Pulps 15:33 Caries and Restoration Removal Before Extirpating? 19:16 Vital pulp therapy 21:19 Isolation Protocol 25:30 Sedative Dressing for Acute Pain 28:42 Temporary restoration of choice 31:39 Post Op Medicaments Tune in for the Part 2 of this episode – next week we cover post-operative pain after endodontic treatment. If you enjoyed this, you might also like my episode with another talented Endodontist,  Ammar Al-Hourani, on Is Single Point Obturation Acceptable? Click below for full episode transcript: Opening Snippet: /Jaz/ In ideal world, we'd love to remove the entire restoration. Remove any caries, access cracks but when I have 20 minutes we need to get in go for the kill. Is that okay? Can you forgive us? /Sanj/ At the end of this. This is about patient, this is about getting the patient out of pain. Okay, and you just need to get in there. I used to call it ninja endo get in there, get the job done. Get out before patient realizing it. That's my principal in endo whether it's emergency or Endo. You want to- /Jaz/ Stealthy. /Sanj/ STEALTH. Stealth. Okay? Jaz’s Introduction:What is your current protocol for EXTIRPATION? So let’s say you made a diagnosis of irreversible pulpitis. Your patient is in raging pain. And you have to squeeze in this pain relieving treatment, a extirpation probably of a lower molar or something in five minutes. What are you going to do? Well, some of you will listen to this and it will be validation and revision. And you’ll be thinking wow, I’ve been doing it right all this time, even though I thought maybe I was taking shortcuts but actually I’ve been doing it right all this time and others will be like whoa, this is so much easier compared to what I’m doing at the moment because the big hint I can give you is that you don’t even need a K file for your molar extirpation anymore after today, because I’ve got Dr. Sanj Bhanderi, specialist endodontist to talk us through what is the right way, the proper way to do an extirpation of your patient who is in pain. And there are just so many gems from pain relief, diagnosis, isolation, and what I love about Sanj in this episode, is that he’s not dogmatic. Yes, he’s a specialist endodontist and so easy for him or anyone say you must always use rubberdam. But yes, he does discuss a scenario that okay, if for whatever reason, you had to do it without rubberdam, how can you optimize the isolation? How can you reduce the saliva getting inside the tooth, so I really appreciated that about this episode. I’m sure it hope you will as well. It’s very much in tune with the real world. And lastly, we do cover his step by step what is the right and proper way to do an extirpation without wasting time and without actually making things worse for future treatment. Main Episode:So hope you enjoy this episode. And I’ll catch you in the outro. Dr. Sanj Bhanderi. Welcome to the Protrusive Dental Podcast. How are you my friend? [Sanj]Very well. Thank you, Jaz. Thanks for the invitation. Excited. I’ve done one of these before. [Jaz]Well, I’m amazed it’s your first time and it’s your real hero of mine, Sanj because I remember 10 years ago, I met you at the British Endodontic Society. Can you believe it was that long ago? [Sanj]God. 10 years? You know what? Everything’s a blur nowadays at my age. Yesterday, still seeing the same but no, thank you. It’s lovely to have, to be here. Thank you. [Jaz]Thank you so much. And I remember your lecture even then I remember some of your lectures the BDA and probably because our paths haven’t collide. I haven’t seen you. I know you’re very active with your teaching, but our paths haven’t collided since then that much, but it’s great to have you on to talk about a very important topic, which is how to get a patient out of pain in terms of your diagnosis, irreversible pulpitis. We’re going to talk about what is the optimum and best Sanj approved way of dealing with that you wish your referring dentist would do. And the other one we’ll talk about is post op pain. But before we dive into the nitty gritty details, just please tell us, listening it’s an international audience in terms of where is it that you work? What got you into endo a bit of your background? [Sanj]Sure. Yes, I’ve been in this game in endo anyway, for, well, dentistry, I suppose we go all the way back. It’s gonna be our 30th anniversary next year. So which is a bit frightening, so now I’m qualified in London, actually in London but I now live in Manchester enough sort of wormed my way up north to the northwest, maybe by accident, really, and just just hospital jobs initially came up, then I did my postgraduate training up here. I mean, back in those days 1995, there was no, there were only three postgraduate endodontic programs outside the hospital training pathway and that was either London or Manchester and I happen to be the right place, the right time in Manchester. I go on to the Masters quite young, actually quite early. I think it was the first one in our batch in our year and guys and I wasn’t I flying student at all. I managed to, there’s one to get an MSc and then I stayed in Manchester that time the mid 90’s I don’t know if you’re too young to remember Jaz but it was quite a good university. And it was a hot thing. I had a better student life as a post grad than I did in London. But, now, it was things were changing in Manchester the Dental School’s good I was teaching. There were not many endodontist one of the reasons I stayed up north actually because I needed a job prospects. This is before endo became really popular and I could see it in fact is by accident fell into endo it was gonna be either implants at that time there was an implant MSc and there was an endo MSC because that was one of the only endo at implant Msc in the country. I was too young I would never go on the people that got onto that were experienced practitioners and I’ve really had no chance but I, that’s where I was gonna go. Ironically, the opposite way and I ended up doing endo and it’s sort of taken off from there and I just got into Endo, the state of Manchester got job offers and I pretty much been full time endo day one from finishing the Master’s since 1997. [Jaz]So how many days are you clinical at the moment in terms of doing your endodontics referral practice? [Sanj]Yeah, so I’m pretty much now full, full time as in I was four days and at three days now. And I’ve got an associate Rob, Rob Jacobs, who covers me so. So I’m down to three and a half days, teaching now just in private courses up and down between London and Manchester with a couple of friends. So that keeps me out of the practice. But pretty much I’ve always been a hands-on clinician. [Jaz]So you’re very wet fingered, very clinical, you, you’ve got a great name in the UK as the person for endo. So again, it’s a privilege to have you on. The reason I have you on is because extirpations, I speak to different colleagues, and we all kind of do it differently. So I wanna find out what is it that you recommend? And I remember asking an endodontist, some years ago, what they recommended, and I got interesting answer from the endodontist. He said that, ‘You know what, as an endodontist, I rarely get to see the emergency extirpation cases anymore, because usually by time they’ve come see me there’s a sinus tract. There’s a perio endo lesion, and they’re really complicated.’ So firstly, I’m just being nosy. How much emergency extirpation do you get? How many of those phone calls you get? How many of you actually treat in that regard? [Sanj]In terms of the practice, you’re absolutely right there being an endodontist. We, by the time they get to us, they are non vital previously root-filled, or the dentist has had to go doing it. We get a lot of phone calls, and mainly from dentists. What do I do? How do I numb the tooth up and this sort of thing, we’ll talk about that shortly. But in that way, I’m kind of slightly lucky, although I know how to deal with it. And we have to back in the training, working in dental school, you’re in the emergency dental casualty where they call it nowadays. So you have to deal with that you have to learn pretty quickly. One of the reasons I went into endo is just okay, it’s not just about the white lines at the end of the endodontic treatment right in the beginning getting patients out of pain, immediately out of pain just until they relax and you get them back into the proper endo. That is really important. And in that way, I’m kind of shielded being in specialist practice, because it’s my general dental colleagues. They’re at the coalface and they’ve got to deal with that stuff on a Friday afternoon, just before they close patient will knocks in you know, they haven’t slept for a week and they’re anxious and nervous that never been to dentists, sometimes you got a lot to deal with, and you got to get them out of pain. And we can’t shove them off with antibiotics. It’s just not appropriate nowadays, medically legally, now you could get into well, or if something happens, so you’ve got to be able to get in there and deal with it efficiently, as painlessly as possible. And that’s a challenge because the tooth is extremely inflamed, and just stabilize everything so you can get them back in when you’ve got plenty of time we’ll get someone else to do it with whatever the protocols are. For that is important. Yeah. [Jaz]Before we go in for the for the kill and talk about the exact protocol that you would recommend to alleviate someone out of pain. Let’s talk a little bit further for the younger audience listening, those students who are listening right now, just coming up with a diagnosis of when it is appropriate to give antibiotics? Because perhaps necrotic infected and really, it might already root-filled or whatever. And then what kind of history and clinical findings are leading you to towards a diagnosis of irreversible pulpitis that needs that intervention that wouldn’t settle with antibiotics? Can you just give a distinction between the two different types of patients? [Sanj]Okay, so you’ve got two different situations, you’ve got the root filled or non root filled teeth, or we’re talking about the root filled tooth yet because that’s a different slightly different scenario, but on a tooth that’s either potentially vital or semi vital or partially necrotic or completely necrotic. Okay, so it starts from the disease process obviously starts at the top of the pulp typically caries, tooth fractures, bugs are going to get into that pulp. Now, sometimes patients will have very low grade symptoms and a niggle, a dull ache, maybe a bit of thermal sensitivity, and they kind of put up with it. And sometimes this pulp will die, but it’s the ones that don’t die or die painfully and they go through an acute phase what we describe as irreversible pulpitis. They’re the ones that the challenge because because the the top of the pulp, the pulp, is the most inflammed closest to the insult, could be caries or a fracture, that bit of the pulp will be difficult to anesthetise. So the whole, when you give a block typically for a lower teeth, you’ll get a block anesthesia, you’re given filtration, the anesthesia will not penetrate up the ID nerve, you won’t get into the pulp, it will get into the pulp, atypically, maybe reticular area, but it won’t get to that point which is the closest to the insult most inflamed. That’s the challenge getting from the, way I describe it to the patients, I show them the X ray, this is your tooth, that’s the top, you’ve got all refilling there we need to go from the top the occlusal surface down to that pulp chamber bit. We’re going to go down to there now a lot of its patient management is preparation. Okay, because we’ll go through the anesthetic protocol, which hopefully will work but sometimes it is not going to work. But you need to know that and you know that from the patient’s symptomology where they can walk in. You just know that as a hot pulp, there’s a chance that they’re not, you’re not gonna melt anesthetise and doesn’t matter what hit them with. There are a few things we’ll talk about how to prep that if they walked in off the street If you know there’s a pulpitis just coming in, you can, there’s a few things you can ask them to do before they come in, just to help the anesthesia process. And then when they get them in the chair, it is management’s a lot of good anesthesia, multiple techniques, different agents, and then going in carefully and managing the patient being empathetic. But up to a point, if they can’t tolerate it, or their anxiety levels too much you sometimes have to do in stages, sometimes you got to gotta go for it. And as it’s sometimes you got to be cool to be kind but in the appropriate patient. You can’t just dive in and you know, you lose a patient and it’s not nice to so you’ve got to imagine yourself in that position. But equally, you want to get them out of pain. It’s a balance. It’s a real fine balance. [Jaz]Yeah, so just the other day I saw an acute, patient in acute pain and after getting somewhat good anesthesia, you know objective, you know, I tried with endo frost beforehand, managed to elicit a necrotic response compared to others actually. But he had recent symptoms of irreversible pulpitis. So it was probably mostly necrotic. But there’s still some element of vitality to it based on his symptoms he was presenting with. And so when I did manage to reach the pulp chamber of his lower molar. Place to file just into distal, this wasn’t bleeding. So it confirmed my diagnosis of necrotic. But I saw the white pulpal tissue. So as soon as I put my K file into the distal, he pretty much jumped out the chair so I gave the intrapulpal. And that just settled him. So it kind of leads communists and like you said, I had to be cruel to be kind for that patient. Now, what could I have done? Had I known I didn’t know who was coming in, but what kind of anesthetic supplement or advice could I’ve given on the phone as you alluded to, to help achieve better success rate of anesthesia? [Sanj]Yeah, it’s about reducing the inflammatory stages that pulp as best you can and systemically, there’s plenty of evidence to say that loading them up with anti inflammatories, nonsteroidal so four to six of Ibuprofen with or without paracetamol, if they can’t tolerate anti inflammatories, asthma or stomach issues, Tramadol, something like that, or codeine, paracetamol, not as good as an anti inflammatory, but it’s better than nothing. That will just physiologically reduce the inflammatory stages, it doesn’t guarantee that that tiny bit of the pulp that’s inflamed will completely needs to dies. But it will definitely, there’s plenty of evidence saying it will help the anesthesia anesthetic process. In terms of the actual local anesthesia for the lower teeth or is notoriously the worst teeth, molar teeth, first second molars, those teeth are really difficult to numb. And it’s because they’ve got accessory nerve supply as well often. And for me, the baseline technique is ID, we do an ID block, I don’t mess about with intraPDLs and this sort of thing. And, you know, there’s usually to knock them, knock that nerve out and not as much as you can supplemented with buccal infiltration is of an age of this absorb as well. And for me, it’s articaine. So if my ID block, I would give lignocaine. As a start, this is an acute emergency, don’t use lignocaine off, and actually, I’ll tend to fall back on mepivacaine. We’ll come to that later on why I use preferred mepivacaine for routine Endo, but for hot teeth need, you need profound anesthesia. You don’t need longevity. But lignocaine works pretty well as an ID. I’m not a fan of giving ID blocks with articaine. But I know the evidence suggests it is very good. And it’s controversial that the risk of paraesthesia. And it may not be anything to do with the agent, it’s probably to do with the fact that’s trauma from the needle. But I’d rather not if there’s an alternative and it which works just as well. So ID lignocaine wait for that to be to work completely work. So we’re talking, the lip is completely numb. The lingual mucosa are completely numb, not even the patient alveolar thing, then articaine buccal infiltrations, it tends to absorb better through the buccal plate is pretty thick, and especially in the sixth and seventh area. And then I might give PDLs as well, or lingual underpressure I’ve got an intra paradata device called the wand, there are few other devices and now available which do the same sort of thing. They basically under high pressure with a short needle, they can deliver the anesthetic through the PDM. The theory behind that is a PDLs is almost as good as an entry onto osseous. Injustice is the other mechanism, you can drill a hole into the bone through these self drilling devices, which has a pretty good effect. I’ve never got are used to those devices, but some people swear buy them. But you need to get that profound anesthesia in there. And you just got to wait. Make sure you just make sure that the anesthetics work, don’t just dive in. And then you want to patient management. [Jaz]Well, with the busy lives of a general dental practitioners, but juggling at getting these patients in, making the diagnosis can take in 15,20 minutes. Sometimes you take a radiograph then give them the block let’s say aren’t getting infiltration, get them set outside while you see a few more patients. I’ll see you in my lunch breaks Mrs. Smith or whatever. Then the lunch rate comes your nurse is rolling her eyes, they swap nurses and so it’s all happening in busy practice. Now, let’s say we made a diagnosis of irreversible pulpitis. And we know we need to extirpate we have given sufficient anesthesia and the patient loaded up with ibuprofen and all the stars aligned when we’re dealing with such teeth. They usually have a large MOD amalgams or something like that. Right? So my first question in terms of making a very tangible for general dentist is in ideal world we’d love to remove the entire restoration. Remove any caries, access cracks but when I’ve 20 minutes we need to get in go for the kill. Is that okay? Can you forgive us? [Sanj]At the end of that, this is about patient this is about getting a patient out of pain. Okay, and you just need to get in there. I used to call it ninja endo get in there, get the job done. Get out before a patient realizing it. That’s my principle in endo. Whether it’s emergency or endo, you want to- [Jaz]Stealthy. [Sanj]Stealth, stealth okay. And the first priority is getting into the pulp. You’re releasing the ,by going into the pulp you will automatically release pressure, there’s pressure buildup, that’s the number one property of inflammation, isn’t it? Then you need to sit basically, you’re applying a sedative material to relieve the inflammation, most common and popular products steroid. [Jaz]Before we talk about medicamento and stuff. Yeah, before we talk about the medicaments I just love to ask some real world questions like let’s say you go in you open up the pulp chamber, do you think it’s desirable for the practitioner who’s going to refer to you in the future? Should we be also removing the roof of the pulp chamber as much as possible? So let’s say that lower molar saw the other day had four canals mesio-buccal, mesial-lingual, and two distals, so four canals. And I did. I opened it all up as much as I could to visualize those four canals and it was mostly restorative material I was moving at this point at now. Is it okay, in that short appointment to just literally go in? See the pulp chamber and then proceed the medicaments? Or would you recommend to open it? Or does it depend on any factors? [Sanj]Okay, in short, forget about the root canals. Job is getting there, relieve the pressure, open the pulp space up and apply the dressing. That’s simple. That’s all you have to do on a Friday afternoon. [Jaz]Even like three or four millimeters in them in the middle that’s insufficient? [Sanj]Because what then tends to happen is, so the inflamed part is the coronal pulp, where in fact just the top bit of the pulp horn, you’ll find once you’ve, in those cases, you’ve got to give an intrapulpal going back to that essentially all you doing is crashing the nerves. It doesn’t matter what agent you can use, there are water, but the pressure crushes a nerve and that inflamed pulp, you’ll often find the rest of the pulpit, okay, it might be hyperemic might be bleeding a lot, but they won’t feel that. Remove the coronal pulp if you can, if it’s not painful, and then just dress it. Don’t worry about the root canals at this stage, that’s not the priority. In fact, if you then start fishing around the root canals, you’re going to start shredding pulp tissue. And unless you get the rest of the whole pulp out, that pulp tissue that you leave behind in the apical or mid third, it’s gonna be inflamed, and then the patient just you get equals other problems. So the pain is coming from the coronal pulp, deal with that, dress it and going back to the restoration unless there’s a gaping hole underneath the MOD amalgam, or it’s clearly this care, you know, it’s just the saliva coming in. Don’t worry about the stage, you can temporarily seal that off with Cavit or Kalzinol or whatever you going to use, just close the tooth, sedate it, close it and then get them back in for to dense the teeth apart, if you have to, it’ll be easy to numb up, you can then the resolvability assessment. If it’s not, if it’s too knocked from the outside, then you just refer for an extraction or book in for an extraction. But if you’re not sure, then don’t worry about that you can assess restorability, and then treatment plan for Endo once the patient is out of pain, and they’re easy to anesthetise. So don’t miss about the pulp root canals at this stage. This is about dressing and getting them out of pain, don’t fish around root canals [Jaz]This is going to be enlightening Sanj there’s gonna be absolutely enlightning because I know plenty of colleagues who advised me in the past and they swear by this Sanj they said, ‘You won’t get the patient out pain until you file all the way to the apex.’ Now is that a myth? [Sanj]Largely yes, it’s a myth because- [Jaz]Have you heard this? [Sanj]Vital so the pain is coming from that topic. It’s not the rest of the pulp. In fact, we’ll come on to this we get tired things are slightly changing. Now the way we treat vital pulps. Okay, this is an interesting conversation where we are now and it was too early to bring this in. We were in the realms of what’s called Vital Pulp Therapy where maybe we don’t need to extirpate pulps at all or the root canal we can do the coronal pulpotomy as we used to do for kids individual teeth. Remember the Cvek pulpotomy back in the day? That concept is now coming in adult teeth, not just immature adult teeth molars for example evan in mature teeth. And this comes this is the kind of crossover between risk cariology, the caries management and restorative dentists coming in. And they’ve been doing this kind of stepwise technique and all that but I think endodontists we’ve always been, not been happy with that because if you’re not predictable, materials haven’t been appropriate. And the risk is the patient could come back in acute pain, they’ll come back with advanced disease, endo disease with the level of prognosis is low. All the pulps completely obliterate and then when you have to do the endo is a nightmare. Things are changing a little bit with the new materials but at this stage in terms of emergency management is enough just as deal with the coronal part of the pulp. The rest of the pulp often it will stay vital whether you then take the dutiful- [Jaz]This music to everyone’s ears, Sanj. This is music. [Sanj]So whether you then go and do new canal was, so yeah, do the full Endo. Or you don’t and you apply these new vital pulp therapies. That’s the that’s the next interesting question. Because endodontics is changing now, we didn’t prevent-odontic, like it. [Jaz]Very good, very good. I think that’d be a whole new episode. But just to continue on the reign of the emergency management, I think what you’ve said is going to be music to the ears of all the GDPs listening who perhaps had this thought that and they’re going to spend this extra time and extra risk in opening up all the individual canals, filing all the way to the apex. So really, what I’m hearing is to get sufficient anesthesia, get in there, open up the pulp chamber, just enough to get your sedative in and we’ll talk about sedative in a moment. Now, and don’t go sticking your K file. So in fact, your nurse now knows not even to give you a K file for this emergency extirpation, which is brilliant. Would you recommend using hypochlorite? Now before we can get to that, let’s take one step back. I personally I would always use rubber dam you know, with your influence on the BES, I can’t go to BES conference and then not use rubberdam for anything like this. So I always use rubber dam but I’ve got some colleagues that were more experienced. And they say, ‘Jaz, it’s okay, because we’re killing the nerve anyway.’ The endodontic, the endo buds will sort the bugs out afterwards. So just get going put some sedative in and come out. We don’t need to irrigate and we don’t need rubber dam. What do you think on that? What is best practice? What do you want from your referring practitioners? [Sanj]Okay, but I mean best practice is you’ve got to isolate the teeth properly, both from a safety point of view and also from microbiological point of view. Now, okay, that dentist may not be doing the endo, and it’s not their problem, it will go to the endodontist. The problem is if bugs get in their, saliva gets in there, it’ll kill the rest of the pulp. Okay, fine. The plan is to do endo, but the problem is if in reverse PYtest actually exist apart from that inflamed bit, it’s actually a sterile situation, which is where relative vital pulp therapy comes in. So you don’t want to introduce bugs there. Because either you don’t know when that patient is going to get to the endodontist. Or when they’re going to have the endo might be weeks, it might be months. And if they get an infection, and it gets into apical, then you’re into different ballgame in terms of prognosis and treatment. So isolation still is important. Now, whether you rubberdam or you compromise, depending on the clinic. And if you’re working in emergency department, and another factors, it’s easy for me to say in my ivory tower of dental school or endo practice, you have rubberdam there and then but again, good isolation, your nurses there good aspiration, open the pulp, give it an irrigation. Remember, it’s only the coronal part, you know, messing about root canals, you just need to bathe the area- [Jaz]Hypochlorite, or Corsodyl or whatever. What do you recommend? Hypochlorite. Now, what do you think about people who, because maybe they’re not using rubberdam, then they’re using chlorhexidine 2%, maybe or- [Sanj]It’s better than nothing, and then we’ll be using 2%, we’ll be using mouthwash, which is useless to be honest, it’s the surface. [Jaz]It’s true, [Sanj]It’s the same for sure, because that’s quite expensive. And most people don’t, even endodontist don’t use that one. Not many of you. Even if it’s as simple as opening the pulp chamber, you’ve got isolations, suction to stop saliva getting in there, dipping a cotton will pledge it in hypochlorite and squashing it in there. So at least is bathed, then dress and close. That’s fine. Just be quick. Everything’s efficient, you know what you’re doing. Hence, keep it simple. You don’t need endo Files. The aim is, all you need is your high speed. Ideally, rubber dam but all good isolation. You need an irrigant enough to dip into whether you’re injecting, that’s another issue, you will send some material and close. [Jaz]But are you happy for us to use a hypochlorite and using maybe a whole syringe of hypochlorite to irrigate the superficial pulp? [Sanj]Yeah. It’s not a problem, whether you’re going to do vital pulp through endo, it doesn’t matter. For the fuse for a minute or to 30 seconds you’re going to do it. It doesn’t make a difference. It’s not going to do anything, any damage. [Jaz]But again, we don’t need to go into the canal. It’s just staying very superficially in the pulp chamber, right? [Sanj]Yeah, that’s all you’re trying to do get some hemostasis if you can, if you can’t get hemostasis, the agent you’re going to use will hopefully no, no, it’ll kill the pulp off. So when you go back and there’ll be less messy next time. But it’s good to have some disinfected within there. Remember the dressing material probably also have disinfectant effects. So that’s fine. But ideally, yes, get good isolation as best you can. And for the sake of a 30 seconds or a minute, it’s not the end of the world. You know, we can be careful. Another thing you can be careful of to use hypochlorite, you don’t need much. You don’t need a syringe that’s friendo. [Jaz]Just in a cotton pellet, as you said is a real gem right there actually. [Sanj]Yeah, just so getting in close. [Jaz]I really respect you, Sanj. And what I’m saying, I really respect you. Because what you’ve given is you really respected the plight of the GDP there, and you haven’t been dogmatic and I really repeat, it’s so easy for you as an endodontist saying, you know, you absolutely must be committing a cardinal sin, which we know we are if we don’t, but sometimes you only got five minutes, and you’re really 45 minutes into it, whatever. Right? So therefore, I really respect that you’ve given us guidelines in terms of best practice, but you’ve said that, okay, if we have to compromise, let’s do it in this fashion, what’s going to help us either way, so really good suction, dip your cotton pellet in hypochlorite. And those guidelines you gave, so I really respect you for considering our position sometimes. So thank you for that. Now, the last question in this segment for Emergency acute situation before we talk about post op pain is which is your sedative of choice and which is your temporary restoration of choice? [Sanj]Sedative choice, very popular one and I still like it, if you can get hold of it as Ledermix. This is purely for a coronal pulpotomy it’s not for sticking down root canals. Okay? It’s got a steroid in it. So naturally, it’s anti inflammatory. The antibiotic component is broad spectrum that’s neither here nor there, to be honest, but it might have some effect. This is the fact that sedative, you just wanna get the patient out of pain. But you need to go back and you can’t leave other beings for long because it does its thing. It doesn’t do much after that. And if there’s any pulp beyond that, it’ll start getting inflamed, the pulp will become inflamed deeper down. So if you’re using Ledermix, it’ll keep it quiet for two to four weeks, maybe. But you need to get back in there and do the full extirpation do the full endo quickly. The alternative and it’s still the gold standard is calcium hydroxide non setting. It hasn’t got the direct anti inflammatory properties, but it’s a necrotising agent, it’s antibacterial. So kind of indirectly, it’ll disinfect the environment it’ll necrotize a pulp because it’s pretty caustic calcium hydroxide is pretty caustic stuff, it’ll fry the pulpit comes in contact with, very alkaline, and it’ll do the job. So when you go back in, you’ve then got the choice whether you do endo or go down and keep preserve the rest of the pulp. Calcium hydroxide’s fine. Nonsetting Calcium hydroxide if you can’t get hold of Ledermix. Because I know that- [Jaz]How much do we need here? Because, you know, sometimes nurses will depending on which dentists they work, when they’ve got previous biases, sometimes give you a huge splodge of it and they give you a file because they expect you to take it all the way to the apex because that’s what they used to with a dentist they work with. Or sometimes they give you like the tiniest bit and, and a cotton pellet. And I personally me Sanj, I like to use PTFE instead of cotton nowadays, we can hear your thoughts about that. But then how do you best apply that? And then how much do you put, and how do you seal over that? [Sanj]Okay, so what I do is once you’ve got hemostasis, or relative hemo state, if you’ve got hemostasis literally inject the, it’s like cream, Calcium hydroxide cream, into the over the pulp chamber floor, a third of the pulp chamber floor very gently. You can use PTFE. The only problem with PTFE. And I know a lot of endodontists. And everyone goes on about PTFE. The problem is, if you’ve put that into place, you’ve run into a ball you meant to roll into a ball, you squash it in it displaces the calcium hydroxide, it just squirts back out so you haven’t got the volume. So a better material and you’re right cotton wool, there’s plenty of evidence saying you shouldn’t use cotton wool, because you can’t, you often can’t see the fibers and they sometimes protrude through and you’re gonna get an infection, it’ll just penetrate through the temporary material. So better alternative I use is a sponge pellets, these sponge pellets, then either endofrost pellets or VOCO pellets, they’re better. Because it compressible, their porous. So they’ll hold the calcium hydroxide or whatever agent you’re in. And it just holds a bit of bigger volume of dressing material. Unlike probably PTFE as you push it in, you meant to displace it. And it’s good because it’s antibacterial. And when I say antibacterial it because it’s PTFE nothing, bugs don’t stick to the material, which is great as an inter appointment between root canal treatment is great for that, what postoperatively before you send back, but for the dressing, you just end up displacing it out and you want the dressing material to soothe the tooth. So- [Jaz]Fair point. [Sanj]In terms of material on top, it did get it depends on how when the patient’s going to come back. The options are Kalzinol traditional reinforcing zinc-oxide eugenol If you think the patient is not going to go see a dentist for a long time, either GI or IRM. IRM is my favorite, because it’s super reinforced Kalzinol. It’s rock hard, and in fact, it was designed. Do you know the history of IRM? Where it came from? [Jaz]No, I don’t. [Sanj]It developed this, I’m not sure this. It’s developed by the I think it was the US Navy for at least during the Vietnam War. So what they used to do is they find the material where they do a dress again is emergency dressings, get the soldiers out of pain, and they knew they wouldn’t come back for months on end. And that’s where IRM was developed. They used it there. So it’s a long term. It’s quite hard. It’s not as hard as amalgam or composite. But it’s pretty rare. It’s the other property it’s got that huge knock components it’s slightly antibacterial, which is why a lot of endodontist love it. It’s called a long term antibacterial and it sort of reflects biofilm and bacteria so IRM is great but otherwise GI capsulated bog-standard GI is hard enough or is resistant enough and is easily accessible for the endo and the choice. [Jaz]Cavit, quite soft. Is that okay? For a short term? [Sanj]Short term is fine. It depends on the cavity. If it’s an enclosed cavity and literally an occlusal access cavity. You need depth and bulk of Cavit. It’s not very, it’s quite it’s poor wear resistance, but it’s okay. For no more than two to three weeks. And it depends on the patient’s occlusion as well. So it’s okay, it’s okay. [Jaz]Sure. Okay, but we do a favor Kalzinol or even more IRM and then use a GIC if appropriate as well. So that’s good. If I was just summarize because the reason I’ve done a whistlestop story of this because I also want to about post op pain, perhaps after doing rc while I’ve got this precious time. For those who don’t know, we’ve been months in the waiting to sync our diary. So I’ve got this very valuable specialist, precious time to extract everything out of your brain and distribute it to Protruserati. So just to summarize so far, guys, we need to get a profound anesthesia. We don’t need to explore in that emergency appointment to get to every single canal. We certainly don’t need to file into every single canal if you open up the pulp chamber, place a sedative like Ledermix or a non setting calcium hydroxide or foam on top, put some Kalzinol or GIC for good measure. IRM maybe if you want something longer lasting, and that should work. Do we have any data? Cause sometimes I’ve done it maybe some years getting patients calls up next day, saying I’m still in pain. But most of the time, I’d say 95% plus patients out of pain the next day because I did throw for a while do an audit the day after especially when I worked at Guy’s in the emergency department. Do we know how successful it is? Or is that not been studied? [Sanj]The emergency dressing protocol? [Jaz]Yes. Emergency Emergency protocol? [Sanj]Yeah, I’m not aware of any specific studies on that. But anecdotally, from when patients can’t had the dressings done, it seems within a couple of days, most patients are out of pain once a denture has been in there. Yeah. [Jaz]What advice would you give to your patient in terms of you know, give it a couple of days and analgesics. Let’s just finish off with what advice you’d get before we talk about post op pain. [Sanj]Yeah, a woman is going to suddenly get get better. So give her a couple of days I could ask them to continue the ibuprofen if they can take ibuprofen or paracetamol. It was acute pain then Tramadol or something like that, and I want the olders just to in terms of just symptomatic relief, I just flattened the occlusion, get all the deflected contacts out to say there’s no, most of the pain is often on lateral percussion. So just flatten the tooth. The tooth is probably going to be indirectly restored probably anyway. So just relieve any, the tooth will be in hyper-occlusion anyway, if there’s any apical involvement as well in evidence in multiple teeth, one pulp could be vital, inflamed, the other part could be dead. So you might have also a combination of apical inflammation, you don’t really know that immediately. So just relieve the tooth out of occlusion. And then yeah, post operative anti inflammatories it should settle within a couple of days should do and tell them to go to the dentist. [Jaz]Amazing. [Sanj]You must, they must follow this I’ve been warn than what could happen. Because if there is, again, medical legal hat on, if you haven’t worn them this, it kicks off. They’ll say you didn’t warn them and you know it just to prevent a complaint you need to warn them put in the notes, this is the advice given if you’re not going to come back to your clinic. This needs to be done. So you just protect yourself for the future. Jaz’s Outro:Yep, and warn them and also make an entry into notes that patient one that needs to this is not the final treatment. You know, some people just assume that, ‘Oh, I’ve got my root canal and I take a radiograph there’s no root for the material. You see, it obviously has been dressed at some point probably five years ago, whatever.’ So yeah, good point, well made. So Sanj, let’s switch gears a little bit. I recently treated a gentleman. Oh, there we have it, guys, you don’t need to find and open up every single canal. Just get in there, relieve the pressure, place your medicament. And we also talked about what kind of materials we can use afterwards, I feel like we covered a fair amount in this group function. Listen, if you are listening on the app, you’re listening or watching on the premium version of the app, just scroll down now. And then you’ll see a form, fill in a few details and answer a few questions. And you’ll get your half an hour’s worth of CPD certificate with all the aims objectives and the reflective log. So it’s like legit and future proof. And if you’re not already on app, look, you can download it for free. It’s on iOS and Android. And the benefit is you can download these episodes, videos and audios and any PDFs and save it to your device in case you have choppy connection. And it’s one of those membership programs that actually let you download all the stuff like if you’re on a membership website for dentistry, then it’s very unlikely they’ll let you download the videos on your hard drive or on your phone or your tablet. You actually download the video and audio to a device to listen in the future. And if you want CPD and exclusive premium content that I’m making all the time, then I’d really appreciate your support if you support the team protrusive and joined the premium package on a monthly subscription. And I’ll promise you, I’ll make it worth your while. Anyway. Thanks so much for listening all the way to the end, your true Protruserati and I’ll catch you same time same place on the next episode.

Orthodontics for the mixed dentition is not well taught at Dental School – for which malocclusions should you intervene and by what age? Dr. Amanda Wilson will show you how to identify whether early or interceptive orthodontics is right for your young patients as part of their antero-posterior, vertical and transverse development. https://youtu.be/8OksXwy_yDQ The Protrusive Dental Pearl: Prevent misdiagnosing ectopic canines by palpating the permanent canine early (from age 10 onwards). Put your index fingers a little bit apical and a little bit distal to the lateral incisors and you should be able to feel a 5-10 millimeter bulge Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 1:58 Prevent misdiagnosing ectopic canines 8:55  Difference between Interceptive and Phase one 16:15 Phase 1 Interceptive Treatment Guidelines 20:20 Arch Expander Guidelines   24:07 Crossbite Tendency  24:57 Rapid versus Slow Expansion 27:42 Guidelines using functional appliances 28:21 Invisalign Mandibular Advancement 31:10 Deep Bite Guidelines 34:08 Q: Percentage of patients that would undergo Phase 2 36:43 Patient(Parent) Communication 39:51 Retention Protocol 43:36 My Phase One Smile PDF Get this My Phase One Step-By-Step PDF Checklist by Dr. Amanda to get started and help you diagnose malocclusions Check out Straight Smile Solutions for more Orthodontic Consulting and StraightSmile Solutions Orthodontic Coach for GPs for Orthodontic Educational Videos If you enjoyed this episode, you should also check out General Dentists Doing Orthodontics  Click below for full episode transcript: Opening Snippet: If you have six millimeters, no vertical issues, no trans issues, no AP issues. Your child may not ever need braces. So that's incredible, right? So what we're aiming for? obviously, the part of the reason why kids have crowding it's actually a first world problem. Believe it or not, it's partially genetic, but it's also for the most part environmental. Jaz’s Introduction:Welcome back Protruserati, I’m Jaz Gulati to your favorite dental podcast and today we’re covering INTERCEPTIVE ORTHODONTICS. Why this topic? Well, actually, I’ve been a super busy boy. And I’ve got so many episodes recorded, a whole range of awesome topics. And so nowadays, I’m pitching it to you guys, which one do you want next? And on the Facebook group, gosh, it was extremely tight. But you guys just about voted for interceptive orthodontics. And this episode, what it serves to do is to help you the discerning GDP to gain some clarity on what you’re looking for in our young patients. When you’re thinking, would this patient benefit from EARLY ORTHODONTICS or for INTERCEPTIVE ORTHODONTICS ie to intervene in their mixed dentition so that they can benefit and have straighter teeth or a better occlusion for their later years and teenage years. Now, it’s important to mention that this episode, it’s not been made with any countries or systems in mind, per se, ie what I mean is, for example, if you’re a dentist in the UK listening to this, you might be thinking, ‘Okay, this is great knowledge. But how can I implement that in the system where I work in the country that I’m in with the political system and the public funding that I’m in, etc?’ Well, that is irrelevant, because what I want to pass on to you from this episode is really good knowledge and fundamental orthodontic diagnoses. And then you can have a conversation with an orthodontist, or know when you should refer for a second opinion. That’s what this is about. So if you’re in the US, and you’re worried about insurance, and whatnot, it’s all about finding out all these issues. And really, I love the way that our guest Dr. Amanda Wilson breaks it down. If you really think about it, the main things we’re looking for are any errors in development or any problems malocclusions that affect the anterior posterior, the vertical and the transverse. If you just look at your growing patient, and those three planes, and you identify all the things that could be not normal, then you have a basis on which to know when you might consider a referral and when you might not. So this episode is going to open your mind to these things and you will see your growing patients differently from now on, I hope. The Protrusive Dental Pearl:The Protrusive Dental Pearl is very relevant to interceptive orthodontics. It’s all about impacted canines. Now, we know impacted canines can affect one to 3% on average 2% of all people, which is a lot of young people affected by this and what I would encourage you to do as my Pearl and this is stuff that we should already know but let me expand on it is to palpate for the adult canine for the permanent canine from age 10 onwards. So you put your index fingers, you try and find the upper laterals which have erupted by age eight, obviously, and then you go a little bit apical and little bit distort and you should be able to feel a bulge 5-10 millimeter bulge above those lateral incisors and distal to them, you should be able to feel that buccally and if you can, great write that in your notes. But if you can’t, descend warrants, some investigation. For example, an OPG and OPD radiograph is usually the first nine investigation. And this is all to help us to make sure that we don’t miss these cases of ectopic canines, which can go surgical and be more complicated in the future. So in terms of our diagnosis, as a general dentist, we all need to be hot and as part of our checklist. So my advice to you is make sure that your notes template for when you’re treating a young person, when you’re examining a young person, make sure your notes system has something that along the lines of canines palpated. And if so were they buccal or they’re palatal, for example, if they’re palatal and you’re really worried about an impaction, obviously, but you need to be able to systematically do that for every young patients from age 10. Are you palpating the canines? And if so, are you recording that in your notes? That’s a good way to stay out of trouble medical legally going forward because 2% of a large number is a lot of young people. So let’s not forget these really good practices of palpating for canines, so that we can better diagnose and intervene with potentially ectopic canines. I will join in the outro guys, but let’s join our guest Dr. Amanda Wilson, on the topic of interceptive orthodontics. This episode is eligible for CPD or a CE certificate by answering the questions of this episode. If you’ve got the app if you’ve got the app on iOS or Android, just answer the questions of this episode. And my team will email you the certificate if you’ve got the questions right, so that you get proof that you listen to this episode and you get a certificate that will count towards your educational quota. So what are you waiting for? Download the app on iOS or Android by searching for protrusive and as you’re already listening to the episodes, you might as well gain the CPD. Main Episode:Dr. Amanda Wilson. Welcome to Protrusive Dental Podcast. How are you? [Amanda]Thank you so much. It’s an honor Jaz. I’ve been listening to your podcasts all weekend. I’m super psyched to meet some of your audience and I’m doing well. [Jaz]Amazing. And you got to tell the people listening right now the Protruserati, the most beautiful place in the world that you are speaking from today. And how you ended up there because we had a little chat before there. So you’re obviously from Hawaii. Tell us more about that. [Amanda]Sure. I think a lot of us go to dental school and I went to University of California, San Francisco for dental school. And I met, I was sitting next to a guy with a last name Huang and my last name is obviously Wilson. And that’s we sat alphabetically so it was me Long, Wang Yang, all in one row. And I ended up marrying him. So he brought me back to Hawaii. And it’s a really wonderful place to raise children. I have two teenagers now and very family oriented, very Asian population. I’m obviously not interesting on video, but I love it here so much. It’s Honolulu, Hawaii. It’s fabulous. If I had, if it wasn’t 9pm, it’s 8am in UK right now, but it’s 9pm here in Hawaii behind me. I have an incredible view of waterfalls and mountains. But I can’t show you but I did pick some flowers from our garden. [Jaz]You’re making us all so, so jealous. Honestly, like, you know, I’ve got people in like places of the UK, like Stoke, and all these places, you know, driving in the miserable weather on the car right now listening to this, and they ‘Gosh, I wish I was in Hawaii right now.’ But that’s great. Thanks so much for making time for this. Amanda, just tell us a little bit about yourself. What is your mission statement? What is it that you do? Because I think what you do is very empowering. But I just want to share that with those listening today. [Amanda]Absolutely. So we all have a different journey, right? And now all of us think we’re going to start we’re going to be dentists. And we’re going to have this practice until we retire. And that’s what I thought and that’s what my husband thought he was going to do. And I listened to a really great podcast about families. It’s a few podcasts back this weekend. And I really felt inspired by that. And it was a very similar story as what I went through. Since I married my classmate. And we both had practices. It got really tricky, especially when we had kids. Every time one was sick, it was like, oh, no, which is all the time right? When you I think you believe you, you said you have a three year old. [Jaz]Big time, all the time. [Amanda]Somebody has to be flexible. And we’d always be like pulling up the schedule. Oh, I have 10,000 production, I have 8000 production, whoever had less had to close their schedule, right? And it was often me so at one point we said you know what this is you know, not working. So let’s do something a little different. He said, ‘Why don’t you take a couple years off?’ And I had started kind of a side hustle, teaching first with him and then his friends how his general dentist, how to do orthodontics. Mostly aligners Invisalign, which a lot of people are doing now. And it started to grow from there. And so I went full time and I started a company called Straight Smile Solutions, six years ago, actually this week, incredible. And full time I help doctors with any ortho cases, not just Invisalign, aligners, phase one interceptive, braces, if it’s ortho airway, I help them. [Jaz]And your orthodontic training. So, from speaking to lots of guests on the US, I know you do your undergrad. Well, this is traditionally what I’ve learned and then dentistry in the US is like a postgrad degree that you would do. And then for orthodontics, was that involved in terms of further training? [Amanda]Another three years and another degree, and it’s incredibly expensive. I think you guys are very blessed. I’d say the average dentist gets out with a half million dollars US in loans close to me because I’m close to 800,000. So it’s such an expensive journey, I went to University of Connecticut for my orthodontic residency. And if you go straight, straight, straight, you finish at age 29. So it’s pretty, it’s pretty crazy. [Jaz]And just because we talked a bit about families and stuff, and it’s great to extrapolate journey. So when you were in Connecticut, hope I said that correctly. And then where was your husband, does he relocate with you to your training or how does that work? [Amanda]He went to Hawaii to start his practice. Yeah, he went back to Hawaii. So when we, you know, commute, it was a very long distance relationship for three years and part of the time we were married, but we made it through. So if anyone is listening to this podcast, doing something like that it is doable, where there’s a will there’s a way. [Jaz]It’s a reality for young aspiring dentists who want to specialize and do further training, whether it’s a masters or speciality, that these things are going to happen whereby you’re going to have to be a time apart, kind of because of the training pathways will take you to different locations around the world. So just it’s nice to share people’s experiences in that. So today, we’re talking about what we call in the UK, interceptive orthodontics and what you have referred in our conversations as phase one, so just break that down. Is there a difference between interceptive and phase one? And just define those terms for us. [Amanda]You know, I’ve always called a phase one interceptive. I use the term synonymously. So either one works for me. I think in the US it’s getting more popular. Unfortunately, our insurance only covers one phase of something you never get both covered. So you have to pick and choose, right? So it is still difficult for our doctors sometimes to convince as my families have not a problem, right? But for the average family, they are, it’s hard to explain the why behind phase one interceptive treatment. [Jaz]So if in the US, the average family if they had that phase one orthodontics, interceptive orthodontics to improve their malocclusion at that young age. Therefore, later on in life, should they require phase two? And we can discuss later on in terms of what percentage would then benefit and end up having phase two, they would not be able to get that covered from the insurance. That’s how it works, right? [Amanda]Unfortunately, yes, that is generally how it works. But I’m gonna get you guys so excited and so pumped about it because here’s the truth of the matter. First of all, if you are a primary care dentist, there’s no reason you can not do phase one interceptive treatment, it’s actually so easy. And I would work on a six to nine year old any day over a teenager and I personally have teenagers, six to nine year olds are so compliant, so lovely to work with, you know. As long as you get along with the parent, the kid is usually so excited. For those who have video, you might be able to see some of the fun things I have on my desk here, I have glow in the dark expanders, you can get decals and glitter in them, they just have so much fun. You can even have entirely removable appliances if you wanted to. And in the US just to add to it. In most states and all of our states are slightly different in terms of what you can do and what dentists can do, or what dental nurses can do, or dental assistants can do, hygienist can do. But in most states, everything can be done by the team, the dentist doesn’t have to do anything but the treatment plan and supervise obviously, you can’t just like you know, leave the building, you could be working on a crown prep or placing an implant and your team is just right next to you working on the Phase One patient. So even if you don’t like it, who cares? You’re only the brain behind it. And I know for my husband one of the reasons he wanted to learn a lot of ortho and not just invisalign. Well, twofold. Number one, he’s a little older than me a lot older than me. And actually, I was the youngest people in the class. And he was the oldest, second oldest. But in any case, he goes, ‘You know, I don’t want to be 70 years old still doing drill and fill, I want to do all specialty work, I want to learn how to do high quality specialty work so that I’m just using my brain, you know, I don’t have to use my back and my arms and my fingers.’ And he loves it, you know, so. But the cool thing about phase one, like I mentioned, first of all, like, your team can do it, you don’t have to do it, you just have to understand it because you’re the brains you make the treatment plan. But also very often when you do phase one treatment, if people aren’t familiar with what it is, phase one basically is defined and this is my definition as fixing malocclusion the bite. So we’re basically fixing things like transverse, so like narrow jaws, we’re widening jaws with expanders to be fixed or removable. If someone had like a small lower jaw, we’re going to grow that jaw. Lots of ways you can do that. And now with Invisalign MA, it’s a fantastic appliance, you can use invisalign first with MA that works really well. You can do if someone has a slightly lower, slightly bigger lower jaw than the upper jaw, most of the time that when it presents in phase one, it’s because they’re maxillary rretrognathic, it’s very easy to jump that bite with a little appliance with elastics. It’s super, super easy, all different ways you can do things. So transfers, AP, and vertical. It’s basically those are the three major things we’re going to fix, you know in terms of bite, the bites and open bites, habits, airway, and then lastly, just watching out for impacted canines. If you start to see those in the OPG, or the panoramic X ray, you can do some expansion, a little two by four or like a, phase one liner really, really, really easy. And get those kids out of trouble. And the added benefit and I can tell you just from personal experience, I started noticing the more phase one I did in my practice, the less phase two I had in my practice, or the less hard phase two. So it took something that was just a big mess. And you break it into two pieces and tackle the harder stuff when the kids are young, compliant and excited and willing to wear fun stuff like this. And then maybe, maybe not if worse comes the worst. Usually all you have is a super easy like go aligner treatment later. I mean, you rarely even need to do the full thing. And it’s definitely something when you could tackle both parts and both could be done by a GP. And that’s the cool part. Now I’m going to tell you, I might really upset a couple orthodontist if they’re listening and I don’t know how many orthodontist listen, but part of the reason I started teaching phase one and pivoting to really wanting to educate as many dentists as possible about phase one is I was at this ail American Association of orthodontics, which is our big orthodontic conference. And I was in this meeting room and I was listening to orthodontics and orthodontist for the most part has always been kind of an old boys network, you know, really single colored, single sex that I always felt a little bit excluded from the whole crew, but they were telling me you should never do phase one. Because if you do phase one, the general dentists will keep the phase two because it’s too easy. So they say when general dentists refer to phase one, and I’ve heard this more than once, I just say no, that they don’t need it, even though they do. Because that’s only a two to $3,000 treatment plan. And if they wait two years, I know it’s gonna get significantly worse. And now it’s a $6,000 treatment plan that they won’t take. And I’ve heard that- [Jaz]That is shocking. [Amanda]It literally blew my mind, because I don’t think like that, and I was so disgusted, to be honest. And you guys, I’m speaking just for myself, in this, maybe it’s only a few dentists. But you know, orthodontics has changed a lot in the last 20 years, especially with direct to consumer aligners, and invisalign, and everything. And it’s become much easier, and many, many more general dentists are doing it because it’s easier and it’s fun. So I mean, listen, us orthodontist, especially those of us who were in the previous generation, when I graduated, really invisalign had just started, it wasn’t really a thing. So we were still getting all these referrals, you know, it wasn’t a problem. But I mean, we’re watching our profession basically, change, you know, a lot. So we’re grabbing at straws trying to keep those patients but it just wasn’t something I could do. I can’t do that. I don’t feel right doing that. So I said, You know what, this isn’t right. How can I educate as many general dentists as possible? I don’t care if they don’t want to do it, not do it, I just want them to understand it. So that way they can, they can educate their patients and say ‘you need this because’, because too often as general dentists will just say to the patient, you need this because you’re seven, you should just go for a consult. If you say it like that the patients don’t and the parents aren’t like they’re busy, right? They don’t want to go unless there’s a reason they need to go. So you guys need to build explain the reason you know whether you take the case, or you refer the case, and then you need to find orthodontist if you’re not going to take the case, who will actually do the Phase One when it’s needed, because that is my biggest pet peeve. [Jaz]I think it all starts Amanda with the diagnosis. I know you gave the subgroups where it’s affected. But let’s talk about, one from each scenario, perhaps. So you see a someone between six and nine, what are the kind of things we’re looking out for? So for example, you mentioned transverse, and you mentioned a narrow arch, how narrow does it need to be for you to then think, ‘Okay, this patient will benefit from expander.’ Do you need to be completely in like a full crossbite? Or do they need to be a crossbite tendency? What are the guidelines that you can look at to decide? And also what age is a cutoff point? And then also, just follow on from that you mentioned about communicating to the parent. Is it because it’s time sensitive and growth related? Is that the main message you want to send to the patient or to the parent? [Amanda]Wow, you hit a bunch of amazing points. So, let me start backwards and go with that last point. So every patient, every child has three different ages, believe it or not. So you know, obviously their chronological age, I mean, my daughter, she’s 13 years, five months, okay, that’s her birthday. But we’ll go back, when she was eight, she only had a few permanent teeth in. So her dental age was much younger than her actual chronological age. They were girls in her class in third grade, who had all their permanent teeth in. There were boys are a class that had no permanent teeth. So we all have a dental age, we all have a chronological age. And then we all have a skeletal age. And this is the most critical part. And I know you have a three year old, I have teenagers, you’ve probably seen, probably have lots of cousins and nieces and nephews. Kids are maturing way faster than they ever were. No one really knows what it is. The milk is chicken. I don’t know what it is, you know, conspiracy theory. But I mean, it’s one generation before me, I mean, girls matured at 14-15, boys matured at 17. Now, you know, my generation, it was 13 and 16. And my daughter’s generation, it’s 10, for girls, on average. It’s crazy, crazy early. So there’s 10 year olds who may only have a few permanent teeth, but they’re skeletally done growing. And this really changes things because we really, really have to do phase one, while they’re skeletally still growing. And it’s a very sensitive topic. It’s less much less sensitive with boys, I have no problems bringing that up. But you really need to understand all those type of growth and how to treatment time. And too often in my practice, when I was practicing full time, I would get these teenagers coming especially these girls who were 12, 13, 14 and they were done, done, done growing. And they needed orthodontic treatment, and we weren’t able to utilize any of the fun stuff that I could do to grow things. You know, we just basically had a compromised outcome. It looks bad, Mom’s not happy, kids not happy. And I’m like, I’m so sorry, you should have come for phase one. And they’re like, ‘My dentists never told me.’ And that really, really bothered me. And then we had to take out bicuspids and I would love love, love for there to be a completely extraction free if at all possible. Generation of orthodontics. It’s slowly moving in that direction, but I’m so opposed to extractions, if we can avoid them. [Jaz]I mean, the most common thing that I see is a narrow maxilla. And what I was taught was I deal ages between 8 and 10. And please, you know, let me know what you are using it but that’s what I was taught by one orthodontic consultant, but it can vary. And then it’s so important to get that you know, rapid and maximum expansion or any sort of expansion. You can talk about in a slow and rapid and when we might consider that. Once I referred these cases and it’s a shame because it just highlights some of the issues we have in the UK because of the funding more orthodontics. The fact that we have this National Health Service, which pretty much covers orthodontics, where there is a need. And most of the specialists, unfortunately, wi’ll wait, just like you mentioned earlier for a different reason, until all the permanent teeth erupted. And then they’ll just, you know, take out bicuspids. So this is a real issue in the UK. And I’m a big fan of the mantra of treat adults realistically and treat children idealistic. Children are not getting the ideal treatment. So tell us about what what age are we looking at in terms of either doing the treatment yourself phase one or referring for a narrow maxilla? And how narrow does it need to be? [Amanda]Yeah, I need to answer your question about that narrow maxilla. So I’ll go ahead and use this as a demo for those of you who have visuals, but I’ll talk you guys through it. So there’s a lot of things I look at when I’m deciding whether or not we need to do arch expansion. And that is just so simple, you guys, if you don’t want to deal with bands, and spacers, that’s fine, you can do removable, we’ve got this really fun one like I had here, it’s got glitter, it actually glows in the dark. So if they lose it at night, you know, you can turn off the light and they will glow, but basically many things I’m looking at I’m just measuring the crowding, you know, first of all, obviously they might only have two to two in on top. But you can kind of visualize and see if you have crowding already on two to two there’s definitely crowding. And just to let you guys know, I will still answer the question but fun party trick for like, say a two, three or four year old? Let’s see if you know the answer to this how much spacing is ideal in your son per arch? What would you like to see? What would you want to see in all baby teeth. You know the answer? [Jaz]Well, firstly, the way I’ve been taught is that I like to see some spacing, because it’s a predictor of less likely to get crowding in the future. If I see there’s no space or definitely if there’s any tendency to crowding that I know my child will be screwed, and more likely in the second condition because there will be crowding. So I don’t know the exact answer. But I do like to see spacing. And when I see my son’s teeth, I like the fact that he’s got some spacing in his lower anteriors. And between the canine and the first deciduous molar. I like that, but I don’t have a numerical answer. Please, please, enlighten us. [Amanda]Six millimeters. [Jaz]Six millimeters, wow. [Amanda]Six millimeters, you should, if you have six millimeters, no vertical issues, no trans issues, no AP issues. Your child may not ever need braces. So that’s incredible. Right? So what’s we’re aiming for? Obviously, the part of the reason why kids have crowding is actually a first world problem, believe it or not, and it’s partially genetic. But it’s also for the most part environmental. It’s you know, we are eating were meant to exclusively breastfeed the age 2. Obviously not many people do that they’re feeding them baby foods and stuff like that. And then to go straight into eating hard root vegetables, meat off bones, very primitive, you know, Paleo diet. And obviously, most people aren’t doing that. Well, some people in California are, you know, when you’re not using your jaw and you’re eating soft foods and you’re feeding your child on a spoon, they’re not using their muscles of mastication, which doesn’t develop their bone structure correctly. And of course, also a lot of there’s tongue tie and tongue knot going up on the roof of the mouth and tongue position and habits, a lot of these things can affect the growth of the jaw not only transversely, like you talked about, but also you know, AP direction growing the lower jaw. So we talked about looking for evidence of crowding, we want to see, you know, spacing ideally is what we want to see in that kind of two to two stage when they were like that, I also like to look at the OPG or the X ray and see if there’s impacted canines or tipped canines. That’s a sign that I know we need it. I’d like to look at the anatomy of the palate and see if it’s vaulted. I don’t want to see a vaulted steep palate, I want to see a nice, you know, broad, shallow palate. And one of the fun party tricks I learned also is you can measure, it’s just one of the additional things I do. I measure from the esio-palatal cusp tip of the sixes, okay. From mesio-palatal cusp tip to medial Palom cusp tip of the sixes, and you want it to be at least 40 millimeters. Now of course, on a child with tiny little teeth, it might be a little bit less than a child with gigantic teeth is going to be a little bit bigger. So that’s a rough estimate. But if we’re seeing 37, 36, 35, 34,that’s a guess you definitely need expansion. We’re seeing 43, 44, probably no not needed. Of course, if the molars are rolled in, it’s a little bit different. But I mean, all you take into account all these different things and then you know, if I hit, you know, one, two or three of those indicators, we’re probably going to go ahead and benefit. I mean, obviously you’re looking at the crossbite in the back tooth, if you see a crossbite you know, that’s another reason. If I see any crossbite remember that- [Jaz]What about if it’s a crossbite tendency? So instead of the lower molar buccal cusps being in the fossa of the upper, what if it’s like a tendency so that the way that occluding is not cusp to fossa is almost cusp to cus? But how much of a degree should we accept that, okay, this is going to be okay. And things will bear in or what’s the threshold? [Amanda]So I probably look at all these other indicators I talked about. And if I hadn’t one of those other indicators, then I’d probably do it. If not, I feel pretty confident I could just get it with some braces, some wires or some aligners. But I mean, there’s also airway benefits. And we got the whole other thing there. You know, I’d like to do an airway screening, looking for evidence of snoring, mouth breathing, things like that. So that would be another indication that I might want to do it. So you can’t do anything wrong by expanding, you can always just expand a little. There will have to fall and expand. And to answer your question about rapid versus slow, I learned rapid in school. But when I started teaching my GPs, I switched to slow only because I’ve seen some very scary things with rapid expansion. One story, I had one patient that in California, I worked with a more lower middle class population in the valley, a lot of farm workers, lot of migrant workers that would pick strawberries and things. And sometimes the kids would disappear and go to Mexico or go to South America for a few months. So we had put a expander in a patient. And we told them, you know, do X amount of turns, I’ll see you in two weeks. Well, they disappeared, and we never, we couldn’t get a hold of them. Well, they kept turning, they kept turning, they kept turning. And basically this child had a full on scissor bite on both sides. I mean, like the whole mouth basically collapsed. And it was like, I mean, we ended up getting it back. But it was so scary, you know. [Jaz]And a huge diastema as well, because that’s one things that maybe GPs I need to appreciate is when you do the maxillary expansion so rapidly, you’re expecting see a diastem, correct me if I’m wrong. [Amanda]Correct. Correct. And that’s one of the benefits of slow is that you actually won’t see that because they’ll slowly start to fill in. And they don’t freak out as much. But you can totally do rapid. Obviously, that works better with fixed than removable. You can do slow to me, they both work exactly the same. Slow is a little less discomfort, a little less risk happens a little more gradually, you don’t get that really ugly, big gap. But it tends does take a little more time. But you know, I do have, I want to let your your listeners know that I made fun fact, especially during COVID, I made over 6,500 How To videos on basically every topic that’s out there for ortho and I tried to explain it as- [Jaz]6500?! You’re the most productive woman on earth. [Amanda]That is not how many I have there. And literally I’ve created playlists. So there’s a phase one playlist last I checked I had 166 videos. So there’s literally something on average, that type of appliance, basically. Only thing I don’t really get into is like jaw surgeries, because I don’t think GPs should be doing that. TADs, I don’t think GPS should be doing. And you know, that’s not the fun stuff. That’s the yucky stuff. So I try to make ortho clean and fun and blood less and shot less. But yeah, people are welcome to take a look at my YouTube channel, which is Straight Smile Solutions. It’s free and everything’s on it’s just like completely free orthodontic education. So the more I can get out there, I think the healthier bite kids are going to be. And that’s my ultimate goal. [Jaz]It’s sounding like Netflix for orthodontics. So we’ll definitely be able to share that in the show notes. Because it sounds very, very comprehensive. That’s amazing. The other common scenario, which I think the UK dentists do get more of or get more done is, you know, the expansion issue can be tough. But the whole functional appliance I feel as though in the UK, we are more for thinking when it comes to the use of functional appliances. Where does that lie in terms of your preference for treatment? And what ages are we looking for with someone who’s got a large overjet to bring their mandible forward? So what kind of guidelines we’re looking for in that scenario? [Amanda]Pretty much same age as I mean, I want to get started as early as possible, you’re also gonna get more compliance thoroughly as possible. So according to some of the literature, it says to wait till pubertal growth spurt, but I’ve had just as much luck doing it earlier, you know, at six, seven and eight. And now with invisalign with MA it’s makes it so easy actually have one of those liners here, just a little ramp that’s built on me- [Jaz]Just to really break it down for those listening and watching for those who haven’t heard of it. So Invisalign MA stands for mandibular advancement. [Amanda]Yes. [Jaz]And so what age can you use Invisalign MA? [Amanda]Well, in the US, we have it built in baked into two different systems. One is called Invisalign first, you can start that as young. They require you to have the sixes in and they require you to have for the most part two to two in at least six anterior teeth, I think is the rule. And then you have to have, you have to be in kind of that intermediate transition where you haven’t lost the back teeth yet because it needs retention. So you know, kind of in that six to eight incisors and six is in is when you can do Invisalign first and the left is not that on that. So to be honest, you can get the same outcome with just a twin block or a bionator which is a functional appliance like you reference and the lab fee on that is only going to be like $100 US as opposed to $1,200 US. So I’m all for that you know and then they can have fun and they can bling it out with colors and glitter. [Jaz]Very good. And in terms of what do you do when you’re too late in terms of you see a child and they’ve missed the growth in terms of you know, the news you give their parents as you just have to wait to a phase, well what would have been phase two, but now it’s going to be their phase one. And essentially, they’re more likely to then need extractions. And that’s generally the the main theme of this conversation is that the benefits of phase one is that it may make a simpler treatment plan later on, and also one that can prevent extractions, right? [Amanda]That is totally true. And I mean, I’m just going to tell you my own opinion, and there’s almost no research on this. But I do follow two of your really good bloggers or podcast hosts. One of them is John Mue, who’s in the UK. He’s pretty incredible. I know he’s a little controversial, but he’s fabulous. I think he’s fabulous. I’d love to meet him someday. The other one is Kevin O’Brien. He’s incredible at breaking down research. And I believe he has some blogs just on that topic. But I do know, there’s a lot of really anti-extraction people that are out there, and I’m definitely one of them. Listen, I’m telling you from my experience, and this is just my personal opinion from what I’ve seen. I feel like the orthodontic community is afraid to do research on this because we’re afraid to get the answer. But I definitely think there’s a correlation between extractions and OSA. I’ve seen it, I see it with my own eyes, my husband sees it with his own eyes. We believe that. So anything we can do, and not to mention, they look terrible, they look sunken in and they get older, you know, adult patients come in and cry that they had four bites taken out or two bites taken out. And they felt like they were never given a choice. They were never given an option. And they feel like it’s ruining their lives and their health. So if there’s anything I can do to stop that, in a new generation of kids, I want to do it. [Jaz]Very good. And then that’s a very noble sort of mission. I think the more we educate ourselves, the better equipped we are to have those conversations with parents either treating it ourselves, getting the training that’s required, or referring it to someone local specialists have a good relationship with them. It’s a really important thing. So let’s just summarize some of these diagnoses that we can make as a GDP. So you mentioned about the crossbites so they’ll narrow maxilla, watch out for a narrow maxilla, watch out for the increased overjet, what about deep bites? Is that a role for phase one therapy for deep bites? And if so, what does that look like? [Amanda]Definitely, definitely. And I have all my toys here. There’s a couple different ways you can fix it. And anytime you have a deep bite you need to find out is my deep bite due to over eruption of the incisors, be it the uppers or the lowers and you’ve been I mean, the ceph is the gold standard for this diagnosis. Obviously, I don’t want you guys to be afraid of cephalometric or lateral cephalometric x-rays are actually really really easy to understand. If you can get one and then I’d be glad to give any of your listeners a free handout, I’m trying to understand them. But in any case, things you can do just without taking that stuff because I know that, that’s a lot to do is just get the child a smile look at obviously you might see a deep bite and a deep bite obviously as when ideal for vertical is when the child bites down we want to see at least half of their lower incisors. You know the the upper incisors should not completely encompass the lower incisors. And definitely they shouldn’t be hitting up on the roof of their mouth and causing trauma. Real quick, fun story. Other people may have heard, I had strict teeth, but a deep bite that was the only malocclusion I had. And my parents, you know, really couldn’t afford treatment at the time. And no one ever told them I needed treatment because my teeth are straight. I just had a deep bite, right. So you know, I went on through high school and then later one of our dentists finally said, ‘She has a really deep bite, she’s causing trauma on the roof of her mouth.’ Well, my top front permanent teeth were all damaged from fremitus, I had no roots left, I had completely busted up those teeth and permanently I have literally have no roots on my front teeth. They’re just crowns. And they’re still there. I was told I was gonna lose them when I was 12. But I just can’t eat, I can’t bite into apples or corn on the cob or bagels. So it’s like terrible, right. But if I had been treated properly in phase one, I would not have what I have now, which is a really big life changing, you know, you have to really alter things in your life. So yeah, so you have to see if there’s, check the smile line. If you see a really gummy smile, you probably give me an absolute intrusion of the incisors, which isn’t hard, you can do some braces, you can do it with you know, just some aligners to push them up, there’s lots of things you can do. Or if sometimes it’s relative just having a very low jaw angle, we call that brachiocephalic. And you can do something called a fixed bite plate. Or it can even be baked into the aligners and it’s basically just a thick thing that they bite on. And again, you can make colors and glitter and glow in the dark. And it’s just you know, to bands, almost like a space maintainer. Lab makes it you just put it in and they wear it for about four to eight months, and it prompts the bite open in the back. So the back teeth can’t touch and you know, teeth always want to touch. So if they’re not touching, they’re gonna super erupt a little bit. And then that helps to open the bite in the back. And usually it’s a combination of both that you do, but it’s really not that hard. And it really does need to be fixed. And it’s much easier to fix in kids than in adults. [Jaz]And what percentage of these patients that have phase one therapy go on to need or want because they’re two different things, I suppose need or want phase two. [Amanda]So I usually end my phase one and that’s a great question. For me, everyone’s a little bit different, phase one is defined ended for me once the bite is fixed. And if we needed to throw some braces or do some, you know, express aligners on the front teeth to for either cosmetic reasons or for functional reasons, like if there were impacted canines, and we wanted to consolidate the space to give them more of a chance to erupt more, if we had anterior crossbite, then we would do some type of braces on that. Otherwise, it’s just fixing the bite. So I’m done with phase one, when two to two are straight, you know, if needed, and the bite is fixed. So we have, you know, perfect bite, no overjet, no, negative overjet, no vertical issues, no open bite, no deep bite, and no transverse issues. So we’re gonna hit it all in all planes of space. So if you do phase one properly, and you’ve done all that, and you know, we basically waiting for the 16 more teeth to come in, right? We’re waiting for threes, fours, fives, three fours, fives and all four quadrants and sevens, not going to count eight, because they’re not that important. Which is 16 more teeth. So usually, if you give the teeth room to come in, and you get rid of all the vertical issues and transverse issues, usually they come in pretty darn straight, you know, can always I mean, with my two kids, I did phase one on both of them. My older son, he didn’t need phase two at all literally, he looks like he had braces, never had any braces, never had any aligners. I think upper left two is rotated like three degrees, like I can see it with my eyes, you know, he goes, ‘Mom, no one sees but you.’ But I mean, let’s just do some invisaligneExpress. Let me make it perfect. You know, the girls are gonna like it. He’s not interested, too busy. So, but I just did phase one. And if you you people think, ‘Oh, well, maybe he didn’t need it, dude.’ He had 100% deep bite and five millimeters overjet, he needed it. So, you know, we took care of it at a young age, and he’s good. Whereas my daughter, you know, couldn’t control it, she ended up with an impacted canine still. But I kind of knew that, that might happen. It was really bad when I took the OPG at age eight. So we did have to do ligation and exposure and phase two, which she’s not too thrilled about. But, you know, it would have been so much worse if we hadn’t done phase one. So at least we didn’t have to do two. So, you know, trying to be positive. But you know, that’s worst case scenario, what happened to her best case scenario? What happened to him? And you know, he can’t predict but all you can do is have the odds more in your favor. [Jaz]What do you tell the parents? So like did you give them a percentage chance? I think impacted canines can be quite tricky. But when it comes to, you know, deep bites, crowding, large overjet. What do you say to parents in terms of because they might ask, okay, if I have phase one, now, I may be paying a lot more in the future, if my child needs a phase two. So how do you pitch it to the parents? [Amanda]Yeah, I mean, well, we tell them that we’re taking something that’s very long and hard. That’s about two years, which, you know, your traditional comprehension is comprehensive treatment is when the child is really, really busy. I mean, 13, 14, 15, 16 year olds are busy, busy, busy and busier than ever, they’re doing sports, they have their studies, then they don’t want to wear things. It’s an awkward time. It’s a terrible time to have braces. I mean, we all went through it. And it was, I did later. Finally, later in high school, when I got my braces, it’s a rite of passage, but it doesn’t have to be why. I mean, I look at my daughter with Invisalign now and she’s gorgeous, to be honest. It’s a 13 year old, and then she looks at the picture of me when I was 13. And she’s like, ‘Ew, she was so awkward.’ But why not take away that, you know, and let them be more have more self confidence. And, you know, and plus, it’s less busy for the parents. They’re already so busy anyways, why have to go to the dentist every month? It’s a hassle. But yeah, to answer your question, I can’t promise all I can do is promise you that it’s gonna be easier and shorter. That’s all I can promise you. And occasionally, it’s not needed. It is an air quotes. Because I mean, like I said, my son still has a rotated number upper left two. Well, is it needed? No, not at all. It’s completely cosmetic. So, certain percentage, definitely, we’d have more of an idea after Phase One was finished. But I mean, think about transverses. If you correct it, it doesn’t relapse a vertical if you correct it, it doesn’t relapse. AP, if you correct it, the only thing that could possibly get worse and overjet will get worse, but a negative overjet could get worse. So if you were class three, you can have a late jaw growth. So that is one thing I can’t control growth. I mean, you might get that in a boy, if they were class three, it’s possible. But hey, if I can stop you from having job surgery, you know, like 50,000-100,000 US dollars, you know, no one wants to put their kid to surgery. So I think I feel pretty confident you will have to do this jaw surgery most likely. [Jaz]Well, before I share with you a sad story. Actually, I’m just completely off script. I just thought of something I want to show you get your opinion very interesting. While I’m finding the photos, essentially, I’m gonna show you a photo of an eight year old child that I referred to a specialist because I thought this kid definitely needs intervention phase one ASAP, and what happened and I said, ‘Mom, look, I really think there’s an issue here. I think it’d be wonderful. You can get some expansion here. And then the orthodontist had a completely different opinion. And the orthodontist belittled me as a lowly GDP and said that, ‘You know I’m a specialist, he don’t know what hes’ talking about. We’re going to wait until this kid is 13, 14, and then we’ll do it.’ Now I’ll show you this photos and maybe you’ll think, ‘You know what Jaz, maybe he had a point.’ And you know, I’d love to get your opinion. But while I’m finding this photo, I’m gonna switch gears and while I’m finding this photo, I just want answer a very good question that I think will help the GDPs listening is that, once you finish phase one, what kind of retention protocols are we looking for that young patient? So what kind of retention will they be having? Is it always gonna be a holy? Because the acrylic allows you to maintain that expansion? Or can Essex style retainers work well to prevent relapse of expansion? I’d love to hear that while I find the photos. [Amanda]Sure, sure, sure, I’ll be glad to talk about while you look for your photo. So, think really depends on what you did. So after I expand, I do transverse expansion, I leave that expander in for a good three to six months, so it doesn’t relapse. So I’m not worried about that. Same thing I said overjet correction doesn’t relapse. So the only thing that you really have to retain would be if you decided to retain like two to two alignment. If you did end up doing some braces or aligners, that’s a good idea to retain that. I do want to, well, mostly one of two different things. One would be a bonded retainer that you can just slap on, it’s not going to be on forever, it’s only gonna be on for a few years, it doesn’t have to be pretty and you probably don’t even have to send it out. Just use like, you know, braided wire or one of those flat braided wires and put a couple of drops of composite on and it’s really easy to floss technique. But if you don’t like to do that kind of stuff. You can also order it from any orthodontic lab and it usually comes in a jig or a matrix and then you just drop it on, you know, etch prime bond, drop it in so easy. You can do that. Or you can with the essix appliance, obviously you can’t do a regular essix because the teeth we’ve got like we said we’ve got 12 to 16 more teeth coming in, right. So that’s not going to fit because you can’t, really have to remake it. But you can make something called a Theroux. And a theroux is a modified essix where they basically scoop out some of the areas so that they can still come in so you can look it up T-H-E-R-O-U-X, I think. Tricky to make in house but there’s plenty of labs that will make them but now you can do that. Some people also do like some of these myofunctional functional trainers they use these for retention. They work pretty well too because I mean if they’re usually already straight they usually don’t relapse that much so but yeah. That’s pretty obviously you can do Nance, you can do lingual arch on the lower just to maintain molars if you want to work on that. But for the most part, it’s not usually a huge- [Jaz]And compliance is good compliance usually with these kids, do you see much relapse? Yeah. [Amanda]No, no. I mean, these kids that are, you know, 6 to 10 they want to be there. They’re, they’re excited to be there. They’re stoked to be there. I mean, with a few exceptions, you know, it really is the parent, that I picked the parent department with, if I have a good parent that’s excited to be there and a kid that psyched to be there. And, you know, it’s all in how you talk. It’s not like, ‘Oh no, you need braces.’ It’s like, ‘You’re gonna get braces what color you’re gonna get? Or you know, we’re gonna do an expander and we’re gonna do removal one, want to see my color chart? You want to see, you can put your favorite team on there and decals, like so excited.’ So, another fun story. When I was in third grade, I wanted a retainer so badly that I actually made one out of candies, toffee candies, hard toffee candies, we call nine liters and paperclips. And I wore it to school and I said did such a good job that the teacher mentioned to my mom at conference. ‘Oh wow, Amanda doing such a good job with her retainer.’ And then mom’s like, ‘Huh, she didn’t have a retainer.’ So that, that was the sign that I was probably meant to be an orthodontist, but I never got one. [Jaz]Definitely. [Amanda]I wanted one. [Jaz]It was your it was your calling? [Amanda]It was. That was the coolest kids were the ones that had head gears and retainers. Very cool. [Jaz]Excellent. [Amanda]Do you want me to tell your readers about, what little gift we have for them? [Jaz]Yes. If you tell them about the handout, the purpose of the handout and how it’s going to help them to get these diagnoses and points as a checklist. Because I’m a huge fan of checklists, please tell them, I will to link it in the show notes. And I when our intro and outro are given a URL to go to, so they can get that PDF downloaded. [Amanda]Great. Yes. And I’m gonna give everyone who’s listening, a copy of a form called, that I created called ‘My Phase One Smile.’ And I’m actually holding it up right now. It’s a two pager, but it’s actually an interactive PDF. So you can, it’s going to ask you questions and you’re going to check them and points are going to be assigned and you know, different questions about malocclusion and habits, overjet. And you know, you’ll need like a little either a boley gauge or a perio of probe to do the measurements because obviously my eyeballs can measure things very quickly without a gauge, but you’re going to need that. But that’s pretty much all you need. And you will need an OPG or pano x-ray, because there are some questions about canine impactions and angles and things like that, but it’s really not that hard. And it’s going to spit out a score for you somewhere between 0 and 80. If the lower the score, if they’re less than 20 points, they probably don’t need phase one treatment. I recommend that you keep them on six month eval. If they’re 20 to 40 points, it’s strongly recommended that either you do it in house or you refer and find an orthodontist to do it. And if it’s more than 40 points, it’s an emergency. So it’s really, really bad. And the reason why I love it because it actually gives, quantifies and qualifies, and gives us actual score. And it’s something tangible that can be either taken to the orthodontist, you know, now, the orthodontist can’t say anything if you refer because they obviously see that the patient’s, the parents know what the issues are. Or- [Jaz]I wish I had that when I refer that patient, I’m gonna find the photos for if I wish I had that. [Amanda]And we could even fill this out for your patient, if we wanted to, and give them a score, that would probably be the best thing. Well, you may not have the OPG. So we probably won’t be able to do it. But well- [Jaz]I do. I found the OPG actually. [Amanda]Let’s do it. Okay, [Jaz]I will show you that as well. [Amanda]I’m trying to deal with my eyeballs the best I can. It’s easier when the patient is in the chair, because then you can actually measure them. But yeah, it’ll spit out a score. And I feel like sometimes also, you know, the mom comes in, but the dad doesn’t then the dad says, ‘Well, do they really need it?’ And the mom’s like, ‘I forgot what the orthodontist said.’ So now they have this handout, and they can come home and literally shut look, they got this score, that’s a bad score that we got to do it, you know. So it took me years to develop this. But it’s basically I mean, as you’re one of the more things when you do, the more you understand it, but initially, it’s like, ‘Oh, my goodness, there’s so many things I have to look at, what did I forget anything?’ This way, you just go step by step. And you’ll make sure you hit all the main points, you know, and you’ll feel very confident with your Phase One screening, and it’s so easy, literally, you’re done. A nurse can do it, your front desk can do it. It’s really, really easy. So anyone in your team, I want your whole team to be screening every kiddo in the practice, you know, so we’re not missing anyone. [Jaz]Amazing. Okay, so I’m gonna share my screen. Okay. I mean, look at this. [Amanda]Let’s do it. Let’s walk through, it’s gonna take me five minutes to go through this. Is that okay? If we go through this? [Jaz]Yeah, of course, of course, of course. And we can go through it. And I know mom’s really cool. And she will give consent for it retrospectively, and we won’t publish it. Obviously, if she doesn’t. But, have a look at this. I’ve only got these two photos that was different patient these two photos, and then I’ve got the OPG as well. So let me know what you want to see. [Amanda]We’ll just estimate but you probably remember stuff. So I might, I’m gonna ask you some questions, but let me know when we’re ready to go. [Jaz]Sure. [Amanda]All right, guys. So we’re gonna go over when a doctor Jaz’s patients that he mentioned. And we’re actually going to run through this my phase one smile index, I’m going to take you through point by point and we’re going to give this patient a score. Now normally, when you do this, it’s an interactive PDF. So it’s going to calculate the score for you. I’m gonna print out so I’m gonna make sure my math is good at 10 o’clock at night. Okay, so first of all, how old is your patient? [Jaz]At this point, he was eight and a half. [Amanda]Okay, good to know. There’s no points for that. But just the questions, so have an idea of what to expect. Okay. So the first question is, is either the child or the parent embarrassed about their teeth, the psychosocial part? [Jaz]I think the mom was very forward thinking saying that, ‘I don’t want my child to have the same issues that I have on my teeth.’ And then the child also was interested as well. [Amanda]Okay, great. So that’s two points. Is the child having trouble closing his lips over his teeth? Or are there any oral habits that you know of like thumb sucking, paci sucking anything like that? [Jaz]No. [Amanda]That’s a zero. If the child is an all primary dentition please answer this question. Otherwise, skip this question. Okay. If the childhood mixed dentition, in which we are pleased to answer this question. Does the child have crowding present? I would say yes, definitely. [Jaz]Yes. [Amanda]Definitely on permanent teeth. So that’s two. Okay. Is there a presence of a constricted maxilla and that’s where we’re gonna go to your maxillary arch picture that I saw real quick. I mean, obviously, I’m sure there’s but yes, that’s definitely a constricted maxilla. And we talked about the, the trick from six to six, although it’s pretty funny because on this construction, it’s a V-shaped maxilla. Sometimes you have U-shaped constricted as V-shaped constricted, so the molars might measure it 40 millimeters. It’s possible, but it’s clearly constricted and vaulted 100%, especially towards the front. So yes, I would call that restricted maxilla. So that’s going to get two points. Is there overjet? There is not overjet, but we have negative overjet, which gets points. But the other question is, is there open by sorry, is there overbite and that would be no, it’s almost edge to edge. So that’s a zero. Is there anterior crossbite or negative overjet? The answer is yes. And so we go from the furthest most deflected one, which should be upper left two, and it says how many millimeters of negative overjet? So if you had to estimate from, you know the cusp tip of lower left two. Incisal edge of lower left two to the facial aspect of upper left to what do you think the distance is in millimeters? [Jaz]I’m gonna say three. [Amanda]It’s exactly what I was gonna say. Okay, good. All right, first page. We are already at seven. Okay. All right. Let’s go ahead and put up that OPG. [Jaz]Yeah, sure. Let’s see. [Amanda]Perfect. Okay, this one’s gonna be a little tricky because I usually use a protractor to do this one, ruler, but basically we’re talking about the, if there’s any angled canines, which there clearly are. I definitely would say upper right three is angled. And they have you kind of bisect it and run a line parallel to the occlusal plane, it’s all explained. And they, we talked about how tip does that. So I’m going to put this at about maybe 60 degree angle, between 60 and 40. So we’re going to go ahead and give the six points because there is an angled one. Oh, and you have to do it for both sides and add them. So that would be the right the left one is just a tiny bit angled. So we’re going to give that one point. So that’s seven points right there. Okay. So we’re already up to 14. So we’re getting there. And then there’s a couple more. This one, we’re gonna look at the tip, the cusp tip of both threes, and by the way, yeah, so we’re just doing uppers. But the cusp tip of both threes and is it crossing over the two’s at all? And actually, we’re not on the right side and the left a little bit. So we’re gonna go ahead and give this four. So we’re at 20. Now, I think, right? And then do you think that either of these canines, especially the right one possibly could be palatally placed or buccally placed? Because it’s definitely one or the other? Because it’s taped? [Jaz]Yeah. So I will, I can just check my notes, probably. But I’m ganno say- [Amanda]Like ligation and exposure? Chain and exposure later or no? [Jaz]No, no, he’s too young at the moment, but we extracted, I extracted his deciduous canine as per the orthodontist advice in terms of to allow a better path for the eruption of the permanent canine. [Amanda]Okay, so that’s questionable, so we probably won’t get it. But at the any case, we’re a little over 20 points, which basically says consider orthodontic referral. And I probably didn’t give justice to the severity of that crossbite in the back, but it definitely would say consider orthodontic referral. So yes, you fell in the, let’s do it. And if and if that was indeed if you’d taken a CBCT. And you noticed it was slightly paddle that would give it five more points. [Jaz]Okay. Hey, guys, if you want download that document, the Straight Smile Solutions, My Phase One Smile Index, then either go to link protrusive.co.uk/phaseone, that’s P-H-A-S-E and the number one, so phase one all one word. Or if you’re on the protrusive premium, and you’ve got a membership on the app, so iOS or Android, you can download it in your infographics section straightaway. Once again, that’s protrusive.co.uk/phaseone, or via the protrusive app on iOS, or Android, this is the same PDF that we were talking about in the episode. And it’s really useful to go through with your growing patient. So that’s either for slash phase one, or from the iOS or Android app, just such protrusive on the App Store or iOS store. [Jaz]Fine. [Amanda]So you did the right thing. [Jaz]Yeah, but I mean, in your experience, and whatnot, and what you teach seeing a child like this, do not feel that there’ll be some benefit to doing some expansion? [Amanda]100% And then we didn’t even we don’t even have the whole airway thing factored in here. You know, I probably would have said recommended doing us a Stevie are asleep for him. And I have kids, one of everyone for Papi. I’m glad to give it to you just screening all different things about snoring and how they breathe. And certainly there was- [Jaz]So he is a mouth breather that can tell you that right now he is mouth breather. [Amanda]Boom. And that’s a 100% do not pass go collect $200. Yes, you get started if you have any airway issues, or a mouth breathing, because it’s gonna make the face grow long, you know, and we didn’t even get into the whole face thing or anything like that. So obviously, there’s a couple of things I noticed here that concern me. This is a boy you said, right? [Jaz]Yes. And I think he’s about nine and a half, I think. Yeah. Okay. So [Amanda]Yeah. Okay. So- [Jaz]He was just slightly delayed. [Amanda]It’s a boy so less urgent for me and unless I started to see him developing a beard or something like that. And he’s six foot tall. You know, I’m not as worried about the skeletal issue on a girl I’d be flipping, but boy, I’m not as worried about that. So yes, in theory, you could wait till age 12 because it will still be fixable at age 12. But the airway is something that’s critical, 2 years of not having an ideal airway and growing in the wrong direction is gonna get worse. Also, I’m worried about the ones you know, the front teeth, that you know, they basically almost one on top of another, you know, negative overjet and you’re gonna have wear. They’re probably going to chip him. This kid is active, this kid’s gonna go bike riding or you know, put ride a skateboard he’s gonna totally chip it, you know, upper ones I know it’s gonna happen. [Jaz]Yeah, so he has already and it hasn’t happened already. We’ve restored with composite, the upper centrals, so that’s happened already. [Amanda]Yeah. So we got that, you know, and like I said, you could theoretically fix it when he’s 12. And he hit it right before he grew. But you know, we’ve got the wear that’s gonna get worse. We have the growth that is going to get worse so and then that canine if we don’t do something now the chance of it being impacted is exponentially higher. And you know, taking up the seats is great. But that’s still not giving that canine enough space to come down. It’s not going to come down unless expand. [Jaz]No, I was only doing what the official advice from the orthodontist came to be. But yeah, I was a little bit disheartened that the orthodontist had zero interest. And this is purely in my opinion, just the way that UK orthodontics is set up in terms of funding and preference. And I’m happy to be shut down on that from any UK orthodontist listening, but I don’t feel that this, clinically, if you put money and funding aside clinically, I think there was a need for treatment. So the mother was upset, I was upset that this wouldn’t be able to be done. And they are now considering going the private route to get done rather than relying on the National Health Service, which rejected this case, basically. So having that kind of having the kind of a checklist like you presented, it’s great that we went through it can be really, really helpful. And I think in hindsight, if I had a checklist like that, to give to the orthodontist, so that they can see my working out, they probably wouldn’t have been as flippant as they were towards me, in terms of how the referral came to be [Amanda]They would’ve said you have 20 something points, you need to have and like I said that for me, airway is always a yes. So you know, should be another score. But that’s so hard to quantify. But what you told me it’s definitely a yes. So what ended up happening then? So are they still looking, they’re still looking for- [Jaz]Yes. So it’s still a patient, I still do provide his routine care, I extracted the canine and a deciduous molar as per the orthodontist advice. And so now, the next step is okay, ‘Mum, do you want to take next door to the private orthodontist? Or do you want to wait until age 12? Plus when all the teeth through to have some treatment then?’ So that’s kind of where he’s at the moment? [Amanda]Yeah, but most likely, he’s going to need canine exposure surgery, possible pre-molars out, there’s a lot of things just going to be so much more painful and complicated if they wait. [Jaz]I agree. I agree now. So Amanda, thanks so much for spending some time with us to guide us through these things. These things are very scary for GDPs. You know, when you’re looking at treating children, it can be outside the comfort zone for a lot of GDPs. But I think listening today, the most important thing we got from today was just knowing which diagnoses would benefit from phase one, and being able to diagnose and be aware and have that conversation. Now, some dentists may feel that they can, ‘Hey, I know maybe I can help my patients out.’ And that’s where I can get further training. I know you do lots of training and stuff. So I’ll put the link so they can reach out to you make sure you download, the download, which I’ll put the link source so you can actually get that PDF. So next time you’re referring, if you’re referring or treating. So whether you’re justifying to yourself, ‘Hey, am I right in thinking that this patient may benefit from interceptive orthodontics and you can go through a checklist?’ But even if you’re referring for your peace of mind, it’s good to show the working out to the orthodontist, you’re referring to potentially, to show them your thought process and how you follow something logical in terms of diagnoses. So I think that handout will have incredible value for those listening and watching. Please tell us some other channels that we can reach out to you Amanda? [Amanda]Sure, no problem. My website is straightsmilesolutions.com. So Straight Smile Solutions, plural, and you can Google it, it’ll pop up. And on my channel, I also have that access or that link to that 6500 ortho educational videos that are totally free and might occasionally see a Google pop up ad. Basically pays for my Starbucks occasionally, but that’s about it. But um, there’s just I, my goal, like I told you guys is to help to make kids happier and healthier and have to pull out less teeth, you know, and prevent surgery. So if I can give away information, then I think I’ve done a good thing in life. So you guys, it’s out there. It’s free. Enjoy it. [Jaz]Amazing. Thank you so much, Amanda, it’s been it’s been great to have you as a really passionate guest, and then someone who’s empowering to dentists, who’s going to help us treat children at the right time to get better care, and better growth, better airways, and less need hopefully, for phase two and extraction. So thanks so much. [Amanda]You got it. Aloha guys. Jaz’s Outro:Well, there we have it guys. That was Dr. Amanda Warson. She’s so energetic and enthusiastic about the development of these young people, and how with the relevant phase one, you could really help these patients avoid a phase two or less complicated phase two. Now, wherever you are in the world, remember that the system that you’re in, it can be difficult to implement these things and also depends on medical legally, where you stand in being able to implement phase one therapy to have the right training and mentorship behind you. But I think we’d all appreciate that all the things that Dr. Amanda Wilson talked about. These are things that we should be looking out for in growing children. And it makes sense when we’re looking at the development of facial and occlusal development of our young growing patients that we look out for these things and refer when appropriate. So have you found that episode useful, and I join you same time, same place, next week.

Is flapless implant placement really a solid technique? What percentage of cases are amenable to flapless implant placement? The cynic in me wondered if this is indeed a novel technique, or was it made mainstream to attract Dentists who seldom raise flaps? I brought on straight-talking Implant genius Dr. Pav Khaira on today’s Group Function to discuss flapless implant placement – ‘what’s the deal?!’ https://youtu.be/679HAttBQ1c Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 4:36 The Rise of Flapless Implants 7:04 Indications for Flapless implants 9:43 Immediate implant placement 13:59 Advice to Young Dentists considering implants 18:56 Implant Mentorship 24:11 Dr. Pav’s Implantology Course 27:46 From Course to Implementation Check out The Dental Implant Podcast for information on dental implants and the Academy of Implant Excellence to learn how to place implants or upgrade your skills. If you enjoyed this episode, you will also like ‘Can I Probe This Implant?’ Click below for full episode transcript: Opening Snippet: You pay to learn in one fashion or another. This is something I've said before, right? Is you either pay your mentor to show you how to do it. And when you do it that way, you'll avoid most of the pitfalls, okay? Or you don't pay your mentor you have things go wrong and then you've got to pay out of your own pocket. Of those two scenarios one leads to a happy patient and another one leads to an unhappy patient. Jaz’s Introduction:Are flapless implants a thing or are they a fad? I feel like there is a lure of some courses that want to attract the inexperienced GDP who perhaps is afraid of surgery or averse to surgery who can’t raise a flap and they thought you know what, if we start teaching a guided system that doesn’t involve flaps and maybe the dentist will come and learn implants and place our implants so that is the cynic in me thinking that but I got on the main man who knows everything about implants Dr. Pav Khaira on today on this group function about IS THERE A PLACE FOR FLAPLESS IMPLANTS? And of course from that we go into different directions in terms of okay, when is it suitable? When is it contraindicated? What are the problems? And how we can learn more and get into this field of implantology. If you are a novice if you are someone who’s thinking about it, but you’re afraid to make that next commitment. How does one get into the field of implants are huge daily topic for young dentists. Main Episode:So let’s join this group function with Dr. Pav Khaira. Dr. Pav Khaira back again for the third time from the dental implant podcast. How are you, my friend? [Pav]I’m very good, how you doing? [Jaz]Amazing. And last few times you came on you really busted some myths and you helped us to understand some basic things. Can we probe implants? What happens when an implant is bleeding? The soft tissues are bleeding. How can you tell if you’re too worried or not? So you cover these really fundamental topics. And you guys if you haven’t listened to ready, listen to those. And of course we had you on for finding your niche in dentistry. So you’ve done some pretty big topics. And when this topic came along about flapless implants, which what we’re talking about today, and I can’t wait to dig into that. But just for those people who haven’t listened to that those episodes yet, and I will urge them to check out those episodes right now, those watching on YouTube, the thumbnails be flying up, you need to listen to those previous episodes to really appreciate all the wonderful things we’ve covered so far. But just tell them about your week to week, day to day dentistry that you’re passionate about. [Pav]Jaz, firstly, thank you for having me back again. Secondly, all I do is place implants. That’s it, I don’t do anything else. So what’s the best way to frame it as an average implantologist and average busy implantologist that quite happy to place 200 implants per year, I’m very fortunate to be in a position where I’m placing about 1800 to 2000 implants per year. So you know, my, in the last few years, you know, my experience is going up significantly. And I say that from a point of being humbled because I thought I knew what I was doing to start with. And then you start placing that volume of implants. And it’s just like, whoa, actually, this is different game. You got to relearn your skill set. So- [Jaz]I see the crazy and amazing you know, life-changing transformation that you do on our telegram group, you know, so good at posting notes and the radiograph before and after. And so if you’re a little bit of burst of blood, you probably don’t look at those posts from Pav. But then he’ll show you anatomy that you never knew existed. He’ll show you what the pterygoid plate looks like. He will tell you all these cool stuff. But with the basic stuff as well, which you cover so well. So it’s been great on the telegram group to see your cases. [Pav]Yeah, I mean, you’ve seen some of my zygomatic implant cases, you’ve seen some other cases where, you know, patients been in dentures for 40 years, there’s no bone left or have to think outside of the box a little bit. And we showed you that case where you know, the mandible had atrophied where it was only 11 millimeters in height, and we were placing 10-millimeter implants. So yeah, I get to see some crazy stuff now. And again, it’s just transforming people’s lives. It’s just, you can’t put a finger on it. It’s just amazing. It’s fantastic. [Jaz]I can see that in the in the postdoc portrait photos in the eyes of the patients, the kind of work you do is very transformational. So it’s great to do any part of that and to see that, and today we’re covering flapless implant courses and just technique of flapless and the position I come from Pav is as a position of being a cynic, in the sense that a few years ago, I started noticing all these like pop up courses, now I don’t place implants, right? But I’m very keen restorative dentist. So I refer out to colleagues who do place implants, but I did see a surge in courses saying, ‘Hey, you don’t even need to be able to raise flaps to base implants, flapless implants.’ And I’m thinking, my worry Pav was, are these courses being set up because they recognize that dentists who don’t raise flaps who can’t raise flaps, this will be an easy lure to get them in to implants. Is that what it was? Or is flapless a valid technique? And that’s a big level question. You’re probably going to break it down which you’re very good at doing, but that’s the position I’m coming from. Is it a fad or is it a thing? [Pav]So let me spin this question around for you. So if something sounds too good to be true, is normally too good to be true, right? So there is a position for flapless implants, here’s the key in the correct circumstance, they’re fantastic. Okay? There are a number of courses available now where it’s very much, as you said, you don’t have to be able to raise a flap, we will do it guided, we will plan it for you, all you have to do is a tissue punch, and then you use the guidance system. And then you place the implant, that’s it. Jaz it’ really not as simple as that, right? You need, you need a certain amount of bone volume around implants, you need a certain amount of soft tissue around implants, not only do you need a certain volume of soft tissue, you need a certain quality of soft tissue as well. And if you’re doing flapless, you may end up having just enough soft tissue, and then you do a tissue punch, and all of a sudden, it’s gone. So what do you do, then, because you’re immediately on the backfoot, with this case, this case is likely to start sliding backwards really quite quickly. And here’s the other thing, as well as what do you do if the guide doesn’t fit? You know? There’s a say, when you get into that implant ecosystem, when you get into that implantology world, once you start doing a number of cases, everybody says the same thing. Guided surgery is great. Okay, it’s really, really good. It’s got a great position in implantology. But you should not be using guides unless you can place freehand. Because your guide doesn’t fit, you’re then relying on this, what’s in between your ears, and you’re relying on your hands. [Jaz]I see as a non-placing dentist, I didn’t even occur to me that you know, you can put in there just like obviously, it’s acrylic and whatnot. So there’s a good chance it might not fit or chance that the measurements are skewed or whatnot. And so it makes sense to me now thinking as a restorative dentist, but you’re right, if that doesn’t fit, then your whole plan is gone. And therefore we need to be able to pivot onto a Plan B or Plan C, which is where I guess you need to have the knowledge and skills beyond just as one way of doing it. So I guess my next question is, what percentage of implants do you place that are flapless? And maybe because you’re different, I don’t know, what percentage of implants do you think are amenable to flapless technique? [Pav]I’d say about 10%, which is quite low. And the reason for that is quite simple. There’s really good data nowadays, that you need a good band of keratinized tissue around implants. But in addition to the good band of keratinized tissue, it needs to be about two to two and a half millimeters thick. And in a lot of areas, particularly in the mandible, that isn’t enough soft tissue height. In order to achieve that two to two and a half millimeters, okay, then it goes back to what we were saying a few minutes ago, if you do a tissue punch, whatever was there all of a sudden you’ve gotten rid of. So when you don’t have enough tissue, there are a number of tricks that you can use to increase the thickness of the tissue. But you can’t do that with guided surgery. Now, you won’t have any significant problems with it in the short term. In the short term, it’s going to be fine, because you’re like, Wow, this is easy. What is everybody complaining about? All you do is tissue punch, place the implant and put it in through the guide. That’s it. But what happens Jaz, is over a period of time, let’s say over about, it’s the medium term that you start to develop problems, right? So probably about three, four or five years down the line. That’s when you start to get the early stages of kind of like perio-implantitis and you’re getting it for no other reason, then you don’t have enough soft tissue around it. Now there are- [Jaz]By that you mean like a cuff of keratinized tissue? [Pav]Cuff of keratinized tissue, yeah. So you need a cuff of keratinized tissue, but it needs to be about two, two and a half millimeters thick. Now there are so many factors involved in this right? It’s down to the restorative material that you use, it’s how you do your osteotomy. How long you wait for it to heal. It’s how you deal with the connection. It’s how your lab workers were processed. It’s how your lab works cleaned. It’s how everything’s fit together, when it comes back from the lab, there’s many, many factors that are involved in this. But a very big factor is good quality and good thickness of soft tissue. And without that good quality and good thickness of soft tissue, which you can’t always achieve with flapless is you’re starting to ice skate uphill, and it’s gonna go south. So when I see people out there whether turn around say ‘Oh, just do everything flapless.’ Is that is not the right approach. Now as you can appreciate when you do an immediate placement quite often that is flapless. But it’s still a different skill set. [Jaz]And perhaps just because of the you know, some students or younger dentists, who you know, just new to the term ‘Immediate Placement’. I know for you, it’s something that you’re very familiar with, define immediate. [Pav]So immediate is basically take the tooth out and put the implant in straightaway. It’s a little bit more intricate than that because it’s like, oh, it’s within a certain number of days and weeks, but let’s just keep it simple tooth comes out and go straight in case. So there’s a tick box that’s that I’m looking at, in my mind. So once the tooth out, I’m looking at a number of parameters, and I’m going tick, tick, tick, tick, okay, let’s put the implant in. If I’m going tick cross crosses, like, you know, I’m just going to do delayed placement in this. So the term immediate implant is the implant goes into place, the same visit that the tooth comes out. And what’s the benefit of this to the patient? Is a shorter overall treatment time, because then you’re not waiting for the site to heal. The downside to it as a surgeon is it’s much trickier to do because you’ve got less bone to play around with. Your implant positioning needs to be pinpoint perfect. You can’t do that with a guide. Not always anyway. [Jaz]And so in those cases, where you do immediate, what percentage of your cases do you think maybe not your cases, but because they do so much varied work, but the average GDP, what percentage of their cases do you think they’re able to do it as an immediate technique? [Pav]So the immediate technique is not actually an easy technique to do. It’s quite advanced. So I always say to the people that I’m mentoring people that I’m teaching, is just start off, taking teeth out, wait for it to heal, and then put it in. As your skill start to expand, then you start to do immediate implants, because what you’re going to notice, soon as you start immediate implants, your failure rate is going to spike, because you’re not used to doing it. But like everything persists. This is something we’ve spoken about before building muscle memory, okay? Is you persist with it, keep learning, it’s a new technique, and eventually your failure rate will start to come down, your success rate will go up. So how many cases do I think the average GDP could probably do immediate placements? Probably about 40%-50%. [Jaz]Oh, wow. So once they’re built in, and once they got their first few dozen cases under their belt, and they’re waiting for the correct healing, and follow the protocols that are a bit more basic, and then they start pushing their boundaries a bit. And then eventually, once you have a lot more experience, you think about 40% of implant techniques are probably suitable or meet the criteria for immediate placement. Fascinating. [Pav]Yeah, absolutely. So I mean, my immediate placement is much, much higher, I probably push to about 90%. But then I know how to deal with cases where, you know, the textbook, say, ‘Oh, it’s not suitable for an immediate placement.But I know techniques where you can really quite predictably do an immediate placement. Do you always get it right? No, that’s the nature of what we do. But that’s, that’s true in every single field. But, again, again, it comes back to just a stepwise progression in your skill set and your career and your understanding and your knowledge. You know, we all started as novices, you know, there was one point in my career, I was just like, ‘I am never going to place an implant in my life. I hate surgery.’ And here I am, my day doesn’t start until I cut somebody open and they start bleeding. So it’s been a fantastic journey for me. [Jaz]Yeah, I always knew you when I was like a dental student, I was like early years and you were like the occlusion restoratives, TMD splint guy, and I’ve seen you, you know, you did the masters. And you’ve been on all these courses around the world. I’ve seen you, I’ve been following your progress. And now the volume of implants you’re doing it’s just been really lean in, gone in, as we discussed in that episode about finding your niche and how you really went all in on it. And then hats off to you and lots of admiration for that. So I think any is a great example to anyone who really wants to commit to one field. But let’s say a young dentist wants to, as we do at some stage we have to then consider, is implant dentistry for me? And we realized that UK undergraduates, you can barely place a crown yet, let alone think about implants. So once you’ve got your basics, your fundamentals, where does the basics of surgery come into it Pav you think?Because I now, I’m happy to raise a flap. Yeah, my flaps aren’t brilliant compared to an oral surgeon. But I’m pro GDP. They’re pretty good, I think. And I can section elevate, I’m very comfortable that I’m happy to even post videos of that which I do on YouTube. So I don’t worry about that. I am now in a position where if I wanted to implant the surgical bit doesn’t worry me and scare me like it did maybe four years ago. So if you’re that young dentist who is considering implants, what advice would you give them? Would you say go down the path of going oral surgery course first, learn how to take out teeth, learn to raise flaps, lift periosteum suturing and then go and implant course? Or go on the implant course where you might then learn those surgical skills as well? [Pav]So the answer to that is, is either all you can do either or, probably the easiest way to do it is to get some surgical experience first. But I know plenty of people who have gotten into implants and they’ve just learned the surgery as they’re going along. Here’s the key. Make sure you have a damn good mentor to show you how to do it properly. Okay, so unfortunately. I have a couple of people that I was mentoring and I stopped mentoring them because they weren’t following instruction. Right. And I was saying to him that this is also what we do in implantology. Whilst the core skills are the same. how you execute it can be slightly different depending on the case. So Periodontal Surgery is not the same as implant surgery is not the same as oral surgery. Although the basic tools may be the same because the old design outcomes are different, right? So if you’re executing treatment based upon what your desired outcome is, so why I always say is that look, if you want to get into implants, don’t let anything stop you. But understand it’s not you do a quick course. And then that’s it, you can do everything. So right, here’s a mistake that I made when I was younger, right? Is when I did my first implant course. And this is one where you go for one day a month for 12 months, right? Is the guy who’s teaching me used to do a lot of all-on-four. And what I used to do is I used to go to his practice, I used to sedate his patients, because I wanted to watch do all-on-four. Because as you’re learning implants, you think, ‘Wow, this is the sexy stuff, this-‘ [Jaz]The pinnacle. [Pav]This is the pinnacle, then you start doing all-on-four, you realize it’s not the pinnacle, even remotely. And not only that, but it’s not as easy with what it looks like as well. There are some people out there who make it look easy, right? And this is the mistake, my third solo implant as a case by myself without a mentor, I decided to do upper and lower all-on-four. Because I’ve seen it 15-20 times I was like, ‘That looks easy.’ [Jaz]Can I just point out to everyone who doesn’t have, I know Pav having a little bit better than someone who might be listening. And I know that perhaps the kind of guy who in his first year of dental school, he was like, you know, did a fullmouth rehab, right? And he you know, I know your story. So like Pav is really good at you know, he’s a massive geek, huge amount of knowledge. And he is not afraid to implement. So that doesn’t surprise me one bit. [Pav]And the deal that I came up to with the patient, because I said to the patient, I said, ‘Look, I’ve done an implant course, I haven’t placed many implants.’ But she because she couldn’t afford the treatment. And I said to her, ‘I’ll do the treatment cost for you, which was 7000 pounds.’ Now the treatment, the treatments supposed to cost 36,000 pounds. So for her, it was insane discount. So I did the treatment, and it went wrong. And I didn’t know how to fix the case. And I had to then ask a mate of mine to come in and fix it. And he was like, fine, I don’t mind doing it is gonna cost you 32,000 pounds. So I had to pay that out of my own pocket to fix. [Jaz]Wow. You did right by the patient. And I admire and respect you for doing that. Because you have to. When that kind of happens, but then the lesson you learned there was- you need that. Yeah, you need that mentorship for those educators, right? [Pav]Yeah. So and this goes back to what I was saying is with the right mentor, and with the right person just guiding you, they should be able to actually make the process really easy. Because to be honest, is if you’ve got let’s say, let’s say an upper five, or an upper six and upper first molar in a healed site where there’s plenty of bone, right, is in those cases that they’re in the ideal cases, they’re out of the smile line, there’s normally plenty of bone is it’s really easy in those cases to teach implants. Because it just like, right, we’ll show you how to do this. And what happens is four or five cases in you start to pick up the nuances of it like how to hold the blade, which blades to use, and your instruments are important as well, right? A lot of people are using the wrong instruments. And if they’re using wrong instruments, you know, I had a mentoring with with a gentleman, I did virtual mentoring with a gentleman from the States. And he was having a lot of problems, because his kit was old and worn. And I said to him, ‘First thing you need to do is buy a brand new kit.’ They bought a brand new kit. I told him exactly what to get half of his problems went away just with decent instruments. All of these things play a factor. All of these things play a role, but you don’t understand it until somebody shows you. [Jaz]Yeah, yeah, absolutely. So in that vein of how do you find that person to show you, so the question is, where can you find impart mentorship? Now I do want to talk about the cool plans that you have. And I’m very excited to read about that. And I want to learn about that. But and then that’s something I know he’s gonna be having an international reach and stuff. But if you talk generically, how do you identify a mentor in implant world? And then please tell us about your mentorship services, because I know that they’re very prominent, like you said, you teach that guy in America, but I know you’ve got really grand plans as well. [Pav]So firstly, what I always say is that the people that I mentor I’m very picky and choosey with regards to who I mentor. So I’m not I don’t get on well with people who kind of like want a cookbook approach. I like people who think and want to be challenged and are prepared to put in the work, because that’s exactly how I was when I was younger. And I think that you can’t really teach this type of stuff if you’re looking for a cookbook approach. Because if you look at any one single scenario, there’s probably seven different ways to do it. So you need to think well, if I do it this way, what can potentially happen and then if that happens, how do I fix it? So I only really mentor very select people who think. So my mentoring works in a number of ways, either people bring their patients to see me, or for a day, right, I will go to their practice, but it’s easier for them to bring their patients to me, because for me to get a day in my diary is booking months ahead. But- [Jaz]Those are the most common ways because I know a few of my colleagues who’ve gone down the implant path, and then I’m very well, but in the early days, from memory, they pretty much made not much money on the first few cases because all that money was going to mentor, but the experience they were getting was worth it. Because then five years later, they can do those cases and much more complex with the experience and knowledge that they gained, right? [Pav]So what ends up happening is you pay to learn in one fashion or another. This is something you said before, right, is you either pay your mentor to show you how to do it. And when you do it that way, you’ll avoid most of the pitfalls, okay? Or you don’t pay your mentor, you have things go wrong. And then you’ve got to pay out of your own pocket. Of those two scenarios, one leads to a happy patient and another one leads to an unhappy patient and having to pay out of your own pocket for an unhappy patient. It’s really not worth it. And the issue is as well, Jaz is there’s a lot of times, people want you to think it’s easy, and it’s cheap getting into implants. It’s not like everything. It’s a journey, right? You’re not going to do a two day course on endo, and be as good as what a specialist is, you’re not going to do a six day certificate in perio and be able to do what a periodontist can, right. But if you put, but nobody was born with these skills, it’s all learned. It’s all trained. It’s all mentored. So if you’re prepared to put in the work, if you’re prepared to to execute the steps properly, everything can be taught absolutely, everything can be taught. And then going back to what we said before is a lot of dentists is it’s just a matter of approaching people for mentorship, you know, is unfortunately there’s a lot of people who don’t want to. It’s just like, No, and then there’s other people like yeah, fantastic calm. And sometimes the best way to start the mentoring is start the restorative process first. And for a busy implant practice. They love it when you want to restore. Because as an implant surgeon, I do the restorative as well. But I’d rather not could see- [Jaz]I hear that all the time from surgeons. [Pav]Yeah, it’s part and parcel. Do it really quite happily. But it’d be better if I was just placing. And so if you went to like your local Implant Center, and you know, approach them, you know, can you train me, can you show me how to do restorations. And then you get proficient at that. And then what happens is, once you understand how to restore, you’ll understand how the surgical feeds into that. And then what you do is you ask them, whether if you do a course they’ll mentor you for some cases as well. It’s just reaching out to enough people, and making sure that you’re happy with the quality of what they’re doing as well. And that’s the issue is, as a novice, it’s hard for you to gauge what’s an appropriate standard. You know- [Jaz]I love that tip, you gave that I think anywhere, any dentist listening in the world right now, if you identify the person you probably refer to already. And they probably had the same problem as you having that, you know, they’re so proficient their surgery, and they, they really learn all these techniques to develop their surgery. But then the restorative is like, okay, fine, I’ll do it. But like, I wish there was someone who I could just give this to. So that’s a great stepping stone. The other things that we covered is it’s good to have some basic surgical skills. But if you don’t then find the implant course, or mentorship, which have been the key theme for all the episodes that we covered, but mentorship is what’s going to save you from those expensive mistakes. And I appreciate you sharing your expensive mistake, and how mentorship and perhaps too soon, you started to go solo. So with that in mind, please let us know because I know you’ve got something pretty exciting coming I’d love for you to share with the Protruserati, in terms, of course, a structured course that’s going to have some sort of a graded system and approval from the higher powers in terms of this being you know, I mean, that takes a lot of work what you’re doing, I appreciate that, but to actually make a curriculum huge. I know. Absolutely. [Pav]Yeah. So, it’s you know, I’ve taken everything that I’ve learned from my MClinDent in implantology, all of my mistakes, all of the courses that I’ve been on, because you end up with problems in implant dentistry, and you go, ‘Oh, I’ll go on that course. It’ll teach me everything that I need to know to resolve that problem.’ But it won’t teach you everything is you know, it might reduce your problems by 20%. And then you’ve got to go on another course on another course and another course. And I’ve just taken all of that and I’ve put it into a structured program, which I’m actually going to release online. And it’s going to be modular, so there will be a basic module, there’ll be an intermediate module, and then there’ll be a mastery level module as well. And my aim is to take all of my knowledge that I have up here, cut through the marketing BS that there’s a lot, not just in implant dentistry, but across dentistry as a broad, there’s a lot of oh, well, you know, if you use this, it will make everything 1% better. And all of a sudden that 1% is- So I’m cutting through all of that. And I want to give all of my knowledge that I’ve gained over the years in a succinct course as possible. And the reason why this is important for me is it actually goes back to a promise that I made myself from my grandfather, because I was very close to my grandfather as I was growing up. And in his later years, I’d qualified as a dentist. And I mean, he lived into his 90s. But I remember a phone call that he said to me, he asked me, he said, ‘If I come out to see you, can you give me fixed teeth?’ And this was before I was placing implants, I said to him, ‘No, I don’t know how to do that.’ And he went quiet, because he got upset. And then when he spoke, I could hear that the hope had just gone from him. And that’s when he told me something, which even to this day makes me upset, he’s eternal. And essentially, he said, ‘I can’t eat with the family.’ He said, ‘I’ve got to take my food into my room, because I can’t wear my dentures, I take them out and eat by myself.’ He said, ‘I’m so embarrassed about taking my teeth out.’ He said, ‘That’s why I see if you can give me fixed teeth.’ So I never got to help him. But I made a promise that I would help as many people as I possibly can. So for me that promises helping patients directly, but also helping patients indirectly. How do I help patients indirectly? Well, that’s easy. I train other dentists how to do implants as well. But for me, I do that all of in his memory. And I can’t do that by withholding information that’s up here. You know, I can’t do it. Okay, well, we’ll do a little bit of a course. Because, you know, I only want you to do the easy stuff, because I want the referrals, I have to give 100%. So this has been my philosophy when I’ve been building this course, I really, really want to make this an absolutely phenomenal course. And I’m in the process. And like you said, it is not easy. Because there is so much paperwork involved. [Jaz]There’s a white tape to get through to get the correct grading for the proper curriculum of the course, behind it, but I mean, for me that the layers of it is great. They’re pursuing letters, but me and you both will agree that the letters is not so much as in terms of the implementation of the knowledge and how you can actually start placing implants, right? Because Pav I’m sure you know, so many dentists who have been on implant courses, and they just placed one or two or just never did, and they just fizzled out. And it’s only maybe someone said about one in eight dentists actually goes and of course, that actually really, you know, flies afterwards and starts placing implants. So what do you think is the secret sauce to make a course like you are, and I’m sure he had been at the very front of your mind to make sure that all the dentists able to implement as much as possible? [Pav]So I think the secret sauce is is building real confidence, and making sure that you’re exposed to enough surgery, so that you can actually build that confidence. So for me, a big issue is a lot of the information that’s given in courses is not succinct, it’s a bit wishy washy. And a lot of people come out confused at the end of it, you know, so I’m not saying, please understand, I’m not bashing courses, because the vast majority of them are actually pretty decent, but I’m talking about trying to, you know, I don’t want to be sponsored by any one implant company, because then you know, you because if you’re sponsored by an implant company, you kind of have to be nice to that implant company, right? Whereas I want to, I want to be able to give people the critical thinking, so that I can think to the source, okay, let’s look at this implant system, what’s the pros and cons to it? How could it work? Because, you know Jaz, the vast majority of implants work, but how you execute them is a little bit different and subtle, depending on the implant, if that makes sense. You need to understand the overall principles that if you choose this implant system, you can execute it correctly. If you choose this other implant system, you can still execute it correctly. And that comes from knowledge. And that’s again, that’s the reason why I want to give as much information as what I possibly can in this course, which I’m aiming to get a do call verified, but that’s not an easy process and go through. [Jaz]Yeah, and like I said, That’s not as important as it is good that you don’t know it’s not as important as just like you said, given that secret sauce to get people to implement and just as you said, it’s about giving confidence. So if anyone’s interested, how do they learn more about your online sort of modular content? [Pav]So the online modular content I’ve written it I’m in the process of recording it. It will probably be ready to release in approximately six months time approximately. It just depends on jumping through hoops with edge and there might be a few tweaks to the course content. What I am doing is because obviously recording a course is not cheap as well. I am for a very, very few people who prepared to sign up sooner rather than later. I’m offering a ridiculous discount on the course. And I’ll message that over to you later Jaz but basically, it’ll be a cheap way to get into implants basically. And the provider is really simple is you pay now, which allows me to record and edit the videos and you just wait a few months for the videos to come out. Because once those videos come out, then there’s not going to be any discounts after that, because I know what I’ve got is going to be good. And so, you know, I’ve taken everything, I’ve sent it to friends who place a lot of implants, and they’ve looked at it and they go, ‘Well, can we do the course?’ I was like, what you’re gonna gain from this? It’s more than what I learned on my master’s degree. [Jaz]Is this for like beginners as well, like for beginners? [Pav]If you’re a complete novice never placed an implant? Yes, you can do it, the mentoring separate, but it will give you because theories theory, right, you can learn that online, you can learn it from textbooks that I’m going to make it as succinct as possible. I’ve got a number of guests coming on to talk about their niche topics as well. So if you’ve never placed an implant in your life, and you want to start, absolutely. If you’re already placing implants, and you want to up your game, it’ll also be suitable for you. Now, if you’re placing a reasonable number of implants, and you want to start doing more complex grafting, you want to start to get into sinus lifting, you want to do more aesthetic work in the anterior region, it’s going to be for you as well. So this is why I’ve split the course up to be modular. So there’s what I call a gateway module, which is a gateway into implants. There’s an advanced module, and there’s a mastery module as well. So I’ve tried to make it as all encompassing for everybody as I possibly can, respecting the fact that some people are going to be drawn towards some areas as opposed to others. [Jaz]Yeah, well, I appreciate that. If anyone is interested, what’s the best way for them to reach out to you to learn more? Because honestly, it’s a bit of a wait until this all happens. But like you said, for those people who are really keen and they love your stuff, and they want to learn, and they know that okay, I want to learn from Pav and if that would make sense to anyone, I suppose to learn from someone, someone is experienced like yourself, which is amazing. But if they’re ready to sort of learn more, how can they reach out to you? [Pav]So probably the easiest way to reach out at the moment is through Instagram, send me a direct message. So you can go to either Dr. Pav Khaira, the Dental Implant Podcast, or I’ve also set up the Academy of implant excellence at any one of those three, basically. There is a landing page being built, but again, that’s in the process. So it’s- [Jaz]Well I appreciate you sharing that. Yeah. [Pav]Yeah, Instagrams probably the easiest way at the moment, yeah. [Jaz]Well, that’d be recurring themes of mentorship and not falling into marketing crap. And it’s going flapless because like you said, I learned a few things, you know, about 10% amenable, I also learned that you know, 40% for the general dentist, okay, you could do immediate and there are some intricacies with that. But I like the way that you propose to the young dentist that perhaps even though you could do an immediate in those first few cases, you kind of describe the ideal first few cases and upper molar out of the smile line. So these are really good nuggets to to appreciate. So Pav, thanks so much for coming on and discussing this very interesting topic of flapless implants. I think we’ve now debunked another myth there. So I appreciate your time always my friend and all the best with this huge project. I’ll follow up again with you in about 6-8 months and see how it’s all going but I can see now how much work you have ahead of you but yeah, very exciting because I know this is your passion. This is your real project that you love so much. So I know you’ll do justice to it. [Pav]Thank you. Thank you so much. Jaz’s Outro:Oh, there we have it guys. If it sounds too good to be true, it probably is. So remember that with implants and with flapless. And anything, anything in dentistry. If it sounds too good to be true, it probably is. So it’s great that you shared themes or mentorship and I appreciate that Pav shared his big mistake, you know, his 32,000 pounds wherever it was the mistake that he made and that really highlights the importance of mentorship when it comes to implants. So if you’d like to learn more reach out with Pav through his Instagram channels. Otherwise, hit the like button, hit subscribe if you enjoyed this episode, and I look forward to making more for you very soon.

As a Dentist, the first years are always the hardest. You have to adjust to unfamiliar situations and people constantly. A newbie’s nerves can lead to self-doubt and hesitation whilst navigating this steep learning curve. I brought on recently qualified Dr. Saeed Cheraghi to guide you through the first few years of the ‘University of Life’. https://youtu.be/PXt3hvsV9LI Check out this full episode on YouTube “You come out of Dental school thinking you know things and then you go into the real world and you realize you actually don’t know that much at all!” Dr. Saeed Cheraghi. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 8:31 Indirect Dentistry experience  10:15 Challenges in terms of treatment phasing 12:17 Level of support being a newbie dentist 15:03 Dental training 18:07 Overcoming lack of experience 30:34 Worrying about litigations 35:05 Importance of Health 39:59 Lesson from experience This episode is not eligible for CPD but you can check out other CPD-verified episodes on our Protrusive App on a web browser or you download the iOS App or the Android App. This episode is brought to you by Enlighten Smiles, a premium brand of teeth whitening. They also run the Mini Smile Makeover Course – a composite course I really recommend. If you liked this episode, you will love How to Win at Life and Succeed in Dentistry – Emotional Intelligence Click below for full episode transcript: Jaz's Introduction: I remember my first few years out dental school extremely well, I was actually really nervous, really scared. I wasn't sure I was worrying about things like taking a bitewing. Can you believe that? The initial worry was how will I take my first bitewing? And actually remember it happening. Jaz’s Introduction:I’m like, ‘These are different holders to the ones I had at dental school. And this is a different unit and do I need to try to memorize the timings and the exposure and radiation?’ And just making really simple things really complicated because let’s face it, you haven’t done this a long time when your first day of the real world of dentistry comes. The other thing I remember about my first few years was CONSTANTLY DOUBTING MYSELF and not being able to make decisions because you can’t really make decisions or you struggle making decisions when you have a lack of experience. You’re constantly doubting your judgment. So, this is why it’s a very UNIQUE CHALLENGE. Being a dentist, fully fledged dentists out in the real world after dental school. So, this episode is dedicated to those in their first few years of career, after qualifying, and all the unique challenges that you face as a newbie dentist. I’ve got someone on today, Saeed Cheraghi, who is literally just finished their first year out of dental school. And so he’s in a great position because even though I remember, he has just felt all those emotions, he’s actually literally has been through it all. So together, we share our stories and our advice. And the aim of this episode is to inspire SUPPORT GUIDE and encourage you to KEEP GOING, you’ve got this. So, I hope this non-clinical interruption because this is an interference cast. It’s very clinical actually this one, but it’s not eligible for CPD. So, the ones that have got enough meat in terms of clinical gems, they’re the ones who are eligible for CPD and how you can get CPD is now by joining Protrusive Premium. So, if you go to protrusive.app on your web browser, or if you download the iOS or the Android app, you can actually join Protrusive Premium and actually get CPD episodes after listening or watching the episodes. Not this one though, because this one doesn’t qualify. But most of the other ones about 99%, are eligible for you to get CPD. So, straight after you listen or watch, answer some questions and get your CPD. Otherwise let’s join Dr. Saeed Cheraghi to talk all about HOW TO THRIVE IN YOUR FIRST FEW YEARS OUT OF DENTAL SCHOOL. This episode is brought to you by Enlightened Smiles a premium brand of teeth whitening. They also run the Mini Smile Makeover course. Now, lots of dentists messaging me saying, ‘Jaz, which composite course should I do?’ One reason I recommend Mini Smile Makeover, which I went on, I paid in full before I ever started talking on the podcast is because of two reasons. I’m gonna give you two really good reasons why as a young dentist, one or two years at dental school, this will make a good course. Number one is because you can actually pay in installments. Okay, so you can actually, when I was doing courses, and I was newly qualified, there wasn’t a such thing as paying in installments for somebody that’s about 1000 pounds, because that’s kind of like the going rate nowadays for for a two-day course. So, you get to pay in installments, which is great. The other thing and this is real world, like from the heart, I’m telling you this that okay, you’ll go on this course. But will you really be able to apply it the next day? And this can be said about any course when you’re a super young dentist, when you’re first few years qualified, it’s very difficult to apply all the things that you learn in the real world, which is why these treatment planning, history taking, basic occlusion. That’s why there’s this kind of bigger picture courses can actually be more helpful to young dentists. But the reason why I think even though you may not be able to apply the peg lateral and the multi-layering kind of stuff, and veneers and stuff straight away. The wonderful thing about Mini smile makeovers, something I’ve taken advantage of is that okay, you pay and you go once fine, I understand that. But then you get to go again and again and again. And there’s no charge the second time, the third time or the fourth time, etc. So, you get to sit at the back of the class. Now, you don’t get through the hands-on fine, fair enough. And every time I go again, I hear Dipesh, I pick up a new gem that I just forgot from the time before. And I’m seeing the delegates threw their hands on again. I was like yes, I can visualize this. So, you get to go again the future for free, which is great. So, if you’re early in your career, and you go on it and you think, ‘I’m worried I can’t apply it.’ Then when you’re in the right environment, hey, you get to go again. And then it will be fresh in your head and you can get a second bite the cherry to apply again. So, another reason to join the mini smile makeover course. Main Episode:Okay, now let’s start the main episode, Saeed Cheraghi, welcome to the Protrusive Dental Podcast, my friend. How are you? [Saeed]Hello there, Jaz. Thank you so much for having me. It’s a big honor because I’m a huge fan of the podcast. So- [Jaz]I really appreciate that man. And it’s great to have someone on because the point of this podcast is to help those who are literally has come out of dental school and they’re doing their first ever job. Now, in the UK that could be or you know, dental foundation training in the US. It would be your first job or wherever you are in the world, Australia, etc. It’s essentially your first few years out of dental school and when we’re talking before the podcast, we’re talking about some challenges. You made a lovely document for me in terms of all the challenges you faced and I was saying to you that you will remember things that I forgotten because I’m now nine years gone, whatever. So, that you are actually the expert and you need to own that because you are the expert of being a foundation dentist because you’ve just done it and it’s fresh in your head. And so whilst all these people who are five 6, 10, 15, 20 years qualified can give advice, they are not as qualified as you are, because you’ve just been through it. So, I just wanted to say that, because any impostor syndrome that you have within you, I want to shatter it, because it’s, you know, you are definitely the expert in that. So, just tell us a little bit about yourself, where you qualified from and where you did your DFT? You don’t have to specific if you don’t want to be for obvious reasons. So, just give us a flavor of that. [Saeed]Yeah, sure. So, life story summarized, I’m Saeed, a dentist based in the Northwest of England at the moment, I actually started off by studying Pharmacy, I gained my master’s degree in that and then completed my pre-registration, get an experience in hospital and community pharmacies. And then pretty much as soon as I qualified, I went straight into dental school. I was studying at the University of Liverpool, which I really enjoyed. And I only just graduated last summer 2021. And literally just now finished my foundation. Yeah. So yeah. [Jaz]Where did you do your first year? Where did you do it? [Saeed]In Blackpool. [Jaz]Blackpool? Okay. [Saeed]Yes. [Jaz]Cool. And it was a funny time because if you qualified last summer, you were one of the years significantly affected by the pandemic. [Saeed]Definitely, anyone in my cohort, anyone in my year across all dental schools will know that we had a lot of challenges. And, coming straight out of dental school, going into your first job, I feel like I can speak on behalf of all of us, we felt a bit more underprepared than anyone else that had previously graduated. You know, coming out of it, we had a lot less experience and a lot of other people. And that was something that was worrying us when we first started working. [Jaz]Can I ask you Saeed, and I hope not to put you on the spot. And if it’s okay, if you’re happy to reveal this, because I’m sure what you will say will reflect everyone else in your cohort is like numbers, what kind of numbers are we talking? How many root canals you do? How many extractions? How many dentures? Because, you know, I felt in all of my cohort, you asked them, we felt super unprepared as well, it’s one of those things, you’ll never feel prepared for the real world. You never will. And we could talk about how the first year went and stuff but just to reassure you never, no matter even if had like a 10 times more experience, you still would not feel prepared for the big bad world. So, talk us about numbers of you, your colleagues, what kind of numbers are people qualifying with nowadays? [Saeed]So, I’m not sure about other dental schools, but in my dental school, a very similar levels. I had only completed two endos on human teeth in real events by the time I can’t work- [Jaz]I’m not laughing at the number, I’m just laughing at the back that you know, the real human reference. Okay. [Saeed]Exactly. Only two endos, no molars. So, that was definitely one thing I was very worried about beginning at work. And I told my supervisor at the start, I’ve only completed two indirect restorations. I had done maybe 12 to 14 extractions and my whole time, no retain roots. Nothing extra challenging. And I had done a cobalt chrome and a few dentures here and there. I felt okay in other things. But the more challenging aspects, I felt really underprepared as I just, you know, as you know the numbers now. [Jaz]Well, I really appreciate you sharing that. And you know, if I was to go back, I did a ton of endo, just the way it worked out. And a good number of extractions, but for indirect, like crowns and stuff like zero onlays, one taught to me, we didn’t do them. We just had crowns. And so I did maybe around about 12, 13 crowns, qualifying. So, it’s again, not massive numbers here, right? Not 50 and 100s. So, I still felt like nervous about doing crown. So, we’ll talk about that. The biggest worry that I had to say, believe it or not, and I wonder was it just me? What do you do? Did you feel this as well? Breaking contact, just breaking the contact. [Saeed]Oh yes! [Jaz]That used to really, really put the fear in me. So, what aspects of indirect dentistry did you feel worried about in your first year? [Saeed]I think when we say indirect restoration, but there’s actually so many different types involved, and each one has its own indication, and own way of preparation, own way of segmentation. So, I think I was exposed to very few numbers. So, for example, in dental school, I think I did a metal ceramic crown. And I think I did an all ceramic crown as well. But aside from that, I hadn’t done any onlays, I hadn’t done any inlays. I didn’t know about different types of materials. And when it comes to the treatment planning, you need to be aware of which situation each one is most relevant to, so that you’re able to prescribe it or recommend it. But I think- [Jaz]And do the appropriate prep for that material as well, right? [Saeed]Absolutely. But before you could get onto that stage, you need to see the tooth, inform the patient. Well, these are your options here. Which one would you like to go for? That was the thing that I would think the most underprepared for because I didn’t actually know what options I could present. I didn’t know. One thing I think we should get into more is how much of a challenge a restorability assessment is. When you first start is so challenging to know well, is this tooth actually restorable? If I go through all that after and you know the patient’s going through the effort as well, is it restorable or not? Do I have a highest chance of success or not? So I think that side of things was more sort of a challenge. [Jaz]And Saeed, these borderline restorable teeth, these are the ones that need the endo. And then again, with the lack of endo experience, these are sometimes really tough endo cases, right? [Saeed]Yeah. [Jaz]They’re not like they’re straightforward, nice big pulp chambers in a 18 year old. These are the 58 year old with the history of large amalgam with pins and the really tough root canal treatment. So yeah, I mean, that is a tough scenario. And even like, when I was DF one, I used to get really worked up and stressed when I’d have like simple dentistry ie just someone who had God brought, lots of caries and just gum disease but which is basic, but even just to face that in my head, and like, do you do GIC first? Like, there’s some textbooks would say, do it that way, then bring it back and and mixing it into the real world and how you actually apply it to real world. Did you have those kinds of challenges as well, in terms of treatment phasing? [Saeed]Absolutely. That was actually one of the biggest challenges I faced starting this job. It took me a very long time to become comfortable in that situation. Because I think in you know, again, something I’ve gone to dental school, you’re in such a nice little bubble where even the patients that come along to you even the challenging ones are too challenging, it seems. But even if they are you have someone right next to you, who you can call over actually, what should you here, what should you here? What should you here? And you take it in that way. But in the real world, you come across patient and for context, again, my cohort came into a situation where majority of patients hadn’t seen a dentist in two years because of COVID. Dentistry was just about getting back into the groove of things just then, around the period when we were starting foundation training. So- [Jaz]And I see you have a lovely beard. Do you have to wear the hood and stuff? Do you have to wear a hood? [Jaz]Yes. [Jaz]That’s crazy! Like, you lack experience, you’re starting new job? And you had to wear that bloody hood as well? [Saeed]Yes, definitely. And it was, you know, all of it together was a challenge. Everything together- [Jaz]Really overwhelming. [Saeed]Yeah, obviously, that’s the one word if I could summarize that initial period of starting that job, I would say overwhelming. There’s just so many issues such a huge step up from dental school- [Jaz]And all AGPs and that kind of stuff as well. It’s definitely hard. Every year group I qualify say they will always tell you that oh, yeah, we had it really bad. But I don’t think any, there’ll be another 100 years for another cohort come out. So you have one, one thing you can definitely claim. So I mean, we’re talking about all these problems and challenges. Tell me about the level of support you got not only within your practice, but within your scheme. I imagine they had to run this scheme in a very different way. Your study days are probably very different to mine, they’re probably back to basics. How well did you feel supported? [Saeed]Well, I would say I was very lucky, I went into a really supportive practice, thankfully. I was the first ever foundation dentist, the practice had. So, it was a learning curve for the both of us. But my supervisor was really supportive always available to help me and the other dentists in the practice were also super supportive. You know, I probably at certain points was annoying them because I was quizzing them all the time about well, what would you do in this scenario? I was showing them my cases, how would you approach this? What is your approach to this, and from each dentists, each clinical judgment, you pick up a tiny little gem that you can then apply to your own work. So thankfully, there was a lot of support within the practice itself, the whole team was really supportive. And then in terms of the scheme, the scheme was the study days that we had what good, a lot of the study days were online, as you can imagine, because of social distancing, and everything like that, which was a little bit of a shame, because I wish I could interact with my fellow Foundation Dentists and my scheme a bit more. It would have been nice to have a bit of a, you know, social gathering as well. [Jaz]But you were still a close knit cohort, right, in terms of speaking probably on the WhatsApp group or something like that. Right? [Saeed]Yeah, we have a WhatsApp group- [Jaz]Sharing with each other some cases opinions, that kind of stuff, looking after each other. [Saeed]Yes. [Jaz]Now, did you have, because even I had it in my scheme as well, where some people felt as though that for whatever reason, personality clash, or just generally the way it was, they didn’t get the best support from their trainers as they wish and they really felt not as supported as you did. Did you know of people in your scheme or other schemes that work that sort of feeling? [Saeed]Yeah, I would say not in my scheme specifically. But speaking of catching up with friends from dental school, there were some cases where like I said, it is a personality clash. And when you’re dealing with humans, aren’t you not everyone is the same, has the same method of approach in teaching everyone is slightly different in their style. So yeah, I felt like some people were a little bit under supported there and I would say for the new dentists that are just about to start their foundation training now. Just please don’t be scared of speaking to your supervisor and they’re not going to think any less of you, they’re not going to think, ‘Oh, this guy’s rubbish. He doesn’t know the basic of like caries removal.’ For example, there’s there’s no harm in that. You’re just about to start there that literally to support you. And don’t be worried. Don’t be scared to speak to someone. And if your supervisor in the practice, you feel like you’re not getting further, you can always speak to the person higher up, which is the beauty of the foundation training. [Jaz]Well, you’re speaking directly there to all the new guys and girls coming through about to get into DF1. But let’s send the message to because a lot of DF trainers listen to this podcast, right? [Saeed]Yeah. [Jaz]If you’re in a position to train, I think it’s important now more than ever, to just be a little bit more lenient of your time, have a few more blocks in your diary, especially in the first few months, where your trainee will need you more. Any advice that you can give to trainers out there? [Saeed]Yeah, I would say, firstly, please just be understanding, like, I’ve just kind of give a brief explanation, for example, someone in my year or the year below might have less experience than the previous foundation dentist that the practice has seen. So, please be understanding towards that, please be understanding towards the fact that the final year of dental school is stressful, you get a really short summer on your back straight into the swing of things into a really overwhelming environment, and everyone has their own pace of learning, you know, it’s like any other skill, some people will get the hang of things a lot quicker, but somebody will take a bit more time. It doesn’t mean they won’t get there, it just means they’ll take a bit more time. Please be understanding towards that. And like you mentioned, it’s the best thing to have those gaps in your diary, where you can go in the room and observe or just help out if the foundation that is, especially on the cases they feel most worried about. [Jaz]Saeed, did you have any over the shoulder training ie you are doing a restoration and then your your trainer was watching you. Did you have any of those kind of you were taking out a tooth and your training was watching you did you have any of those? [Saeed]My personal style is if I feel like I need that level of assistance then I will ask for and my supervisor was super welcoming towards that. But otherwise, I kind of feel a bit more pressure. If someone’s just watching me the whole time. I feel I would much rather, if I feel like it’s within my competence, I’ll give it a go myself. And then if there are cases where I can’t, you know, I can’t overcome it myself. That’s when I’ll ask for assistance. [Jaz]That’s exactly how I was as well Saeed as DF1. But then something interesting happened to me when I was in DCT1, I was at Guy’s hospital. So, my oral surgery post, and I was really struggling taking this tooth out. And so this registrar came over I said, ‘Okay, I think I need some help.’ And instead of jumping in helping me she just stood by me and said, ‘You do what you gotta do. I’m gonna watch you.’ And Saeed, that was the most powerful learning experience I ever had. The way she was coaching me to hold the instruments the way she was guiding me on what to do was a super and I’m actually extracting myself with her support. And so sometimes maybe for those listening out there maybe to have a chat with your DF1 trainer and maybe if you struggle with extractions and you’re nervous about extraction is some really okay so what, can we do some over the shoulder training where you watch me and and this needs a special type of trainee as well that you need to accept that it’s gonna be a lot of pressure on you, when someone’s watching you. It’s not nice, I agree on that. But if your principal’s up for it, and they’re supportive and you feel comfortable to do that, then I think take up your principles on that opportunity would be a good thing because now what I want to shift this podcast towards. Yes, we’ve mentioned all these problems and all these issues. Let’s come up with some solutions. So Saeed, tell me about the kinds of things that you think helped and will help the future generation coming through in their first year to overcome this lack of experience? [Saeed]Yeah, so in regards to the lack of experience thing, to any young dentist just about to start, what you need to do is initially don’t put any extra pressure on yourself, be understanding towards your own situation you’ve literally just at the start of your career and there’s so many things you need to learn. You think that you come out of dental school thinking you know things and then you go into the real world and you realize you actually don’t know that much at all. So- [Jaz]So true. [Saeed]Be understanding towards your situation. At the start, don’t get upset at yourself because you know all of us in this situation we really we’ve worked really hard to get here so we really care about what we do. We care if something goes wrong, it really does affect us. But try not to put extra pressure on yourself because at the start, you’re just figuring out the absolute basics like when I first started even taking x-rays was a challenge. I was coning everything at the start. [Jaz]I’m so glad you mentioned this because like you people think about the crown preps and struggling with endo. [Saeed]Yeah. [Jaz]But I’m with you. The first bitewing I had take, I was like wait am I put this on correctly? Was it like this or was it like that? And then the x-ray machine will be different to the one that you trained with and then the settings and stuff so you’re so right actually even just taking radiographs. You need training on that all over again. [Saeed]Absolutely. It’s the little things that you don’t think about that you think, like I remembered column about this topic I could run my column my dad once after work and I was like all my extra combat and my dad was like, ‘Wait x-rays, is that is that hard?’ I just thought everyone can just do it like all dentists just seemed like they can do it. But instead, at the start is those little things that you just don’t have any experience. And that seemed like the biggest challenge. So, don’t stress yourself, I need to do these, you know, extremely beautiful restorations or these complex cases and treatment planning at the start be really understanding towards yourself. Just learn the absolute basics, deal with the absolute basics. As times goes by, the way that you elevate your game is by keeping good records of what you do. And at this point, I really want to recommend everyone to get yourself a DSLR camera if you don’t have one. But I think even better is to just get an intraoral camera because firstly, they’re not that expensive. Secondly, they’re super easy to take pictures with. What I was doing, I was just taking pictures of teeth. It looks like a little thicker pen. You’re just putting them out, take a picture of the tooth. Later on in the day, when I’m sat down with my supervisor, I’d be like, ‘What do you think of that? Do you think that’s restorable?’ For example, how would you approach that? Would you take up the caries? All those kind of stuff? [Jaz]So much better than just showing a radiograph, right? [Saeed]Yeah. [Jaz]So much better. And so, if you’re not in a position to get a DSLR for a reason, or certainly if you’re gonna get a DSLR and when we sat in the corner, you won’t be using it, then definitely just get an intraoral camera they’re about 180 pounds nowadays, this week. 150, another 180. But it’s worth every penny. Even if you have to like first paycheck like my first paycheck, I bought a DSLR. I’m very vocal about that. So, if you’ve got an intraoral camera, it will be the best investment you make. Get it in your first month, go on Amazon now, get it, order it. Stick into USPS, plug and play. It’ll work with your software usually exact to whatever using and you need start taking photos, not only because you can discuss that with your trainer, but it’s going to really help you, the young dentist, first year out when you need to communicate with a patient. That picture is a thousands words in itself. It does half the communicating for you. [Saeed]Absolutely, exactly that. Because for example, like I keep folders of all the pictures I’ve taken across the year and at the start if you look at my the photos I was taking on the site, it was just literally did I remove all the caries? I was just checking for myself or to show my supervisor, did I remove all the caries? This is where I started. This is what I ended my cavity preparation with all the cariers gone. Later on in the year, I was doing taking pictures of preps and I was like what did I get the right margins and everything. I think you keep track of your own work. And this is really just a tool for yourself to be able to reflect on it and be like, ‘Well, next time that this same case comes across, I want to do it differently. I want to do it this way. And that is like you mentioned. [Jaz]Really good. [Saeed]When you come out really apprehensive about the level of experience that you have. These are the things that will slowly, slowly get you to elevate your game. [Jaz]And if you come across a tough case, you know, sometimes a tough case can be a single tooth problem, which is really puts you on the fence and not sure. Okay, and that can be tough. Or someone’s got a multiple teeth problem, failing bridge, and a bruxist and TMD on one side, and some perio localized as all sorts going on. Just focus on getting a records and saying, ‘Patient, there’s a lot of going on. To give you a flavor, it’s x, y, z to come up with the best plan for you, I need to sit and think about it, there’s too much going on. I will invite you back. And we’ll have a chat.’ And in that time, that’s when you speak to your trainer. And that’s where you maybe hit the books or go to some online webinars or whatever, because I’m a big fan Saeed of just in time learning. For example, imagine you want to improve your root canals of central incisors, for example, right? You’re not gonna, on Saturday evening, just like you know what today I’d like to improve my central incisor root canals and open up a textbook and watch some videos on YouTube, wherever. When that case comes along nd you know that you’ve got it next week, that’s when it’s actually going to stick in your head. And that’s when it’s gonna be relevant. So, just in time learning accept that okay, we don’t know very much. But as an everyday, you know, okay, today I need to focus on the wax tryin stage, because I’ve got that next week. Today, I need to focus on how to prep the distal margin of a lower molar because that’s what I’ve got next week. And if you keep doing that, by the end of the year, you will have covered a lot of ground because it’s a more focused way of learning. Did you employ that technique when like that? [Saeed]Well, yeah, definitely did that kind of, Can I just say something that you really quickly brushed over that I think for you is now really second nature. But for young dentists in my position- [Jaz]Please. [Saeed]Was actually a big deal, which is you said about how when you speak into a patient, you could be like, well, I take these pictures that aren’t getting an answer for you next time. I know from experience this time last year, doing that was a really scary thought because I felt like I should have all the answers right now. And if I tell the patient, ‘Oh actually can I tell you next time.’ That might come across as incompetence, but I think with time you learn that that’s completely normal. That’s completely fine. Like, that’s something my supervisor really instilled in me as well. When I was at large case with multiple different issues going on, I would be really upfront and say, ‘Look, these are the urgent things that we’re going to deal with. Here’s an answer for what we should do. But we also need a long term plan. Can I please just get you back next week for a 15-20 minute discussion by then I’ll have the treatment plan ready for you?’ So- Unknown SpeakerVery good. [Saeed]Yeah, that’s a really important skill that I think young lads shouldn’t be scared doing that. [Jaz]You’re right, that you feel as though that you should know the answer. And I remember being incredibly frustrated with myself saying, you know, this is simple caries and perio case, why do I need more time? But actually to even just sit down and chart on the software exactly how many restorations appointment one appointment two, appointment three, exactly how you going to the face it, to have a think about how you can restore it and stuff, discuss costs with the patient, etc. that, aside from the examination can take a lot of time. So, even the simple dentistry at the beginning, it’s completely okay to take those photos, deal with the urgent thing like you said, and say to the patient, look, ‘An architect will go away and give you a blueprint, I’d come up with blueprint for you. And then when I do, I will make sure that when we make this build this foundation that will last.’ And if you just communicate like that with confidence, the patient be like, ‘Okay, I’m glad.’ Because the opposite of that is what we call shotgun treatment planning, right? Someone’s got a gun to your head like, ‘Okay, treatment plan right now.’ And we feel this pressure everyday. But there’s no need for that, especially in your first year. Because you haven’t had enough failures yet to know what’s gonna work, what’s not. And so you need to have those discussions and don’t be shy. So, I’m glad we emphasize that on that a little bit more. [Saeed]Yeah. [Jaz]And so following on from that camera, taking a pause and then discuss with your trainer, which other strategies would you recommend to our peers? [Saeed]I would say that the biggest skill that you kind of, throughout this entire year is learning how to manage patients and talk to patients. And that should be the bulk of the emphasis of a lot of the subsidy, especially at the start. There’s two things that you need to really be able to do. One is to truly be able to get valid consent. And by valid consent, it means explaining to the patient in layman terms, what’s going on, pros and cons of whatever you’re suggesting, and then allowing them to make a decision for themselves. Because it’s really easy for us, we have our own dental language. And it’s really easy for us to throw those things like upper right six, all these things. But a patient like, just imagine if your parents are in the dental world, they wouldn’t understand half the things you say. So, learn how to speak to patients in a really nice concise way. The second probably the biggest skill that you can learn is learning how to manage expectations in my personal opinion, it’s managing expectations. And that’s going to save you so much pressure and stress in the future. When I deal with a patient, I’m completely honest with them, I say, ‘This is the treatment that needs to be had. This is what we need to do. Here’s are the pros and cons for this. What do you think? Would you like to go ahead with this or not?’ And then, for example, managing expectations that I’ll just give one quick example Jaz, from what I learned in dental school. In dental school, I was having a real struggle with getting nice, accurate impressions. And I was taking maybe three, four or five attempts sometimes. I’ll go to a tutor show. [Jaz]I’ve been there. [Saeed]Yes. Show the truth. I never like no go again. [Jaz]Hearts and comment. [Saeed]Yeah, I’m going back again to renovation. I was so sorry. Again. So, sorry to do it. But if one thing that someone taught me was if at the start of the appointment, I just told the patient with today’s the impression stage, I might need to take a few different impressions because I need to, I want to get the most accurate impression for you so that I can give you the best product at the end of this. Then if you go to your fourth attempt, fifth attempt, instead of them thinking, ‘Oh, this guy is taking so long.’ They’re actually like, ‘Wow, he’s really putting the effort. He really wants to give me the best.’ [Jaz]Guys, if anyone’s multitasking and you miss that, you need to listen that again. Because Saeed has given you wise beyond his years, what he just told you is essentially what he’s changed. He’s changed the frame of the appointment. So, before the frame was apologetic, I’m sorry, I’m sorry that we’re doing this. But we changed the frame and set the tone the beginnings that, ‘Hey, we really are serious about getting high quality dentistry and to get high quality dentistry it might take me a few impressions to make sure I’m really happy with it.’ And then you’ve really set yourself up for success. So, that is a really great tip. Well shared, Saeed. [Saeed]Thank you very much. Yeah. So, I would say genuinely there’s the whole dental side of things, the technical aspects of things. But, if you are good with communicating with patients, managing patients, because you’re going to deal with conflict is guaranteed. I mean, at some point in your career, it’s different guaranteed. I don’t know if it’s in your first year but you need to deal with conflict. You need to learn how to cope with that. You need to learn how to cope with nervous patients. The biggest shock to me, that I don’t think I was fully prepared for. It’s just how much of the population adults especially are so scared of the dentist that you know, genuinely some are petrified. How do you deal with that kind of patient? How do you deal with children? How do you educate patients? How do you provide the information in a way that’s concise, and they can understand it, so that when they go away and come back to you in three, six months, that I will actually I’ve been doing the interdental brushes, like you explained, for example, those I think this year, there’s a lot to learn dentally. But these, if you can develop these skills this year is going to set you up for the rest of your career, it’s going to have the biggest impact, [Jaz]Very true. And building rapport. And having conversations with patients is just the most, I think, if you just master that in your first year, or try. I don’t thing you ever master it. But if you really put some attention and energy towards actually conversating with patients and communicating in the best way possible in a concise and clear way, that’s going to really give you a leg up for the for the rest of your career. So, when you are speaking with your patients, I would say actually, just I’m gonna backtrack. Now I’m gonna say you mentioned and I picked up on it, about when it comes to speaking to patient, you said that how important it is. And obviously, it’s important because of consent, as you mentioned, and you mentioned about good record keeping, did you in your first year, worry about litigation? Because now that you’re qualified, it gets drummed into us that in your first few years, you get litigated so many times over. Was that a concern for you? Or were you just focused on learning in dentistry that actually that was in the back. That wasn’t really at the front of your mind. How did you approach that? [Saeed]I was listening to your podcast with Lincoln Harris recently. And he mentioned about how the last lecture you have before finishing dental school is someone coming from like these defense organizations saying, ‘By the way, you’re gonna get sued.’ So, it’s impossible to not think about it, I think it’s something definitely that’s in the back of all of our heads. And it was definitely something I was aware of. Now, I can’t prepare myself, because I don’t know what the real world is like, that’s where the experience of someone a lot more experienced than you will help you along with that. So for example, my supervisor was showing me cases, for example of complaints that have happened, or people are making claims. And he would tell me about, well, this happened because of these reasons. And these, this is how you avoid it. And then he would, for example, give me pointers on what to definitely include, in my record keeping. The conversations that I’ve had with patients, make sure you mentioned this, make sure you inform the patient that for example, that they have something called gum disease called periodontitis. These are the consequences of it, that could happen later down the line, you know, we live in, unfortunately, we live in that kind of, well, there’s no escaping it. It’s just something that we need to learn to deal with. Because God forbid, if it does happen to us, then that’s when the real stress comes. But if you’re already aware of it, and then you can always try and protect yourself in the long term. [Jaz]Well said. And it was just must been so tough, you know, already coming out with less experience and trying to learn but the same time with this knowledge that actually you got a little bit defensive what you do. So yeah, I mean, kudos to you for making it through. One lesson I can share with those listening is a lesson that is not my own original lesson. It’s a lesson that I picked up from I think was a book and was a chap called, Amen Armenian, very well known dentist and he wrote something really fantastic. He said, ‘The secret to not being sued’. And this is, who knows, is evidence based or not, but it really resonated with me, he said something really great. The secret to not being sued is there’s three things which you need to do. And if you do two of those three, well, then you’ll be okay. Right? So the three things are the following. Be nice to your patient. Okay, be likable, be nice. Okay. Number two is picking the appropriate and appropriate treatment plan. And three, executing that plan well. So, even if picked the wrong plan, not a good plan, but you did it really well. And you know, the quality of dentistry is really good. Okay, that counts. So, if you do two of those three really well, you’re probably gonna be okay. And that’s always stuck with me, right? So sometimes, you know, because of lack of experience, you might not pick the best treatment plan, but you did it to the best of your ability. And the patient liked you and you’re nice. And I’ve always loved that. And I think if you extrapolate further from that, you can always be nice to your patients. That’s an easy one we can do. And you know, just if you get the other one of the other two, right, you’re gonna be okay. Have you heard about one before? [Saeed]Actually I haven’t. That’s a really good way of summarizing. And I think in regards to the like you said, you can always be nice that’s for free. You don’t have to put in the extra effort or money into it be nice is always free. The second thing, the final thing you mentioned the quality that is something that will hopefully improve with time, you can’t always guarantee it. But I think if you genuinely, in regards to the second point, if you genuinely have the patient’s best interest at heart, even if the final result, you come to the end of and you actually like I wish I did it differently. But if you go put yourself in the first instance and you tried your best like I’m doing this out of pure good intentions, I think that this is the best course of treatment for you. Then you know a patient will always read they will understand that you tried your best that you didn’t do something that benefits you as a dentist you tried your best to do something that benefits the patient. And I think a lot of them really understand that and appreciate that. [Jaz]Very good. Any more on your list in terms of trying to cover one or two more themes here in terms of interest time. So, what other tips? So, you mentioned already about the intraoral camera about getting good at communicating, we tackled a lot about, you know, preventing litigation and how that should be the back your mind, managing expectations, I love the frame that you taught everyone. That was wonderful. What else? [Saeed]So, again, I’m not gonna go specifically into dental things. But this is a topic that I think deserves a lot more attention that I don’t think we get enough attention about. And that is the health is our health. What I mean by that is both physical and mental health. This isn’t a mental health, yes, there’s a bit more awareness towards, especially physical health, I don’t think a lot of attention is placed on it from training in dental school, or our schemes or work or social media or anything like that, in every single profession, you need to protect the tools of your trade, in order to be able to have a, you know, a nice long career, hopefully, for example, footballers, they need nice healthy legs to be able to have a living to have an income. If they get injured and they can’t play, then that’s the income done, it’s finished. It’s kind of the same for us, we have a very physical job, which means that we have to be able to protect the parts of the tools that allow us to work our hands, our eyes, our backs shoulders. Next, there’s not a lot of emphasis that’s placed on this, which I think is a shame, because what is it that provides you longevity in your career is if you can keep your body healthy, and get it to a point where you can keep continuing to work. Otherwise, that’s the income then. So some of- [Jaz]Did you have a epiphany moment in your training that you made you realize this, or is this something that you have a background in? Because you have to do a degree before? What makes you compelled because it’s wonderful advice. But what made you realize this? And then also, what have you been doing to practice this? [Saeed]Yeah, really good question. So, I was younger, I used to play a lot of football or a pretty decent level. So I was taking football really seriously. And the lessons that I learned from there, I’ve kind of started to apply for the rest of my life. That’s football as a career just like dentistry, for example. And into and when I first started working, I think I have kind of like an old man’s body because I was in a lot of pain from my neck, my shoulders, my back, when I first started to the point, sometimes we’re sleeping in certain positions was painful that night, I was actually struggling about at the start. So, that’s what really got me into it to focus a lot more into it, look into it, research and see what works best for me. And I’ll share some of the things that have worked for me in terms of physical health, and what number one thing that’s made, the biggest difference is regular routine stretching, I stretch, I do a full body stretch before work before I go into work. And I do want at the end of the day as well. And I stretch all the muscles in these areas that allows me to just loosen up, get some recharged again for the next day. Number two is I started going to yoga lessons at my gym. And yoga was again, another really helpful tool that I found. I do weight exercises in the gym as well we strengthen those muscles that I need for work. And swimming, I found to be really helpful as well. So everyone might have a different style of doing things. But I would just recommend everyone to really put some more emphasis into your bodies, to allow you to hopefully have a nice long career. Otherwise, maybe by the time we get to the 40s, 50s you don’t want to carry on and well because you’re in pain. And then if we step aside from the physical body, in terms of mental health, that is also a huge part. Because when I’m at work, I’m operating a hyper focus level all day every day because I’m at the start of the career and I don’t have that much experience, it doesn’t feel second nature to me, I can’t just do things without thinking too much about it. Which means that I’m hyper focused on thinking about every single decision I make every single action that I do everything I say to the patient, everything they say to me, so my mind is like full throttle all day every day, which can tire you out it can that’s what leads to burnout in my opinion. So, the way I’ve learned to deal with that, which I hope could be useful for this to listen to, is what I did was I created like a mental barrier in my mind of which separates my professional life and my personal life. And that mental barrier was the physical building of the practice. And what I mean by that is when I’m within the practice itself when I’m physically in the practice that’s me say the dentists, you know, really on top of it with work, taking things really seriously. Any responsibilities to do with work such as admin work, record keeping, portfolio referrals, anything to do with dentistry, that’s when I do it in the building, which meant that a lot of the times I was leaving the practice an hour or two after work had finished because I was just, I wanted to get all my responsibilities done. Because the moment I stepped foot after practice that saved the dentist. And that’s not to say that dentists anymore, that’s just mean almost normal Saeed. And that is what allows my mind to kind of recharge. Because if I take work home with me, I’m always in that mindset. And I’m don’t ever get a chance to recharge, refresh, get ready for the next day. [Jaz]Very good. I think like I said, why is beyond your years, my friend, very good. Just to wrap up the episode, let’s talk about one experience, each that you remember from your DF one year, your first year out, that you found like a real challenge. And then what lesson we can draw for that. So, I’ll go first give you an idea of what would the angle I’m taking. It was Christmas Eve of my first year in work. So, DF one for us. And the volume of patients I saw that day, in pain, tomorrow is Christmas, you got to get them out. It’s just really, really, really was a challenging day for me, I just felt so physically destroyed and burnt out on that day. So yes, all the advice that you gave there. But when it comes to those scenarios, you just have to really keep your composure. And obviously, because you see if there wasn’t much support available for me on that day, you have to keep your composure and give your everything, to that one patient that’s there who’s put their trust in you. And so you’re gonna have these days that you have just a huge volume of patients. But the show must go on. And you have to have to have to give every single patient your best. So, it’s kind of like showbusiness, even though you’re like destroyed inside, you have to give your best, present your best self to your patient, and you have to care. So, like you said, put your best patient’s best interest. That’s, you know, the classical way to say it, but you’ve just have to actually care, care with a capital C-A-R-E. So, that’s my sort of memory of having a really tough experience, do you have an experience that you want to share either isolated incident, or just generally? [Saeed]If I can cheer, can I give two quick examples. Som the first incident is a bit of a lighthearted one. In my, I think my first or second week, literally just about to start seeing patients, just for some context, I was taking on the patient cases from the previous practice owner who’s semi-retired. So, these patients had seen the previous dentist for like 20, 30 years, some of them, they were really used to that previous dentist. I remember seeing this 78 year old, I think it was 78-ish gentleman he came in, and I was going through the same history taking that I learned at uni, you know, everything risk assessment, every tiny little question detail. I was asking everything. At one point, he looks at me and I could tell it was losing him. At one point, he looks at me and he goes, ‘Look, kid, can you just look at my mouth so I can leave?’ And I was like, ‘Yeah, sure, of course, I was just about to do that, I should just quickly do that.’ And the lesson that I learned from that is you have to be adaptable as well, you know, I have my own style, the previous dentists had their own, but you have to be adaptable, you have to kind of know your audience, and know how to approach each patient in their own way. Because that’s when you can kind of win their trust, and be able to provide good treatment. And on a more challenging one, there was this lady who hadn’t seen a dentist again, for two years, you know, there was a lot going on her mouth, a lot of retain root, a lot of unrestorable teeth. And she came to me and she said, ‘Could you just please, like, whatever you do, just please fix my mouth so that I look presentable for my daughter’s wedding. That’s all I want to do. We’re on the top table, everyone’s gonna take pictures, please just make me look presentable.’ And what I said before you always try to manage expectations, and you never try and make promises. But in that case, I said, ‘Look, I can’t promise anything. But for you, I’m going to try my absolute best.’ And I went through the stages, you know, we did some extractions. And each stage I was going along with a denture stages as well. And it got to the point where we were just about to fit it where the patient had a lot of post operative swelling, and abscess from the area, which was something I couldn’t predict because we were under a time pressure. We had to kind of speed things up, we had the same amount of time that could give to allow healing to take place. And it really, because you get emotionally invested yourself in this situation, it can have an impact, it can have an impact on you. And by the end of it, she couldn’t wear her top denture unfortunately. She could only wear her low one. It was enough to kind of take pictures with. But I think the main takeaway that I could take from it is, like you said, care as much as you can. But just know that some scenarios are just out of your control, no matter of how much of a good intention you have, how much you try your best. Sometimes you just can’t achieve it out of things, out of your control. [Jaz]Saeed based on that, I mean, great lessons you shared there. And I think some things to remember is you’re not a pizza, so you can’t make everyone happy. You have to care. You have to care. But ultimately you can’t take your patient’s problem and own that. So, I think it shows that what a sweet and caring dentist you are that you feel emotionally invested. And I, for the first four years, like I was in bed thinking, oh my god, I just did an extraction today, what if my patient has a dry socket? And what if they’re in pain and I used to be emotionless of myself, it was silly. You know, I always teach now, don’t own the patient’s problem and don’t take their problem home with you. But that’s different from not caring, I’m saying care, still care about the patient, but you can’t own their problem. We have enough problems in our own lives. We don’t need to start carrying all our patients problems. So that’s, that’s really important. And then yes, the other lesson there is, if you don’t talk about stressful dentistry, you talk about dentistry under a time deadline. Oh, my goodness. So, these are the cases where anyone if anyone ever says there’s a time deadline, okay. And even if it’s a decent time deadline, you always, always, always have to put that frame on that. Listen, anything can happen. We cannot guarantee anything and try your best be like but listen, this is unrealistic to put any sort of time pressure, because we want to get the best outcome here, not a rushed outcome. So just be careful in those scenarios. Saeed, thank you so much for giving your time. And you know what Saeed, I really respect you. Because you’ve made yourself vulnerable, you reveal a few things about your experience levels and the annual training and stuff, which I really appreciate. Because a lot of people will be able to listen to this, oh my god, it’s not just me. I’ve got someone out there who’s who’s who’s been through it just and I can do as well. So, that’s really great. Tell me what you’ve got planned over the next year, what kind of things you want to learn? What’s on your personal development plan? What kind of feelings that you’re having in the real big, bad world of associate life? [Saeed]So, in regards to dentistry itself, at the moment, I’m really just enjoying kind of getting a taste for every little tiny pocket of dentistry there is. I’m enjoying that it’s sneaking my head through through the door. I mean, ‘Oh, this is what oral surgeries like, this is what endos like.’ So, at the moment, I don’t have a clear set plan. I’m kind of just finding my feet. And then with time, hopefully whatever feels right for me, I can pursue. But one thing that I’ve always known that I want to get into in the future is I’d hopefully like to get to education. And whether that’s in the form of being a clinical tutor at university or becoming a supervisor for foundation dentists or even like setting up courses like you do. And teaching others I know that’s hopefully something I want to get into in the future. And the reason why I kind of came on here to share my stories is because I want others to know that what you’re going through isn’t unique completely to you. You know, I wish the kind of stuff I know now, a year ago, which is kind of why what gave me the idea to come and share my stories with others and people should know that you know, this is a hard job. This is an overwhelming job. For a lot of cases it might be the most difficult graduate job straight out of uni coming to your first ever full time job. This might be the most difficult one out there if you compare it so don’t feel bad about it, be understanding towards yourself. And definitely with time you’ll get better because experience is the best teacher in life. [Jaz]Man you are so wise beyond your years and I think you’ve got a great career ahead of you just your attitude, your mindset, everything’s just seems perfect to me. And I think keep doing what you’re doing. I think you’ve definitely got your head screwed on right? So, it must be saying about these postgrads you know postgrad dentists are always just on the ball always finding something you know about having a prior degree already. So, I always find you guys are so much more mature. So, that probably explains why you are so mature despite being so young. So, that’s amazing. And I wish you all the best with that. [Saeed]Thank you so much. [Jaz]Please tell us how we can follow you on the socials. [Saeed]Yeah, so Jaz, I’m sure you’re going to tag me on the social but I’ve got a dental page. It’s D-R Saeed, drsaeed_dental, is my Instagram tag. Any young dentists out there if there’s any help or advice that you think that I could give, any help at all, don’t hesitate. Find me on social media, get in touch. If I can help I’d be more than happy to do so. Just before we wrap up, Jaz, I really need to thank you not just for inviting me on here today but also for the huge amount of inspiration that you provide not just for me but anyone that listens to the podcast. I have learned so much from listening to your podcast that I’ve been able to apply to my work and I just hope that you keep doing it and you achieve bigger and greater things hopefully with time. [Jaz]Amazing. Well, I appreciate you being part of the Protruserati and you’ve done us proud. You made us proud of this episode. You should be really proud, I think you’ve handled everything you get. So many gems that will be really helpful to all those new events coming through. Saeed, all the best for your career. I’m gonna keep an eye out for you, buddy. I wish you all the best. [Saeed]Thank you so much as much appreciate it. Jaz’s Outro:Well, there we have it guys. Some real well themes covered there in terms of just how difficult it was for me to break contact, right? Like breaking contact is a thing that we don’t talk about as being tricky but it is, especially when you haven’t got the hand-eye coordination because you haven’t done enough preps because you haven’t gotten enough muscle memory yet. And so I really appreciate that Saeed shared his sort of numbers with us and they’re probably very similar to you listening right now. If you made it all the way to the end of this episode, so kudos to you Saeed for making this happen. Thanks so much for supporting all those young dentists listening here. And whether you’re a seasoned practitioners, just want to get a feel for what our younger colleagues are going through at the moment then thanks for sticking around to the end. And if young dentists you’ve just discovered Protrusive Dental Podcast thanks so much for joining me. You’re officially now a Protruserati, so hope you enjoyed that episodes and I’ll catch you in the next one guys.

My story of coming to the UK as a refugee from Afghanistan aged 6 and my journey in to Dentistry. I share some tough times and what drives me today. I explained why I think Dentistry was mis-sold to many of us as a 9-5 job (HA!) and my top books and influences. I’m delighted to be a guest on the Soft Bites Podcast. The hosts, Manuela and Jorge, have both been guests on the Protrusive Dental Podcast in the past. https://www.youtube.com/watch?v=pznVMyEDwTE Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 4:48 My Story: Refugee 1996 7:17 Life adversities 17:13 Importance of going through difficult moments 22:31 Podcasting Journey 27:38 Practicing a positive mindset 31:51 Importance of education and information 35:36 Good communication skills 45:38 Balance between the professional and personal life 55:25 Core values in life 59:30 Future goals for The Protrusive Dental Podcast and clinical dentistry Dr. Mahmoud Ibrahim and I are launching an occlusion course called OBAB (Occlusion Basics And Beyond). This course is o help you design and execute restorations from a single tooth to anterior aesthetic cases to full mouth rehab. Also, sign up for our monthly occlusion tip for you to get the kind of clinical content that we are preparing with OBAB If you loved this, be sure to watch Dentistry is STRESSFUL – this Podcast will help you Click below for full episode transcript: Jaz's Introduction: Hello, friend hope you're well it's a super busy time for Team Protrusive. Let me tell you, we've got the iOS and Android app almost ready so it's like so, so, so tantalizingly close. We're super super excited to launch it. Jaz’s Introduction:It’s gonna complement the web app on protrusive.app really well. And if you are Protruserati through and through, you will love the additional content on there. So, keep a close eye out in the next couple of weeks for the massive launch of the Protrusive app on iOS and Android. The other big news I want to share with you before we joined the main episode today is that Mahmoud Ibrahim and I are launching an occlusion course called OBAB. Now, OBAB stands for Occlusion Basics And Beyond. Mahmoud, once joke with me, they come for the OBAB but stay for the kebab, so we don’t know where which direction is gonna go in terms of food in the future. But this is predominantly an online course actually. So, it’s called Occlusion Basics And Beyond. And we think we’ll be ready in a few months now, we’re really trying super hard. But in our busy lives, it is a tough thing to do to actually plan and create the content recorded, get it edited. We’ve got beta testers lined up already. So, we’re really excited to get it out them to make sure that we get the correct feedback to enhance it as much as we can. Because ultimately, our goal is to help you design and execute restorations from single tooth to anterior aesthetic cases. And then later actually, in module five, we also cover full mouth concepts that will help you feel confident to deliver all this type of dentistry to patients and not worrying that things will break or chip, because we will teach you to apply keyword APPLY in capital letters. Because the principals, I’m going to show you in the videos and cases, if you can apply them in practice, that’s where you’re going to get success. So, if you sign up to our monthly occlusion tip, you can get flavour of the kind of content we have planned and we’re putting together to make it extremely tangible. So, head on over to occlusion.wtf so www.occlusion.wtf, sign up if you haven’t already. And if you’re a newcomer to this, if you sign up today, for example, if you haven’t signed up already, then what I’ll do is that when I send an email, I’ll make sure the previous videos I’ve sent will also be sent to you. So, for example, the first one was how to adjust the occlusion on resin-bonded bridge. And the second one coming in a few days is how to make a canine riser direct freehand. So, a full video and commentary of how to do that. This main episode today actually is one where I appeared on the soft bites podcast from Manuela and Andre, both have been guests on my podcast in the past. And essentially it’s my story of coming to the UK when I was six years old from Afghanistan as a refugee. The themes we cover are overcoming adversity, why dentistry is no longer a nine to five job in my opinion, and how you can make your children resilient. So, we kind of discuss these philosophical things but also key influences and books that changed my perspective in life. Plenty of references back to clinical dentistry and the busy lives we lead. So, I’m hoping it’s going to be something a little bit different for you guys. And I hope that you find some inspiration from this even if it gets you to pick up a new perspective or a new book that you hadn’t heard of or read before. Main EpisodeSo, hope you enjoy Manuela and Andre’s podcast and I hope to catch you in the next one very soon. [Manuela]Hello, guys. Hello, everyone. Welcome to another episode of the Soft Bites Podcast today we have a very, very special guests. We are very excited about this one. And yeah, welcome Jaz! Welcome to our podcast. [Jaz]Thank you so much for having me on Soft Bites. It’s a real pleasure to be- I would say my two favorite Portuguese people in whole wide world, but I will upset hundreds of Portuguese friends that I’ve made over the years a lot of them dentists so I will say you guys just I have yet to meet a Portuguese person that I just didn’t gel so well with, you guys are amazing. [Jorge]Thank you so much as I was talking to Manuela, how excited we are to have you here. I think you are, I’ve dealt with many Dentists in Guys connected to education, I had to say you are one of the most authentic persons in the field. So, I’m really excited to have you here and have this chat with you. So, thank you so much for spending this time with us. [Jaz]Thank you for having me. [Manuela]Okay, so I’ll start. We want to know a little bit more about you Jaz, about your story. So, tell us about if you feel comfortable to share your story on being a refugee that I don’t think most people know about that. [Jaz]Correct. They don’t and I kind of kept it like a little bit of a secret on my podcast that I never share. Because I didn’t feel like you know, I don’t want to distract from the talking about sub gingival dentistry, retraction cords, crown preps, then suddenly, it’s all about this. So, I guess thank you for providing a platform for this, you know, you guys are mixing the dental and the human together, which is a beautiful thing. And so let’s talk about that, right? So, I came to the UK in 1996 as a refugee. I was born in Afghanistan in a place called Jalalabad, and from speaking to my parents, and my grandparents, everyone, Sikhs, which is what religion I am, live and Han Hindus lived very peacefully in a predominantly Islamic nation, Afghanistan. And since, you know, over 100 years, Sikhs and Hindus live there, and in peacefully with the locals and Afghanistan. Unfortunately, when the Taliban troubles up rose, it caused a lot of issues. Lots of Sikhs fled for the safety of their lives. Also Hindus fled. And over the last few years, there’s been lots of violence and war and the Sikh temples being destroyed and all that kind of stuff. So even now, unfortunately, the amount of Sikh people now living in Afghanistan is probably less than 100. Now, which is a shame because we thousands so that community has now gone to in Belgium, gone to Germany, it’s gone to the UK, it’s gone to India, it’s gone east that way. So, it’s gone all over the world. So, it’s like Afghani seek just for a very well connected very close knit community, all over the world. And in West London, where I grew up, huge community of Afghani Sikhs, and I’m just in everyday I pinch myself, I’m so lucky, I’m so lucky that I managed to somehow escape all those monstrosities, and receive a British education. And it’s just down to luck. It’s just purely down to luck. And when I see all these refugees now and what happened in Syria some time ago. And then the new Afghani refugees coming in, everything comes in circled in the Taliban again. And then recently Reading where I live now, these Afghani refugees coming, I’m like, ‘Wow, man!’ all they just need an opportunity and education. [Jorge]Jaz, thank you so much for allowing yourself to share this story with us. I remember that I talked to you, when you were in Portugal. And you just said that, to me, I was really surprised. I had no idea which may view for me to respect you even more. And not only about the work that you do, but especially all these positive character that you have. And when you were talking, I was just thinking about well, you say that you were lucky, right? But do you think that this positive personal that you have in this, that you look like a guy that constantly looks to the bright side of life. Right? You’re not that much focusing on adversity, and you are always looking for solutions, at least that’s that’s the feeling that I have. Do you think I’m just going to leave a little bit off the script that you have here. Do you think this is something that you have developed intentionally? Or do you think this is something that was born with you? I mean, do you have to work towards that? I mean, DB adversity made you this way, or you think that someone that is genetics, or that’s something that was already inside you? Have you think about that? How do you see that? [Jaz]Yes, that’s a really good question. The answer is, I don’t really know. But I can guess guess as to how it is. And Steve Jobs famously said that, ‘You can’t connect the dots looking forward, you can only connect the dots looking back.’ And I’m a huge fan of that. And so when I look at my background, and the biggest, fortunate, I mean, my parents, you know, they took a huge risk to do what they did. My mom was pregnant when we came to the UK and stuff. So thanks to my parents for making it through UK and making it live and all that kind of stuff and in the community and stuff. So you know, I think wow, luck was a huge part in that. And then what really changed me and my path was the education I mentioned, again, the education I received just when I was six years old, and being able to learn English and I took a liking it was the only thing that I was good at, for the first time in life. The only thing I can actually do so, I just went and went ourselves, poured myself into learning and education. And I gained a lot of self confidence from being at the top of my class at a very young age, because that was the only thing that I could call my own, I didn’t really have much growing up but to have these sort of getting a good mark on my homework, for me was like the highest praise at the time. So, I guess when I look back, that was good. And then going forward, when I think about the books that I’ve read, there’s a book called ‘Quiet’ and looks at the brains of introverts. And when you cut the brains of an introvert, they have a huge amygdala, you’re smiling Manuela and maybe you read this book? [Jorge]I haven’t. [Jaz]You haven’t? Have you read it Manuela? [Manuela]No, no, no. I’m smiling because I’m writing it down because I think it’s important. I would like to read it. And because you were talking about the amygdala, go on, go on. [Jaz]Yeah, I know you’re very much into this field. And so when you dissect an introvert, you will find a large amygdala compared to someone else. So, what that book taught me was that we all, in our development from a young age, yes, there’s a huge genetic component. Like I look at my son’s personality at age three now. And they say that your personality at age three will closely mirror your personality at age 18. And it’s because you have all these channels and pathways. But if you exercise, certain channels, and certain pathways that become stronger and stronger, so I don’t know where it was, in my time. I was introverted in the past. I was quiet. I had bullying, I had adversities in my past. I was the only brown person, the only guy with a turban and stuff, you know, growing up in this huge school of mostly Caucasian children. So, I went through all that. So, when I look back, because okay, what was it that made me so positively focus? I think it’s just the books that I read into the slowly being exposed to these kind of schools of thoughts and whatnot. And it kind of just happened, I guess. But I do believe that, when it comes to nature versus nurture, I think nature plays a huge role. And then what you feed it, how you nourish it, with the nature and just fell into place. And I do want to say that when I had braces, and it sounds really, I went on dental podcasts and sounds really cheesy. But if you ask me why I became a dentist, I will say the same thing. I had braces, and it completely changed me as a person. And I think that was a huge part in my journey. I used to be really embarrassed of my teeth and whatnot. And I really can pinpoint age 13, 14, where I really started to smile more and become more confident. And I think that for me, part of my journey was huge. [Jorge]Jaz, so I guess you will say just before next question, I think that there’s a big part of intentionally changing yourself, because I think this is really important for people listening to us, because I am 44. And in Portugal, when I was like in my teams, there was not this culture of something very simple as you are able to change yourself, this notion that you are able to change yourself. And I had to discover that I had to say that I had discovered that very late. So, I think this is a question for you, don’t you think that in traditional education, they are lacking this part in terms of the curriculum. Because you said you that you read the books, right? So on your own, you read some books, or that’s what emotional development or personal development but I would submit out of this, the notion that you can change yourself, not only your body, but also your emotions and your personality to achieve whatever you think is your goal in life. So I think that this notion that I don’t know that everybody has that in their teens, which is you are able to do some positive changes yourself. And don’t you think this lacks in the traditional curriculum? I don’t know how it is in the UK now, but at least in Portugal, this is likely. [Jaz]I agree, I think, welcome this change and how you’re able to change your thinking and your mindset. And we are amenable to that, and we can change the way we think and that manifests in a physical change, emotional change, and that they’re all connected. But I was saying to Manuela, that I, for some reason, I must have read something that I started to seek these scenarios, these positions where I would be uncomfortable, I would purposely seek these out where it would make me feel really, really sick to the core that okay, I’m going to be you know, I don’t want to do this, I don’t want to stand up from 30 people and say this, I don’t want to put myself out there. And I would seek those opportunities out, just like a maniac. And I think that really fast track my growth and in terms of my emotional intelligence, because I was able to flourish in these very uncomfortable scenarios. [Manuela]That’s so interesting. Let me just say something because I completely identified with what you were saying because I remember being in my more than 20 years ago and in university and feeling that nauseous and completely out of my comfort zone when I had exams and things like that and at the time because I didn’t know how to deal with it. At the time, I shut myself down you know, it was very difficult for me. And fast forward, 20 years after, I realized that those are the situations that made me grow and I could not see that at that time. I was not ready. No one told me. I remember going into the toilet you know calling my mother and crying and say, ‘I cannot do this and I cannot do this.’ And my mother, ‘Okay. Okay, okay.’ But she also didn’t know how to help you. That’s not the way that we grew up. That’s not the way that we were educated, no one told us about these things. And nowadays, just like you said, I put myself out there. When I have a situation is like, ‘Okay, I’m going to write this email, I’m going to do this proposition I’m going.’ And then I have this, ‘Oh my god, but I’m not going to be able to do this or to talk on this.’ Yes, yes, you are, just you will learn it. Second time, it will be easier. So, for me, it was something that it needed learning. But nowadays, it’s also like that and also what Andres said, I think that in our generation, it was more about self control. So, we had this notion that we could not change ourselves, but we’re able somehow to control certain parts of ourselves. Nowadays, with all these notions of emotional intelligence, just like you said Jaz, we learned that it’s all about self management. We can manage ourselves, we can learn, we can grow. And even though our neural connections through neuroplasticity, everything changes, everything changes with- [Jaz]That’s the keyword right there, neuroplasticity, that’s probably the word of the century. [Manuela]Yeah. But, we have to do the work. And I think this is in the dentistry is very important. Because sometimes, dentists complain about their everyday dentistry life. But they have to realize that, to realize that they have to be able to do the work in order to bring some change into their into their days. So, that’s really important. [Jaz]They need to sweat, everyone needs to sweat, whether it’s emotionally or physically, that is what needs to happen. And I saw this amazing photo quote, the other day, guys on Andre and Manuel. So, it’s really amazing quote, he said, ‘Don’t be afraid to suck at something new.’ [Manuela]Yeah. [Jaz]And I put a caption, I share mine. So, I put a caption and it said, ‘This is how I feel every time I learn a new technique on a course.’ [Manuela]Okay, sorry to interrupt and continue. [Jorge]So, Jaz, looking back at what we were talking about, and the importance of going through difficult moments. Can you tell us about some of those moments in your life? And how was that helpful in any way? [Jaz]I’m gonna share something with you guys that I’ve never shared publicly before. And you know what? Fine. So, you guys are getting a lot of different stories here. I kept this one a secret but no longer. Growing up, didn’t have much money. And around about age 14, in our teenage years, all your friends got nice things, and I couldn’t afford it at the time. And my parents bless them. I didn’t feel like I could ask them for money and stuff. So, I felt like I need to take matters into my own hands. So, I found this dude online. He’s from Hong Kong, or China, I forgot where it was from. And then he was like, and I was on eBay and stuff. And like, there was this like idea to do kind of like drop shipping. So basically, I fulfill an order, and someone else will post it. So as a 14 year old, I was using my mom’s, I made my mom and eBay account, I registered her credit card. But I was doing everything right. So I thought, ‘Okay, let’s start some sort of business.’ And so what it was, was that I was advertising and selling Tiffany and Co jewelry. Okay, I hope I don’t get if anyone from Tiffany is listening. I had no idea that was counterfeit at the time. So I’m, I’m gonna come to that in a moment. Okay. So I was selling this, Tiffany and Co jewelry online. And I was like, learning about copy and marketing, which I guess, you know, fast forward to 15, 20 years. And that does come in handy- [Manuela]It’s useful. [Jaz]With the course and education stuff. So you know, you look back. Exactly, it came in handy back then. But I was learning about, okay, how can I present this product and stuff. So, there’s people in the UK would buy this Tiffany jewelry. And I didn’t know what Tiffany was. I don’t know how much Tiffany was. The guy just said recommended retail like $60 or whatever. And I was selling it. Obviously, Tiffany costs a lot more than that. I didn’t know it was fake, right? So, I was fulfilling this order. This dude from China was with shipping it and I would keep like 20%. So for me at the time, making 10 or 15 pounds a day. I thought I was like, wow, I was it. At that age, and it was going really well and I was enjoying it. And then suddenly all these orders were being fulfilled, but the shipping wasn’t happening. So, I liable for my mom was like liable, technically legally to 100% and the we had some people complain that was fake. I was like, ‘What?! This thing is fake jewelry exists?’ So, as a 14 year old, 15 year old at a time suddenly, the guy who you’d liaise with every day of MSN. You remember MSN? I was lazing on on MSN every day, and he wasn’t responding anymore. And suddenly, I had like 800 pounds worth of orders that weren’t fulfilled and was all on me as a 15 year old, and my parents had no idea I was doing this for like last two months. And so this was crippling. Like, I laugh about it now. But at the time, I was like, I was feeling sick. I was stressed. I broke my leg playing football as well. It was a bizarre time so I was there on the crutches, and emotionally, mentally, all I could think was like, ‘Oh my God, how I’m gonna find 800 pounds to pay these people?’ Because, you know, technically what I’m doing is wrong here. At the time, I almost, almost spoke up to my parents like every day I was waiting on MSN waiting, ‘When’s going gonna come online? When’s this guy gonna come online?’ Anyway, long story short, he came online. Turns out he was hospitalized and whatnot. He sorted it out. But it was most the difficult 50 days of my life, daily email exchanges with these unhappy customers saying, ‘Look, I’m really sorry. I’m gonna figure out what happened.’ Whatever, whatever. Real stress that was extremely stressful. And of course exams, GCSEs, everything that was all happening. It all got resolved. And I promise I never wanted to touch this kind of stuff again. Never wanted to do business with someone I didn’t look in the eyes and I didn’t know. So, that was my very dark moment in my life. But yeah. It taught me a lot. [Jorge]So, you have spent the money that you have won could you get it back? [Jaz]Yes of course. I like that I’ve won. Because it was like gambling it away. Yeah, of course, man. I bought like a guitar for 40 pounds. I was buying clothes I could finally afford for like nice clothes. Like I was going out. I was going to movies was I couldn’t do as much for so yeah, I was really enjoying my teenage life finally had money. So yeah, it was a really strapped but I look back and like, wow, I learned so much like I never wished that upon any teenager, especially with someone who’s like looking for money at time. But yeah, it was it was an interesting period of my life. [Manuela]And you learn a lot. [Jaz]I learned how to manage upset customers. I learned about the importance of who you do business with and what kind of businesses are a high risk and low risk and that kind of stuff. So yeah, it taught me a lot. [Manuela]Jaz, let’s talk about your podcast, because I think it’s the podcast of dentistry. It’s the reference for- [Jorge]It is! [Manuela]It really- [Jaz]I don’t know if it is but you know, that’s about very sweet coming from you both. Thank you so much. You both been great guests on the show. [Manuela]I want to know, how did your podcast started? How did you come up with the idea? I personally feel and because I already read your motivations. And I think they are very novel because you have this mindset of wanting to help and wanting to share knowledge, but I want to hear it from you. How did you come up with the idea of the Protrusive Podcast? And how did you felt that could be useful to the dentistry? [Jaz]The idea was really random, actually. And it didn’t envisage to become what it becomes today in terms of, you know, I get so many nice comments and a nice community that we’ve built now and I’m so glad that you two are part of it and been previous guests and whatnot. And just making knowledge accessible. These questions, these little niggly questions that were always, you know, usually you get that information at the bar at 2am. And you ask a prosthodontist for some question and they give you the answer, direct and obey the podcast so that you know you can get that anywhere you’re on the world. But the way it started was, you may or may not know I was in Singapore for 18 months. I was working in dentistry in Singapore. I was a dentist there. I mean, my wife was there. We were enjoying it. We’re traveling, we are working, then my wife got homesick. And then I came back. And then amongst the UK dentists, this word started to spread the hate as a dentist. He went to Singapore, he lived a good life, he came back and now he can teach you how to move to Singapore and pay little tax and enjoy the sunshine and go on holidays and that kind of stuff. So, my phone number started circulating. So, as I was driving from London to Oxford, like what an hour back. I was speaking to a different dentist every day on the phone answering the same damn questions. ‘How much do you earn? Is there a language barrier? How do I get my license? What’s the indemnity like?’ Etc, etc at the same things. And after about the eighth person I was okay, well, I want to listen to my audio books a gain. I want to speak to someone, answer the same things again, how can I get my message? How can I hit record on a WhatsApp message or something and deliver it to the world? And so the first episode was expat dentists in Singapore. And so that was the reason. It was actually selfish. I didn’t want, I want to not have to do one on one phone calls anymore. I want to do one too many by putting this message out and then the second episode was, ‘Oh that was fun.’ How about we speak to my colleague who went to America recently? What’s it like to move to America as a UK graduate? Then episode four was at Australia. And then you know how you mentioned Manuela about sharing knowledge and that kind of stuff. I’m a lifelong learner. So, I want to ask the questions that I want to know about at the same time. So I was selfish, I was learning, but at the same time, you know, people are there like a fly on the wall learning as well. And that’s the origin of it. And now what has become now is a lot more we’re gonna come up with CPD and stuff because the demand is there, people will listen, they spend hours listen, and they want to go to click on and get a CPD certificate. I get all sorts of weird, wonderful requests for speaking and stuff, which is, which is amazing. I again, I pinch myself like, ‘Woah, how does this happen?’ It helped me to, I was able to tear a hole in the wall. And I thought, ‘You know what, I’m here. And I’m here to share. And I’m here to have fun. And let’s do this.’ So yeah, it was a nice little position that- [Manuela]Manuel, she was talking. So, sorry. [Manuela]No, no, no. I’m just going to say this, because I think one of the reasons of your success is that at least I feel that you are having fun. And you can see that. You are having fun, you’re authentic, you really enjoy what you’re doing, you really feel that what you are doing makes a difference. And it brings content, useful content. And you’ll really enjoy yourself. So, I just wanted to mention this. [Jaz]And Manuela you mentioned that we were talking before we hit record button about some struggles and impostor syndrome and thinking, ‘Ah, is it worth what I’m doing and stuff.’ And a few times in my podcasting journey so far for the last three years, I’ve been like, you know, I’ve got a team now. I’ve got a team we spent hours producing each episode now. We now we’ve moved to a situation, we’re gonna have the notes on the left hand side, over the video on the right, so it’s becoming a real big operation. And it used take five hours to make an episode. Now it takes upwards of 20 man hours to produce an episode. So it’s getting there, sometimes is it worth it and stuff. But sometimes when I get an email saying that, ‘You know what I was in a dark place in dentistry. And I just feel as though I needed you in my morning drives to get me through the day. And now believe it or not, I actually enjoy it. And now booked onto this course that you recommended, and I’m really enjoying it. And I did my first crown prep I did my first onlay. And if it wasn’t for Episode 59, I wasn’t able to do it.’ And on YouTube, someone oh my god. So, this dentist one year out of dental school on her last day at her sort of foundation training position, she was able to section elevate from a molar to remove it. And she commented on the YouTube saying, ‘On my last day, I managed to do this because of this episode, I didn’t understand dental school, I learnt it from Episode 88, or whatever it was.’ So it’s feedback like that things ‘Wow, wow, this is working people are learning, people are sharing. And so that’s what keeps me going. [Jaz]That is so cool. And I don’t know if you if you met Jaz in person, but it really is this character that he really really wants. And I think this is something that is very rare, that he really wants you to be good around him. You know, there are some people that is just like, they just want to keep the energy from themselves. And Jaz, is one of those guys that really wants you to make you feel good around him. And that’s something that is really rare and special in dentistry. So, regarding that I haven’t read the values and the goals of maybe have it written down somewhere on on the podcast. But we know that you have this sharing and this abundance mindset. I mean, so your success is not at all it means that someone else is losing. Can you tell us about that? And was it something that was- Did it grow with you? Or is it something that you transform yourself into, because you realize that that was the way to be? [Jaz]I think when I look back at the different books I read, self development, I’m a huge fan of self development, it must have been the Seven Habits of Highly Effective People, which like when you google self development books, that’s like the number one recommended one. So it must have been like, you know, in my teenage years, when I read that, and then it talked about the scarcity mindset and the abundance mindset now hope I’m not confusing books, I’m pretty sure that’s one of the better parts of it. And so having that in learning, okay, what is scarcity mindset? And why identify with that, are there any things that in my life that I look at, and I’ve adopted the scarcity mindset and being open to change and changing the way that you move your perspective? And to have the abundance mindset so yes, scarcity mindset when you think that if my podcast is doing well, other podcasts are not doing well. Or if this dentist doing well that means that this other dentist is not doing well. That’s absolutely yes, we know that there is all of us to grow and learn and share. And it’s amazing. It’s not like it’s not a net zero game. Everyone has a benefit to be gained and we can all win in this. I think once you adapt that, the positivity just infuses you’re more open to collaborations, you’re more open to share and good things happen when you share. [Jorge]But I think it really is important that in dentistry because I don’t know why but dentistry is a very unique profession, probably because of the excessive dentistry almost all over the world now. I don’t think that kind of mindset is something that is really present. So, thank you for that. For trying to, to share that kind of vision because I think that we all, not only a few, that we all need to understand that. We all need to understand that dentistry is ultimately about helping people. And the closer and the less competitive that we are in ourselves. And the more that we want to help ourselves ultimately, will help more people. And so thank you so much for that. [Jaz]Thank you, Andres. And I think it’s one to add that, you know, in practice and making bring it back to the real world of practice, you know, let’s say you work in a local neighborhood, and then there’s a competitive dentist down the road. And I think we see this too many times where, you know, you worry that if you’re patient, lose a crown. [Jorge]Yeah. [Jaz]Then they go to the dentist. And yeah, man, there’s gonna. This is gonna be good. Why do we have this fear? Because, you know, it’s unfortunate. We hear the stories and whatnot, right? And it worries you. So, I think the sooner we dentists look after each other, learn not to throw each other under the bus. Because you know, I’ve done it before, where and I’m sure Andre, you’ve done this, as well, where I see a patient, this is my first year out of dental school. I see a patient large amalgam on the distal of a second molar, which had an overhang I was like, ‘Look, you know, you just got overhang. It’s not very good, it’s sealed. But you know, let’s, let’s improve it.’ And then you struggle so much doing it, you think, ‘Oh, my God, no wonder this amalgam will be better than all I could do.’ So you never know, the struggle that the dentist had doing it. I think we need to remember that. And always be present with that, you know, we need to promote each other, we need to make sure that we don’t throw each other under the bus. And that pretty much embodies exactly that abundance mentality. [Jorge]And have this respect for this for this wonderful profession, isn’t it and having this this respect for something that that can really have such an impact on the patient’s lives? [Manuela]Just to close this segment, I would like to, we already talked about that, between to talk a little bit about the importance of access to education, because I think that just like you said, and you gave that wonderful example of someone that has done a clinical procedure based on one of your episodes, and I think that’s a beautiful thing. But I know that this is very important to you to share education. And you also mentioned that while growing up, education and it was something that you had to also feel confident that you use as a confidence factor. You also think that’s why because now that’s the reason why nowadays, you feel that you are this vehicle to share education and to share information with others. Because I mean, Education and Information is power. [Jaz]Yes, yes. Knowledge, power and implementation more and more, I’m realizing, as I’m sharing with one that, you know, your knowledge is great, but implementation is where it’s really at. And I guess if I go back really in time, and to link it back to the very first thing of the podcast about my journey when I was six years old, so maybe seven. And it was one year in the country, and I was just learning English. And then we had this big leaderboard at the front of my primary school. So it’s like, you know, grade three or something, right? Take the leader board, everyone’s name on it. And every time you managed to get all the spellings correct, there’s like six or seven words you have to write. Every time you get the spelling, correct all of them, you get a star next to the name, okay, everyone had all the stars, I didn’t have a single star. And that first day, age seven, I got my first star. And I remember at home, being you know, practicing writing the word home, H-O-M-E DOGDOG, practicing, practicing, practicing. And I got my first star, I will never forget that as the moment of my life that changed mantra and try directory, because it taught me a very valuable lesson that hard work always pays off. That was when I learned that age seven. And then I always think back to that moment when I’m in trouble that you know, that if I didn’t do my practicing at home, and my mom really watching and she was like, ‘You know, didn’t know how to help me my homework, whatever, but I did it myself.’ And so that was a really important part. So, in terms of now, sharing and getting everyone involved, it’s only natural that I got into this space in terms of promoting that. And there was this book, I know talking about lots of books and stuff like so important to read. [Jorge]Of course. [Jaz]This book was recommended to me. And it was called Strengths Finder 2.0. Strengths Finder. And I encourage everyone to do this. So you do this, It’s like, it’s a book that you buy, and then it’s some like an online quiz that you do. And then by doing this quiz takes like 15-20 minutes. It tells you evidence based something, your five top strengths. And the book argues that we should focus on our strengths, not on our weakness, we focus on our strengths. And my number one strength was very competitive in sports and everything like that. And so maybe it’s because I was competitive that star that I got when I was seven that really fueled me is like, ‘Wow, I make it I got my faster, how do I get all the other star so I can race to the top.’ So, when it comes to that, you know, you have to look at your strengths. And now I’m playing to my strengths. I’m trying to level up myself and learn. But in that journey, I’m sharing to level everyone up at this level everyone else up as well. And there’s so much beauty. [Manuela]Can I just? [Jorge]Of course. Yeah [Manuela]Sorry, sorry. I just want to talk the alignment. Can I ask you Jaz? And what about your communication skills? Where does that come from? Because you are very outspoken in a very authentic way. And you are always smiling is that one runs in your family? Or you have also to put yourself out there? IS that a natural thing? Because you have very good communication skills. [Jaz]I appreciate that. I never saw myself as that but more and more from feedback. And so people say that you present yourself well, I don’t know how that stems from. I do have this one theory is that at school, I did enjoy drama, I enjoyed acting, role playing and that kind of stuff. And that helped me to become more confident as well. And so I I believe that when we’re in practice, when we’re working, it’s showbusiness. I believe that we have to put on a show. And even if it’s a bad day, you have to, right? You have to. So, once you start to internalize that and want to do things like power posing upright in your body posture, and that changes your internal sort of a physiology and emotions and it all runs together. So, your body represents your mind, and there’s a huge connection. So, those things I think I’ve absorbed and adapted over the years. And now that’s how I like to live. Because even if I’ve had a bad day, like, you know, it’s very British thing to do when you walk. And you’re right. And everyone says, ‘You’re right, right?’ No one ever says actually, no, I’m not. Okay. Now, I’m not saying that it’s firstly, it’s okay to be not okay. It’s, firstly, I want to say that. [Jorge]Of course. Yeah. [Jaz]But at the at the end of the day, you shouldn’t be dwelling and focusing on the negativity, when you could be trying to change your physiology, change your reality. And I think maybe that’s how I I’ve come to be this smiley, positive person, because I truly believe that if I project that to the universe, that will get reflected back at me. [Jorge]Yeah, that’s very interesting what you’re saying, because both me and Manuela, we are firm believers of that. And that just reminded me of a book that I read from a Portuguese guy that’s working in the States, Antonio Damasio, the most important book that he wrote was Descartes’ Error, and basically talks about neurology and neurophysiology and one of the last books he was very clear about one thing is that we usually believe that you need to have good internal mindset conditions, so that you can improve your external world. But now we know it’s actually the opposite. You have to change your external world, inclusively, your body, like you’re saying, you had to change your physiology in order to feel good. So for example, if you like, ‘Well, I’m just going to work out, I’m just going to do this when I feel good.’ No, you have to start doing this. So, that then you start to feel good. So you have to, there’s something that you need to intentionally change on your external world, which might be your own body, so that you can start to feel okay, so that’s very, very interesting. So you get- [Jaz]And Andre body languages. [Jorge]Yes. Exactly. [Jaz]I mean it’s the same thing, I read something when I was 17 this power of body language, and that’s always imprinted in my mind. I always think, even like facial expressions, when you’re speaking to your patients, the tone of voice, it’s a bit like saying to a patient, ‘Well, we can do some crown lengthening, or we can do some Crown Lengthening.’ GCI, obviously won’t use that term. But it’s a huge difference, of course, how you project yourself that universe. [Jorge]Of course. But it’s really this notion that you really have to work. You have to be intentionally on how you want to feel it’s not you cannot wait to feel good to do something, you have to do something to feel good. Even the smile. If you smile, you’ll feel better, right? It’s not only from mind to the body, it’s just mainly especially from the body or the outside world to the to the mind. [Jaz]And I also think what we’re worrying and happiness is a choice. I do believe that. I know there’s lots of dark things that if you’re actually clinically depressed, that’s a . [Jorge]That’s important to say, yeah. [Jaz]Yeah, and it’s important to seek help for that. But when you know, in less serious things, when my wife tells me, she is stressed, I correct it. I say no, I say, ‘At this moment in time, you are choosing stress at this moment in time, you’re choosing to feel stress.’ And I live by that mentality. Yes, I get stressed. And I sometimes I choose to feel stress and I choose. And I know that okay, you know what, for the next 20 minutes, I’m going to be miserable. And I’m gonna do it in a corner alone. I want to get on my system. And I do that. But I’m being mindful about how I project myself to the universe. [Jorge]Yeah, we all want sometimes to feel miserable for a few moments, because it just, you want to spoil yourself. [Jaz]Yes. [Jorge]No, but I think it’s really important that, for me, this is something really personal because I think that I found this really late. I mean, we Portuguese, we have this, I don’t know if you know, we have Falho the kind of Portuguese music which is very sad. Which is basically- [Manuela]Dwelling on the negativity. [Jorge]And it’s like, you are the victim of the universe. Therefore, there’s nothing else that you can do. [Manuela]Yeah, like your life is very sad. [Jaz]When I did the city tour, when I did the tour in Porto, she was talking at the end of the tour, talking about this about, you know, there’s nothing really barely universe and all these things happens to you. [Jorge]Exactly [Manuela]Then even though exactly life sad is like this feeling of something that it’s not here. So, we are always anxious or looking for something that we don’t have. So, that’s a sad way of living. [Jorge]And fado is basically using that feeling and making it exponentially and feeling as sad as possible. Right? That’s something really Portuguese. And that is something that personally changed my life, which which was understanding that you have in every second of your life, you always have the ability of trying to do something to help yourself. I mean, if you can’t run, you just walk, if you can’t walk, you just crawl, but just keep trying to help yourself in the best way that you can. Sometimes it works better, sometimes it’s worse. It’s not so well. But I think that having this trying to overcome this victim mentality is really, really important. You are one of the biggest examples of that. And you were talking about for the vertical preparation course. So, it was really a pleasure for me to have met you there. And I have to say that I’ve said this before that you really have this very positive energy around you. And I think that one of the things is that you can clearly see that your main goal is that people around you feel good. And this is something that really, really struck me. So, how was your time in Porto and when’s the next time that we’re going to do it? I really look forward for that. [Jaz]I’m thinking already. Maybe we’re talking maybe next year or something like that, because I get messages all the time saying, ‘Jaz, I want to learn to verti prep but I want to learn only from you.’ I’m like, ‘No, you don’t learn from me run from Andre.’ So let me take you to Porto. And like, you know, it was such a great time. And I think that the need for it was there. And the timing was there after COVID. We want those. It’s like a retreat, right? It was such a nice retreat. [Jaz]We had we had such a great time. [Jaz]Which Limoncello was it? Which what was it the drink that we had? [Jorge]Sangria? Yeah, we this is the place where I usually go out to have dinner and to party. It’s called shinko fish, which we have dinner, which we ate on the day before. And we had also the limoncello sangria. [Jaz]Limoncello sangria, right? [Jorge]Yes, exactly. [Jaz]Out of this world. [Jorge]That’s a classic. [Jaz]And then your dad’s restaurant and everything. It was amazing. What you told me the restaurant I’ve been in. I don’t know if you’ve listened to a podcast. But on two or three episodes already. I’ve echoed this. Once again, I’ve coached you every time. I said that, ‘You know, Andre was sat next to me. And he said something so beautiful. So cliche in a way, but we need to hear it right, is that life is not about the destination life is not even about the journey.’ You said this? [Jorge]Yes. [Jaz]Life is about the company. And honestly, I need to hear that. It’s a beautiful reminder, life is about the company. [Jorge]Yeah. But that was something that even personally for me, because it really only strike me over the last, I would say the last one or two years. And we do this, we do this course me and Manuela, and it’s a mix of the mindful and emotional part with my practical and very, very practical tips on management and stuff like that. And we were talking and I was talking with one of the I was talking. Well, this is not about the destination. It’s about the journey. So yes, so I think these are very three important steps in life. So first of all, you want to have the goal you want to prove that you are rather than someone else. So then you have to, well, this is not about the goal because when you reach the goal, you realize that you’re not happy, so you have to enjoy the moment. So, then it’s about the destination. But I also think that it comes a point in your life, it’s not even about a goal or it’s also about to goal, it’s also about the destination but the company? People that are next to you or the people that you actually can influence that’s actually what makes everything special because otherwise it’s just okay yes, I have a goal. Yes, I have fun during the goal. But- [Jaz]That is a basic human need, isn’t it? It’s a tribal thing. Right? The goal. [Jorge]Yeah. [Jaz]And the journey that they’re not tribal. That is the people is the company that is the tribal nature, isn’t it? [Jorge]Yeah, and it was such a wonderful time to have to have you there. And I really hope that we can do this next time, next year. [Jaz]A hundred percent. Well, I’m thinking already, maybe next year or something, I’m getting messages all the time saying, ‘When they’re going to happen?’ I’m looking at my diary like, ‘Oh, not this year.’ But next year for sure. It’d be great to take a group to Porto again, what a beautiful place. And I told you, April was a tiny bit. So, maybe May a little bit warmer, the beach is beautiful. I had Francesinha, right? We have Pasta Lenato now on a monthly basis. My son loves it. So many things I learned about Portuguese culture was absolutely amazing. [Jorge]That is so cool. That is so cool. [Manuela]Jaz, I want to ask you, because I started listening, I still didn’t reach the end, one of your latest episodes on the podcast about parenthood and dentistry where you had Dr. Hardeep as your guest. And you guys talked about unique challenges that dentists face as parents. You are a father. Also, I would like to hear your opinion on, because for dentists I think finding balance between the professional and personal life it’s a big thingand some colleagues really struggle with that. So I would like to, to hear how you do it because you have this professional, very busy professional life with the oldest sides of it. You’re not just a clinic dentist working in chair, you have all this other things going on. But you are also a father, a husband, you have a personal life, you were just telling us that you are having a very busy summer family wise and wedding wise, how do you do it? Any secrets to have that balance? [Jaz]I think I can share a few things. I mean, firstly, when I was in final year of dentistry at dental school in Sheffield, I opened up the magazine and it was all these people in the year above who had just qualified and there was interviews with them. And one of the images was of a lady dentist who just qualified and it was a speech bubble. Next to her, it says, ‘I like that I’m going to profession that I can work nine to five and I don’t have to take my work home with me and that was me.’ And my final year in dentistry that brainwash me. I was like ‘Oh, that’s interesting. Okay, cool.’ So I go home, I treat patients, I come home, I don’t have to think about teeth. That’s pretty cool. I thought at the time, the biggest lie ever. Huge lie. Okay. And so you realize that- [Manuela]That’s really important because other dentists have struggle with this because they try to live that and that’s impossible. That does not exist. That’s a very important thing to be set. That’s a life. Yeah. [Jaz]Wow. I love that. You said that, Manuela. Because you’re right. Maybe I thought that maybe because the world I’m in that maybe I fell into this or I forced this upon me. But I do believe that dentistry as a nine to five job. It doesn’t exist anymore. Right? [Jorge]That’s very interesting. We usually talk a lot about this in the podcast. And I think that Dentistry has changed so much. I think that in the last maybe 20 years ago, you will tooth you do like single tooth dentistry. So you come into the tooth, you come three times to treat this tooth, or you come four times to treat four teeth. But now everything is changed. There is no more unit disciplinary dentistry. Everything is multidisciplinary. So, and the consequence of this is that you have homework, lab communication, colleagues communication, treatment planning, to plan presentation, you have so much homework and I think this is really important that there’s the job from nine to five doesn’t exist anymore. [Jorge]And so- Continue, Manuela. [Manuela]Continue. [Jaz]So, that made me think that I was a nine to five job like we said it’s a lie. So how do we do it? You know, we come home, we have our clinchecks, we have a treatment plans. And of course in the first five years I was course after course after course after I was a course junkie. And I needed that. I needed to because dental school didn’t prepare me, it prepares no one, right? It’s a bit like driving you only learn how to drive after you pass the test, not before. So, you need to get those hours behind the wheel and the hours behind the chair. And then with dentistry, you get less dental education. Dental school is getting diluted and diluted and diluted and it’s really unfair because the post graduate education world is having to pick up the slack and it’s costing us money it’s costing us time it’s costing a best part of our childhood. We know we sacrifice our 20s for the dentist who really wants to do good and get into the right practice environment and try and do the kind of cases that they want to do. It robs us of our 20s almost because he just got courses, courses, courses, courses. And your way you’re trying to balance everything. So, it’s a real struggle. So I think, to answer the question, I came to a point where I said, What do I want for my life? And how do I do life design? So I got a paper. And I decided that I don’t want to commute anymore. I don’t want to commute, I just want to reduce my commute, okay. I decided that if there is out there a shift pattern system, so I can work early in the morning or late in the evening, I would like to have half a day to do all the other things. Otherwise, I can’t do these other things. So, now I work eight till two, or I work two till eight in a practice that’s been doing this system for the last 40 years. So, most practices doing this, it was inflicted by COVID. At least in the UK, I know you guys have a different hours in Portugal, maybe. But in the UK, this practice been doing for 30 years. And I chose to find a property 15 minutes away walk to this practice. That’s how I can now fulfill my duties as a father and not having feel guilty that I’m not doing my work because I cut out the commute time, I’m nearby to work. I sort of picked in to chose these aspects of my life to make it and now I don’t edit the podcast episodes, because I still in five hours now, can I find a team? So, I found freelancers. And now we’ve got a team who’ve now just worked for protrusive. So, that we can work together. Because they are better at editing, quicker editing, they enjoy it more than I do. So, it’s about realizing whether you own a practice, whether you are an associate, wherever you are, if there’s any aspect of your work that you can give to someone else. And I guess I don’t know if it’s a right place to say here, but even things like gardening, right? I don’t do gardening. I don’t know how to garden, right? And my wife’s like, ‘Oh, the gardening bill was so much. So so much this month.’ I was like listen, it will take me hours to learn how to do it. Okay. It’s better we just pay the gardener and I can work on the business. I can have time with Ishaan. So, anything that you feel as though you can delegate someone else and you earn more during work than you can do in terms of doing that task, then I’m a big fan of delegation. [Jorge]Yes, I agree. You were talking about Ishaan? Is it the name of your kid? [Jaz]Ishaan is my son. Yes. [Jorge]Ishaan? [Jaz]Yes. [Jorge]Yeah. Even your face it completely changed when you talked about him. Even your expressions. So, it’s going to have a life completely different than yours, isn’t it? The bringup. And one of the things that I know that worries you and I’ve heard this subject mentioned many times, I think there’s this thing that says that, ‘Good times create weak people, weak people create something like that.’ But basically is that the grit and the effort and the adversity that you went through. It’s almost impossible that you try to implement that in the life of someone that you love so much, isn’t it? [Jaz]100% [Jorge]So, if you love him so much, how will you be able to make him go through things that you know that he needs to be able to be, I won’t say even successful, I would go even further. You need to you know that he needs to go through some things for him to be happy and confident. So, so- [Jaz]happiness and headstrong, headstrong and happy and have the grit and the determination. And so he’s beautiful characteristics that we all like. [Jorge]So what’s your doubts? And what’s your plan for that? I mean, if you do have a plan for that. [Jaz]I don’t have a plan yet. But it’s something I told you in an email like this keeps me up at night. This this is a real big level, big philosophical question. I asked myself that, ‘How would I do it?’ In the book Out Lies, it talks about income and how much income you need to be happy, right? And after like $70,000, any further income does not influence happiness at all. Not in the slightest. And this is evidence base. In fact, it might have the opposite effect. [Jorge]Yeah. [Jaz]So and then what they’ve talked about is okay, your children being spoiled, and whatnot, and how do you actually raise them up the right way? So you know, I look back at my childhood, I didn’t have my own room, I was sleeping on the floor in the living room for 17 years of my life. At first time I had my own bedroom was I went to uni, I didn’t want to go back home. I had my own room. At uni, this is a huge thing for me, right? So me and my sister. She had room for many years. And then she had the room and I was sleeping in the room on the floor and stuff. So I was like, ‘Okay, well, is it ethical for me to make Ishaan sleep on the floor? So he can learn to be adaptive? And not be so comfortable? How do I do it? I don’t know.’ But something that I’m gonna be working consciously very hard on is that how can I instill the values in him that make him not too comfortable so that he appreciates that everything has been given to him but I’ve had to work hard for it. My parents had to work hard for it and not to lose sight and touch of that. How can I make him humble? How can I instill humility? How can I make sure that ego doesn’t come up? How can I make sure that he has all those attributes that we talked about? But nowadays where everything’s handed to him. And I look at him and you know, my wife buys him these branded shoes like why does the freaking three year old need brand new shoes right? But my wife has those values and handled, ‘Okay, fine.’ But I think, how are we going to instill these important values in this young person? And that? I don’t know, I don’t know the answer. I don’t know the answer. If you guys have any ideas, I’d love to hear them. [Jaz]I have no idea. [Manuela]I have no idea. But really, the example is very important. And you are giving it to, I think that they, they learn with examples, but that’s all I got, nothing else. [Jorge]If I think about like, for 30 seconds, and I have to, I can talk about my own experience, I live in the room with my parents up until I was four, right. And then my father opened his restaurant. And my life started to be more comfortable around 10, 15, 10, 14. So, I think that I do have memories when I slept in the room with my parents. And I completely agree with Manuela is that example is very important. And you have to always keep reminding them, where you came from and your story, because I think that one of the things that reveals to me the most was actually being aware on a very frequent basis of what my parents went through. And I think that I don’t think that should be done in a dramatic way. But just look, there’s a huge amount of luck everywhere. I mean, if you were born in Ethiopia, your life chances will be really, really low. So there’s really something that you have to celebrate by the fact that you live, that you were able to travel to a developed country, and how have all this opportunities. So I think yes, so I think having that example, and having a healthy reminder of the things that you had to go through and really working as an example, because even though you are successful, I think that the core values they need, they need to be present just to treat people well, just to help others as much as possible. And then yes, that will be my 50 cents on that. [Jaz]I like that and just give me an idea to do charitable projects and countries and maybe I can’t subject him to all the things that I went through, but to observe and see, look, how can we help these individuals. But you know, if it was for a different circumstance, you might have been this individual, you were born into a family that could look after you in the way that they do. But that is by pure one in a million chance. We need to really appreciate that. And I think we all need to address that. [Jorge]And the thing that, I am a very evidence based guy and stuff like that. So if you really look at the psychology, there is no happiness without struggle, isn’t it? I won’t say dramatic struggle. But I mean, if you have to have a good body have to work out if you want to have, if you want to have more stable emotions, you have to meditate. So there’s always something that you need to intentionally do. It’s not something that is born with you or just drops out of heaven, you really have to be intentional about that. [Manuela]I would just say- I was just going to add a very short thing to what you said, Andre. I would just change the word struggle with challenge, I think that it has to do for even the stress. There’s a good stress, okay, when it’s too much, then when it’s part negative, then you have the distress, that that stress was for you to to be able to be motivated and everything’s stress, a certain amount of stress is good. And that’s what challenges the challenge gives yoy that’s a very important thing in life. And I think that’s some people that’s why they get stuck in this comfort zone, which is not even comfortable. It’s just what they are used to. [Jorge]Yes. [Manuela]Because they fear the challenge. They fear the struggle that you just said also. And they know that they have to make changes, they know that they have to get out of their comfort zone. And that’s really scary for some people. So, if you look at it from a positive side that, a certain amount of challenges good for you. It’s going to make you grow, it’s going to make you evolve. That’s a positive thing. Okay, sorry. Continue. [Jorge]It’s gonna make you happier. Yeah. So I think that all the topics that we written down, we went through, but I would just like to ask you just for as a final thought from you. So Manuela said that, I think you are you you have developed the podcast in dentistry. So yes, there’s a huge, huge responsibility in that as well. So what are your goals? How do you see Protrusive? Do eventually see that, as a physical space, it’s only going to be online? What are the main goals because I think that, up until now you have really placed the refreshing and very new and very positive energy in dentistry. So what’s your goals for for the podcast and for protrusive? So what’s the legacy that you want to leave behind? Youyou have already left? [Jaz]That’s a good question. I like that. I appreciate that. Legacy is a great question. I mean, in terms of direction, goal, nothing major. But you know, most of my listeners are about 70%, maybe 65%. UK. Number two is US, Australia, there’s still so many dentists who haven’t checked out protrusive. And if I can inject them with some enthusiasm, and some clinical tips. So I think it’s a more about discovery, I think I’d love more dentists to learn more about protrusive, and learn and share and come on as guests and stuff. So I think there’s a lot of growth still to happen in terms of legacy. In fact that legacy can be that listening to this podcast, made me feel good. Before I started, my day is one thing. And number two, that thing that I struggled with, listen to that podcast, it made it tangible, I finally get exactly why you put the thin cord in first, and then a fat cord in second and the role of things like that, where maybe those little questions, you can’t ask at dental school because you need a bigger picture first. And also, sometimes when you’re interviewing someone who’s like, you know, 40 years experience, and then they’re a master of composite resin, and they can teach you how to use 16 different layers and stuff. But the dentist just wants to know how many seconds to etch for, and which one do you use? Right? I want to be the guy who just says guys etch for 20 seconds? Yes. You know, I want to get that direct information out there to make people get started in their journeys and fulfill their clinical desires. [Jorge]Yeah, I really think that you have been very successful in that because I think that the online dentistry field has been filled with that rock star mentality and the superstar that only superstars can do good dentistry. And I think that you can, you did inject a lot of confidence and self esteem in the dentistry that the average dentist, which is all of us, but at the end of the day, we are all ever dentists because 90% of our work is average dentistry, isn’t it? And at the end, it just you’re just dealing with the person in front of you. And honestly, I don’t know any dentist that does not want to do a good job. So, thank you so much for that. And thank you so much for the inspiration. And I really hope that we can have you for for many years in dentistry. And by the way, do you think you’re going to do clinical dentistry for the rest of your life? Or you do have some other plans? [Jaz]I mean, if you asked me five years ago, I’d say yeah, clinical dentistry until I’m 70. And I’ve now changed that to clinical denstistry til I’m 55. And so I’m 55 maybe, but yeah, clinical dentistry for sure. I mean, I love it. And I look at my laptop. Same as you, Andre, you’re opening up your Google Photos. It’s like teeth and gingival margins everywhere on a daily basis. I still like to buy the new gadgets and still like to do all the things. I think it’s backbreaking work, and we look after our health and stuff so my focus is definitely you know, looking after myself but doing more exercise. I think since I became a father, I realized that we joined the gym last week me my wife, my son. [Jorge]Yes. [Jaz]We’re gonna do family gym time, but I think. [Jorge]Very good [Jaz]Yeah, as far as until at least age 55. I see my future in clinical dentistry and I have so much to learn. I think my future is more TMD airway, but just as comprehensive dentistry, but I just love being a general dentist. And so I’ll put one last thing up there, opportunity people that qualify, they think, ‘Okay, I need to be a specialist. I need to to be a specialist, I want to endodontics, I’m gonna do perio.’ There’s not enough people who qualify and say, ‘I want to be a generalist.’ And I feel as though three years ago, when I started the podcast, I started talking about the beauty of being a GDP. And I think that’s one more legacy is that I want people, dentists, 93% of us are general dentists. I want them to get validation from what they do. And remember that being a general dentists is the most difficult role in dentistry there is and let’s not forget that. And remember the most beautiful thing also, and the best thing about being GDP is cherry picking. So when you have that sour cherry, you pass it on, it’s okay. Okay, you get the best cherries. And there’s no shame on that because we have all the downside, let’s have an upside as well. [Jorge]That’s so cool. So I guess that we are not going to steal you more time but I am 100% sure that we’ll have that we want to try it for a second time here in this in Soft Bites to talk of the same things or some different things. So it really is a pleasure to have you with us. And- [Manuela]Thank you, Jaz. It was really wonderful. [Jorge]And I hope yeah- [Jaz]Pleasure is all mine guys. Honestly, it’s been great to get to know you both. Andre will see you again in May. We should do a dual thing and Manuela you should also come to Porto. [Manuela]You’re real first and all so- [Jorge]We do can that. [Jaz]I think more and more I get demand for courses abroad and retreats and stuff. [Jorge]Yes. [Jaz]And you know to work on the mind. [Jorge]Yeah. [Jaz]You know, the brain hands? The work on the brain, and mind with Manuela and work in hand with Andre, we should totally do that. [Jorge]And we are we are giving a course in October. It’s like it’s a four day course that we do in Sagres. About mindful dentistry and practical tips on management. [Jaz]Wow. [Jorge]But yes, yeah. But we can make something about the vertical preparation and do like a full day of mindfulness and some and some tips on career orientation and management of teams. [Manuela]I would love that. [Jorge]And I think that we have some positive things to discuss. [Jaz]I think that will go down really well mixing the clinical, non-clinical and in abroad. I know there’s a huge demand UK to go to see and Andre. So, if you marry that up when it’s something non-clinical as well, I think will add more value. [Jorge]Absolutely. And it’s always an excuse for you to stay at longer and to party longer and to go to more restaurants and stuff like that. [Jaz]More, more friends more. [Manuela]Okay, fado and saudade, but then we are very good at partying also. [Jorge]Yes, yes. [Jaz]This is very true. [Jorge]We want to forget our sadness by- [Jaz]It’s very evident. That was very clear. I’m glad this has been the birth of something very exciting in the future. [Manuela]Thank you so much for being with us. [Jorge]Thank you Jaz. [Jaz]It’s been a great. You guys are doing amazing things with soft bites. And I can’t wait to share this with my community as well. So you can check out all the good things we’re doing. [Manuela]Thank you so much. Thank you. And thank you for everyone that- [Jorge]Thank you Jaz. Jaz’s Outro:Thank you.

Preserve bone, be kinder to the tissues – but NOT necessarily at the expense of time. A great insight in to Atraumatic Extractions from Dr Diyari. Some say that ALL extractions should be atraumatic, and therefore this is a ‘made-up’ term by implant bods. By clarifying some misconceptions today, Dr. Diyari Abdah gives us an inside look at WHY and HOW atraumatic extractions can be efficient and effective. https://youtu.be/gS7h0L69hJ4 Check out this full episode on YouTube Protrusive Dental Pearl: Life Advice: “Never take advice from anyone who you wouldn’t switch places with” This episode is brought to you by Enlighten Smiles which is a premium brand of teeth whitening that guarantees B1 shade. If you want to know more about teeth whitening and get better results for your patients, do check out their webinar, Enlighten Online Training. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 1:28 Protrusive Dental Pearl: Life Advice 12:08 Atraumatic Extractions 15:02 Additional skill set and tools to achieve atraumatic extractions 24:24 Atraumatic Extractions Protocol 27:19 Literature regarding Piezosurgery 33:01 Collagen Plug Check out these studies regarding Piezosurgery: Clinical-Success-Bone-Surgery-with-Ultrasonic-DevicesDownload Essentials-in-Piezosurgery-Clinical-Advantages-in-DentistryDownload Learn more about Implant Dentistry with Dr. Diyari’s The Most Accelerated Practical and Comprehensive Dental Implant Course with ADDITIONAL 10% off (including the Early Bird pricing) If you enjoyed this episode, check out Make Extractions Less Difficult: Regain Confidence by Sectioning and Elevating Teeth Click below for full episode transcript: Jaz's Introduction: Is there such a thing as an ATRAUMATIC EXTRACTION? I remember one lecturer in oral surgery, she was up in the podium, and she said, this is BS because all extractions should be atraumatic, but in the real world, from my experience, I know that my implant colleagues would do something called an atraumatic extraction. Jaz’s Introduction:Be very proud of it. And from what I understood, it takes a bit more time, like you need to be a bit be more gentle, need to preserve that precious bone. But from speaking to our guest, Diyari Abdah today, using specialized tools such as the Piezo, like this was all pretty new to me in terms of its applications for atraumatic extractions. But using that, your atraumatic extractions don’t have to be very slow. They can actually be very efficient. So that was a real takeaway for me. Hello, Protruserati. I’m Jaz Gulati, and welcome back to another episode of your favorite Dental Podcast. Today I’ve got Dr. Diyari Abdah, who’s such a fascinating man, like to me he was this like educator and implant dentist in Cambridge. From our conversations, I figured out that he’s been nominated for an Emmy before. He’s got an MBA. He’s a bestselling author. He is got books on business, completely not related to dentistry. He’s a really smart cookie and I’m sure you’ll finding very fascinating, but in terms of what we’re covering today, it’s all about atraumatic extractions. What do you need to use? Can you just use luxators and do everything you need to do with that to call in atraumatic extraction? What is different about a traumatic extraction compared to a regular extraction, and what are the benefits of doing it in this way? Protrusive Dental Pearl:Before we get to that though, the Protrusive Dental Pearl. So, today’s pearl is philosophical in a way. It’s gonna give you just generic life advice, and it’s something I just came across in a book. And I just wanna share with you guys, never take advice from anyone who you wouldn’t aspire to be like. So, there might be an amazing dentist, let’s call it a male, for example, male dentist, who’s really cool. But I wouldn’t take advice from this dentist, even if they’re an awesome dentist. If they were abusive to their wife and their children hated his guts and he was failing at every other aspect of his life and he wasn’t looking out for his health, for example. So that’s someone who I wouldn’t wanna switch places with. Cuz for me, I value family very much. And I value relationship with children, et cetera. So just because their dentistry is good, I wouldn’t take advice and especially life advice from someone who’s failing in that regard. And it’s because I wouldn’t wanna switch positions with that person. So, I’d only take advice from someone because advice is quite freely available nowadays. You have to kind of be selective about who we take life and clinical advice from. So always think as a rule of thumb, never take advice from someone who you wouldn’t swap with. If you wouldn’t trade places with that person, you’re probably not best taking advice from that. This episode is brought to you by Enlighten Smiles. The premium brand of teeth whitening. If you do their online training, which I’ve talked about so many times for the link is in the show notes, is well worth it. Even just for the one hour of learning you can do with Payman Langroudi, their training is awesome, but I posted a case recently on my Instagram and my Facebook, so it’s @protrusivedental for Instagram and the Facebook page just lets you type in Protrusive a full protocol. So, 10 images on Instagram, cuz that’s the cap’s kind of annoying and about 25, 26 images on Facebook, how I replaced this lower incisor that was aesthetically failing and a crown, the upper right four. But also, as part of that case, we did some teeth whitening with Enlighten. We got a great result with that. So, you can see the kind of results I’m getting with my whitening plus the vertical preparation that I did on a lower incisor and how I replaced a aesthetically unacceptable lower incisor crown. So that’s all available on social media if you check out the full case. And thanks again to Enlighten for supporting the podcast. Now let’s get to the main episode where Dr. Diyari Abdah. Main Episode:Dr. Diyari Abdah, welcome to the Protrusive Dental Podcast. How are you? [Diyari]I am very well my friend. Thank you very much for having me. I’m a big fan, by the way, for what you do, and it’s just amazing, you know, the way you described things. [Jaz]I really appreciate it, and I’m excited to tap into your brain and share the knowledge with everyone. And just so you know, I always like to give a little bit about how I know someone. So, I know you through Dylan, your son, went to dental school together. And when he always spoke very fondly of you over the years, and I actually didn’t know how involved you were with education implants. And I thought, okay, we have to do an episode. So, we were kind of brainstorming, okay, what should we talk about? And one thing that’s always talked about is atraumatic extractions and perio-implantitis, there’s two separate things, but that’s the main theme for today. But before we delve into that Dr. Abdah, just tell us a little bit about yourself. You’re obviously very much into personal development cuz you were talking about Tony Robbins via WhatsApp the other day or by email. So, just tell us a bit about you. Who you are, where do you work and where you developed this interest in implants over the years. [Diyari]Sure. Thank you very much again for having me. I really appreciate it. Yes. I mean, Tony Robbins had a big, major influence in my life many years ago, over 20 years ago. In fact, Dylan was with me. went there on his 15th birthday party, you know, father’s from- [Jaz]You are the coolest dad ever! [Diyari]To turn to walk on fire. Thank you. So, we have the hat and we have the set of kids. So, we, yeah, we’ve done it. Been there. So, no, it’s always good to revisit these things. I mean, one of my mentors, my special mentor said, in a motivation or it’s a bit like taking a shower. You can’t be motivated once every 10 years and say, ‘That’s it.’ And it’s like a shower you have to take every day. So, there are all these routines you have to get yourself into now, saying all that. I mean, that led me to a different path altogether. I was talking to college students in the States telling me about my story, how I all started. sometimes you need to hear from somebody else, your story. And it was quite a humbling experience because that led to something, something else led to something else. And doors opened and I met great people, you know, like yourselves and when you have an open mind, you know, like a parachute, you do land well, you know, so we ended up doing some charity work in Mexico for orphans. And at the time they invited a some filmographer from Hollywood and they did the documentary. And then one day I get this phone call to my clinic in Cambridge. I’m just this little humble dentist in Cambridge. I get this phone call from the Emmy Award nominee committee, and they said, ‘Well, Dr. Abdah you are invited to the Emmy Awards because you are one of the producers of this documentary, which has-‘ Anyway. Long story short, the documentary- [Jaz]That’s so random, and so brilliant! [Diyari]So I can brag and say I’m a n Emmy award producer, but that was all for humanitarian efforts and also, I always wanted to develop, I always want to go further. So going back to my dental background. I have two dental degrees from two different countries, and believe me, that’s not my choice, my friend, because I studied in Romania for six years and then, I could not go back to my country at the time, which was Iraq, and I had to move somewhere else. So I went to Sweden, and at the time Sweden was very welcoming, but also very difficult in the face of foreign certificates. So, I mean, the study in Romania was unbelievably helpful in terms of practicality, maybe not so much technological. Now I go to a place where it’s all about technology. But the practicality was quite funny, talking about the extraction later. When we had extractions three, four students had to train on the same patent because you know, one will wiggle it and the other one will do something else, and then we all pretend the tooth is out. We put it back in only because the oral health in Sweden apart from the chewing tobacco that they use sometimes. It’s actually quite high. You don’t see many people with dentures. You don’t see many people. And of course, I was at the clinic where- [Jaz]Wow! [Diyari]Bruno Merk was only 20 meters away in his office, you know, and some of the biggest names now we hear in the world of perio or implants, they were all either with us or something. So, you can imagine being in that environment now, finished Sweden, then moved down here to UK. My master’s degree in implants. Very early stage, but for about three years. This is interesting bit for about three, four years. I was actually a very, I don’t mean any disrespect. I think there’s greatness about being just a general dentist as doing your thing. Listen, as long as we all do what we do perfectly, I think that’s great. The trouble is to be trying to be master of everything because you’re gonna be master of none in the end. So general dentistry, I loved it, but I wanted to move on from there. And this comes from a guy who, and I just say this to your audience cuz I respect you and I respect them. This is coming from a guy who probably didn’t like to hold a scalpel in his hand, okay. For a few years I thought. I don’t wanna do it, but then I fell in love with Implantology. It was still quite a normal thing to do. I mean, when I finished my master’s degree, I think there was only probably in the tune of 20 people in the UK who had master’s degrees. [Jaz]Okay, so Diyari, what I wanna just pick on further is how did you know it was your calling? Because if you hadn’t placed an implant before, I imagined before doing your master’s, and you correct me if I’m wrong, and there weren’t many people doing implants. How did you know to commit to something that you were, was almost like a novel field? I guess it’s a bit like someone nowadays committing to laser dentistry, having limited experience in lasers and committing into a master’s and laser dentistry and whatnot, and going all in. How did you get that sort of premonition? [Diyari]Sure. Well, the thing is, as I said before, we were actually only few meters away from Professor Bruno Merk’s office. And this is a guy we used to see you know, around the cafeteria. He used to hang around sometimes talk to us always in that bow tie. And so, everybody wanted to be him. You know, everyone wanted to be, I can’t imagine anybody in my class who actually didn’t wanna place implants. I think, I haven’t followed everybody, but I think most of us actually became Implantologists in the end because there was just such an aura. Such, it was in the air, you know? In Sweden, other department, they did train everybody on implants, so when we came out, we were actually ready to place implants. We already were certified to place implants. [Jaz]Wow. [Diyari]Yes. As a result, I was already placing implants and then I thought, well, I wanna go a bit deeper in this and do a master degree. Little did I know that a master degree was more academic than practical, so I still then had to go and pursue other forms of knowledge and basically in anything you do, if you wanna do it well, you need to look who’s the top guy and you go for that. So, I had my eyes on somebody for years in the States. So, I just pursued him, and I went to him and I said, look, I wanna learn everything from you. Was there to learn? And then I spent a good time. [Jaz]Who was it? Share the name. [Diyari]This was Professor Dennis Tarnow. So, Professor Dennis Tarnow. He’s very widely referenced everywhere. I mean, you cannot do your master degree if you don’t have gone through two studies of him. So anyway- [Jaz]Yeah, I mean, I don’t do implants, but I still appreciate Tarnow’s, lore of, you know, five millimeters from the crestal bone, the papilla that kind of stuff. That’s all from Tarnow, right? If I’m not mistaken. [Diyari]And he’s just an amazing guy. So, and then again, there was a late Carl Misch as well, and I also approached him. So, with Professor Tarnow, there were a few courses happening that I attended. It was only for like 20 people and you got to spend a week with him and that was great. And also with the late professor Carl Misch, I spent some time with him as well. And these are by far the two biggest names out there. And of course, there are other people who have my respect. I’ve been running courses and lectures and things, but I’m still a student, you know, because the learning never stops. [Jaz]Absolutely. Well, we’re gonna extract some more fundamental, basic concepts from you today. [Diyari]Sure. [Jaz]To help those Protruserati listening in and want to gain some nuggets, maybe on their commute to work or chopping their onions as they usually do. Let’s start with atraumatic extractions bit of, you know, I want to remember this lecture, this oral surgeon. At the front of the podium. And she said that atraumatic extractions is bs. And she said this because all extractions by nature should be atraumatic. So why do we have this entire separate field called atraumatic? Another thing I wanna just mention as a buildup to this is I remember being in DF1 and an extraction was, okay, we can do this. But if you wanted atraumatic extraction, it was gonna cost you a little bit more. Can you believe that? So, tell us, what do you think about that statement about, you know, there’s no such thing because all extractions should be atraumatic, and then also what actually is an atraumatic extraction? [Diyari]So shall we agree on something, atraumatic extraction? Should it cost more? Because, I mean, the question here is this, I was thinking you know what, Jaz, seriously, I was thinking the other day. When you sent me the question, I said I want to talk about atraumatic extraction. I’ve got a series of lectures that’s, they’re called The Dreaded Extraction, you know, so atraumatic extraction, I thought this is a very interesting question. Who is this atraumatic two or four? Is it to the patient or is it the bone and the surrounding tissue? Or is it to the dentist? Because, I mean, nobody wants to do a difficult extraction on a Friday night, you know, and usually they happen Friday. That’s why I don’t work Friday. So, I don’t see any patients with extractions, it’s just laws of universe. So, I think the definition of atraumatic extraction we can all agree on, it’s probably the best definition or the most clinical, clinically accurate definition will be atraumatic to the surrounding tissue. Bone, soft tissue, everything else because, and then depends what you wanna do with that socket. I saw a video of yours. You were doing some extraction, and I know you’re a big fan of separating roots, and I totally agree with you. Sometimes. I mean, in the old days we used to sit down and try with a root and wrestle with it. And in the end, after half an hour, 40 minutes, people say, oh, let’s get the drill out. Well, why didn’t get the drill out after two minutes? Or from the beginning, why didn’t you-? [Jaz]It took me years to actually gain the confidence and the awareness. Actually, why don’t I just skip the trauma inducing part and actually go straight to make my extractions easier? But by sectioning the teeth. So, I’m a huge fan of that. So atraumatic extraction, as you said, is making it kinder to the bone, to the soft tissues for the patient. And so, when we are training at dental school, the way I was taught was we had to only use forceps. We weren’t even allowed to use luxators because what if it slipped and the luxator went through the floor of the mouth or something? Right? So, loads of us were breaking crowns off and then we were being rescued by the tutor who’d come and then, you know, razor flagged, draw some bones section, et cetera. So that’s our background. Obviously, you learn to use luxators and stuff, so if we want to be atraumatic in our extractions, what are the additional skillset that we need and additional tools that we need to be able to achieve that? [Diyari]Very good question. Now, my story with atraumatic extraction started with luxators. And you’re right I mean, the whole notion of atraumatic extraction is that instead of horizontal wiggle, you try to lift the tooth out vertically. So, it’s through vertical forces and whatnot. So that then comes the separation of roots. I mean, I sometimes in the past had to separate an incisor root going from distal to mesial so I can separate so I’ve got more control of the buccal. Or sometimes in implantology lately there was this trend to do this leave as like a flake of the root buccally so that you don’t, I mean, that proved to be not such an exceptionally successful thing and mine has evolved over the years. So, I completely agree with what you did on that video, and I think that’s amazing because I think it was upper molar that you were separating the roots. Taking them out one by one. And I was looking at where you were keeping your fingers very accurately, you know, especially that buccal wall. I mean, until you take CT scans of the mouth case after case for implants and things, sometimes you just don’t realize, or you forget how thin this buccal bomb plate is. I mean, it’s just paper thin sometimes. So, at all times that finger has to be there, whether you use a luxator or anything. But lately I’ve gone into Piezosurgery, and I’d like to talk a little bit more about that because I think that’s something which is doable because you are talking about tools. That’s something that’s doable. It’s actually very cheap to buy a device nowadays. I mean, I remember my first device ever that I was like 15,000 pounds. Now, in the old days, most of Implantologists and you know, bone pickers, we all bought these big devices. They used to be coming in a big box and device, but they were pretty much useless. And that’s why most of us, the device ended up in a drawer somewhere. I was actually thinking, where’s mine? You know, I’m sure it’s not in the eBay. But we don’t even know where it is because they were slow. They were hard. It was actually hard work. So sometimes the extraction took me like 10 minutes with the peers that was taking me 45 minutes. I’m like, what’s the point in this? Now they’ve changed and I had the fun and the privilege of being part of a study with my good friend, Professor Angelo Troedhan from Vienna, who’s the president of the International Ultrasonic Surgery Association and or academy rather. We were doing a research study in at University of Bordeaux few years ago, just before covid. And the beauty of that was that we had some human cadaver specimens that we were working with. So, it was a real deal, but also, we had every single, I think this was 2019, and we are supposed to be publishing a paper at some point. But that got delayed because of Covid. We had every single Piezo machine out there that’s available on the market now. We had about 12 of them. I mean, by the way I told you in the beginning of the whole talk tonight, I’m doing something for the first time ever in my life and that is talking without my slides. So, we have to describe things now, because there’s a photo of me on my lectures when I, there’s a photo of me there with all 12 machines in front of me. So, it was a bit like a top gear kind of thing. And it was nice. I mean, it was me, two other professors. We were having all these toys and we found out that they were not all the same. No wonder why some people get frustrated. So, this is the problem. If we buy the wrong one, we might end up frustrated on losing, you know, our enthusiasm and everything. So, I’m not- [Jaz]Excuse my ignorance here, but just want to bring this in. I mean we recently doing up the surgery where I work in, at the practice and my nurse said that ‘Oh, Jaz, you won’t be having a Cavitron anymore. You’re gonna have a Piezon.’ I’m like okay, fine. Can I still do what I’m gonna do with it? She says, yeah, you can do what you want. So, but now will I be able to use that Piezon unit, which is primarily there for your scale and polish kind of stuff, and to remove calculus. Is that the same Piezon I can use for surgery or is it different? [Diyari]Excellent question. No, that’s not because it’s all in the frequency. We need to know which frequency are we using. The ones we are using. So basically, a at the end of testing all of these, we found out that three of them were top, you know, got top mark and the one I use. Without mentioning names, I mean, I’m happy to say it if you push me, but- [Jaz]You can mention it. It’s fine. It’s cool. It’s cool. You can mention it. [Diyari]Yeah. So, it’s called The Cube. It’s from a company called Acteon. It’s a nice little cube. It looks like it was designed by Apple. I mean, if Steve Jobs designed Piezo, it was designed yes. It’s all little Bo and I call it the Jackie Chan because it’s very cute, but very powerful. So that works with a frequency of between 24 56 kilohertz and what it does. So, what they do, the one you mentioned about you might get away with certain things, but definitely not bone cutting and all that. And I hope not. So, the way these work, they work in two ways. They work through ultrasonic vibrations. Okay. So, they’ve got ceramics inside that vibrate through a transducer, and then that translates into the vibrations and the ultrasound or ultrasonic into their tip, and that’s how you cut. But then there’s water coming out as they do, and the water creates this cavitation effect. And the cavitation effect is like micro explosions. You know, when water, it’s almost like micro boiling phenomenon happening in the liquid that’s hitting the hard surface. I call the micro explosion basically. So, what it does, it gives you better visibility, it gives you hemostasis, and also it has a antibacterial property. Why? Because it can break down bacteria, cells, walls, that in that vicinity, which is amazing. You get three, four things, which means it’ll decrease morbidity and increase predictability. Now what are you gonna do without socket, that’s your business. Okay. Are you leaving it? Hope not. Are you putting some collagen plugs in there? I hope so. Are you putting graft material in there just to keep that bone architecture, wonderful. Or are you placing an implant? And of course, I develop this technique called the 360 technique, which has been trademarked and all that. And that is exactly to show how you go about because it’s not just kind of sticking this tip into the periodontal ligament space and hoping that things will break down because after all is designed to break, to cause like micro shattering of the mineralized tissue. The mineralized tissue definitely is not the periodontal ligaments. So why are we breaking here? So, we are actually breaking the bond between the periodontal ligaments and the roots and the momentum. And that’s where these paradigm, you can imagine, you know, if you can imagine a certain five rocket in the days of Apollos, you know how this whole scaffold will come off before it takes off. So that’s what we are trying to break down all these ligaments. So, then the tooth, I had teeth and upper left two, I think it was, if I remember it was beautiful. After we finished all this, it actually popped out. I didn’t even need to listen. Because the water got underneath it just like a, the pressure made the tooth come out, and that was beautiful. Now then after that, obviously, you have the thickness of the bone that you have to then preserve because depending where you do with it, so going back to atraumatic extraction to simplify everything. It’s any extraction that allows you to keep the surrounding structure intact to quite an extent. So, then you could do what you are planning to do with it. Now you do that through separation. Wonderful. And luxators. I’ve done hundreds of those and they’re amazing. Whether you do that through the- [Jaz]And that’s about my limit, Diyari I dunno what I couldn’t tell you what a perton looks like. I’ve heard great things about them. Maybe you can tell us about it. But my limit at the moment, my knowledge base is luxators, and sectioning. And those are my skill sets that I use to make my extractions atraumatic, but also just for me to make my extractions predictable more than anything. Atraumatic is actually a secondary outcome for me and being preserving of the soft tissues and the hard tissues. So, I dunno much about Piezotome. I dunno if you’re gonna go in that direction. Are they useful? [Diyari]Piezotome are just like the nicer cousins of luxators, you know, they are just kind of a bit more final. They go in that ligament space. Easier, better maybe than narrow. And they have different shapes so you can use it for various you know, corners and things like that. It’s a bit finicky and a bit more fiddly, but there’s a job, you know. But- [Jaz]Do you use them much or do you just use your box standard luxators? [Diyari]I used to use them. I tell you exactly why I do. I use my for every extraction. And now Dylan, my son, he also uses the piezo for every extract. Every single extraction, so we are fighting over it. We have to buy a new one now. And so, no extraction. [Jaz]Let me just make this really tangible. Sorry, Diyari, I just wanna make it really tangible, right? So yeah, the patient’s numb. Let’s say we’re taking out a lower molar, lower first molar, patient’s numb. You’re gonna take your Piezo on, it’s probably a specialized tip of some sort, and you’re gonna use it. I guess in the PDL space all the way around and just describe, because again, I’ve never seen this before. It’s something new to me, so- [Diyari]Absolutely fine. [Jaz]Yeah. Explain. [Diyari]Absolutely fine. One piece of advice is, so if somebody gets excited and they say, let’s get one, the trick is not to- you don’t have a scalpel. So, even the tip looks very aggressive and pointy. The idea is when you go into that PDL space, you don’t go back and forth. You actually go in a pumping direction. So basically, continuously you’re going up and down into that space. Why? A) you wanna allow the water, the spray to go in. That’s where the cavitation happens. And also, the idea is you don’t wanna cut these because if you wanna cut them, you might as well grab it looks later. You grab something else, you know, so you go around them and then you notice how all of a sudden, the tooth becomes slightly looser, then you go back to your luxators. That’s absolutely fine. And you do that, or even sometimes I use the Piezo, I go with my luxator, I go with a separation, and then I go back to my Piezo a little bit and this whole dance could take no more than seven minutes, you know? But it just happens quickly. Everything happens predictably that you said the word predictable before. That’s the name of the game, my friend. Whatever we do, whether it’s a simple humble buccal filling to, I dunno what, is predictability. And so that’s where you do, you go, the machine patient is numb, it’s a lower right, let’s say six. And it’s amazing if you break a root. So, remember when, if we broke a root automatically the bone drill comes out and the whole thing and this entire army of tools will come out. Well, no more. I mean, sometimes Dylan shows me where a tooth came out, but the tooth, the tip was a little bit curved or something and he just grabs the piezo. And because of that cavitation, there’s so much water going in. Sometimes the water actually just lifts that, that root, as long as you create that space around it and when you look down, I’m sure it cuts a little bit of the bone, but nothing that the normal human eye can see. But that’s enough for the tooth to be loose a nd come out. Yeah. So gone the days when I used to lose, I mean, if I didn’t do many 360 socket preservations, I wouldn’t actually go and trademark the name, you know, 360 socket preservation protocol because you can’t be trading a name or trademark a name where it only happens 50% of the time and the other 50%, it doesn’t happen. It’s a bit like Apple saying, well we are apple sometimes we are oranges as well. It doesn’t happen. You have to be consistent. So, in that case, I saw- [Jaz]Are there any studies to show how much difference it actually makes? Like, you know, is there studies of teeth are extracted without using techniques that didn’t involve the piezon versus techniques that. Did involve the piezon how much more bone you preserved? [Diyari]Absolutely. I mean, there’s so much study out there. There are actually so many books nowadays on the topic and if at some point your audience would love to see a list of things. I’m happy to provide you and then you can put on the telegram or on the chat or somewhere that they can see. [Jaz]Sure. [Diyari]Because it’s great, because there’s so many, we can’t even talk about them now. But one thing, let me just tell you a funny story is all this is are wonderful. We are all clinicians at heart, but also a practice builder. And I tell you why. One day I see this patient coming, lovely gentleman, and he is sitting in the chair. I look, he got an upper right canine, broken completely. So just a root there, but it’s a bit of a, you know, that nasty diagonal fracture. So I look there and I say, ‘Yeah, so what can I do for you? He said, ‘Well, I would like to take this tooth out, but I wanna preserve the socket. Now all of a sudden, alarm bell starts to ring, preserve the socket.’ Is he a dentist? Was he going on? How does he know about the socket? Did he have a bad experience before? Anyway, long story short, he told me I’m in Cambridge, as you probably know. This guy came from North Cumberland. Now I think that was a good seven-hour drive and I said, ‘Why here?’ He said, ‘Oh my general dentist said that he was at one of the dental shows and he heard this guy lecturing about Piezo and he showed case after case and slide after slide, how he managed to scoop out these roots outta these most difficult areas and he preserved the bone for later on to use with an implant. And he said, because we need to place an implant and he doesn’t do it. He said, so he said to me, you should go to see that guy.’ I said, ‘Well, that’s wonderful, but how did he find me?’ He said, well, I had to ask him. He had to look up, you know, to see who lectured at on that day, what happened. And then he sent other people. And then people send people because they say, oh, it’s so easy. I didn’t feel a thing. And Dylan has a little trick. I like it. He takes a tooth out, he finishes everything, and then he’ll say, so now you might feel a little bit of pressure as we do this. And the patient says, okay. And he says, no, I’m joking with you. The tooth is out. I love that line because it just puts people at ease. [Jaz]That’s such a Dylan trick. I know Dylan and that’s such a Dylan thing to do and I love it. [Diyari]And to me that’s like handing a referral card to somebody and say, could you refer other people to be, you know, it’s amazing. Seriously. It’s a practice builder and you are talking about your level of expertise in the separation. I would love to invite you one day to my clinic and just show you a few cases and we can get some models. You have a go at it. You just find that it’s so much easier than doing other things. Now, I did this test, which I shouldn’t have done. I know probably this is gonna be on the internet as they say, or the www’s. But we were doing this clearance down here, so it didn’t really matter that much. Implants were already, we had a two kilos of graft material already. So, and I told the patient, I said I will do two things here. One side of the mouth with this, one side with that. And he said, okay, that’s fine. So signed it all and that was all cool. So, I did one side with a piezo. This is just my own clinical thing, one side with the piezo and I did the other side just with luxators and this is, by the way, is not a secret. It’s all of our lectures. And on the other side, I broke the buccal bone on one of them and on this side I didn’t. Now whether, because I’m now used to the piezo, and I use it before the luxators because like I said, my luxators are complimenting my piezo, that’s a different story, but just pure luxators. And that bone was so thin, it broke. So of course, that was the area that we had to grow most bone and the case was successful later and we placed the 8 implants for him. And he’s happy. But what I’m saying is that whatever works in your house- [Jaz]That was a good opportunity for a split mouth study. And I’m glad you did it. [Diyari]Exactly. With the patient’s permission and I knew that we are not risking anything. So the effect will be good. Anyway, so the idea is once you do this 360 socket preservation and let’s say that you are an implantologist. A) if you are not an implantologist and you are just doing it, patient broke teeth. General practitioner doesn’t do implants, they have to do the extraction. Well, instead of sending a mess later on to the implantologist, they will love you, if you send them a nice healed socket, beautiful with beautiful height, everything, and if you’ve done some nice cleaning and decontamination of the socket, then even better. So, I think we ought to do it. We have to do something. With any socket that we take a tooth out. And we have different levels of grafting. We say, look, even if you don’t do wanna do anything, because some people don’t wanna do anything, we say, look, why don’t we just play some collagen plugs for you? At least it’ll act like a kind of mini scaffold. It’s good for a while. Until you figure out what’s what. Okay. So- [Jaz]I’m glad you said that cuz my next question was gonna be, most dentists listening to this won’t have a piece on, but they’re now gonna, you know, their interests will be peaked, and they’ll be like, whoa, okay, this is something new for me and they’re gonna look into it. And any papers you send, I’m happy to link to ’em. So that’s really good. But I was gonna ask you. For a tip or some advice that you can give for the everyday dentist, young dentist who can, who wants to be atraumatic, and you’ve just given it there. So, to use a collagen plug, just tell us a little bit about that. Does it matter which brand it is? How does it actually work? [Diyari]Okay, so the brand, I would say to an extent, stick to a well known brand. You got things like Bio-Oss like Geistlich Company, you got Biohorizons. They do the BioPlug, which we are big fan of it. I use it a lot, Dylan uses it all the time and they look like root shape. They look like a bullet. So, all you need is just to form slightly, and it just goes down. And it keeps us shaped. So basically, what happens, it’ll integrate with the coagulation and becomes an extra scaffold, obviously is not bone grafting per se, but still it’ll buy time and it doesn’t allow the crystal margins to collapse on themselves. Because as we all know when you leave a socket to heal as is trying to heal over, over time, we lose the margins because they come down as part of that healing. And before we know we lost 3, 4, 5 millimeters and then patient might knock your door again. You know, Mr. General Practitioner? I love you, but I now like to have an implant. What can we do? And you say, and that’s why I’m saying. I had people being referred to me and when I look at the bone, obviously you don’t, you have to be careful what you say, but I’m like I just wish that you place something here just as scaffold, you know? And they’re cheap. I mean, those collagen plugs, I think you’re looking at probably 10, 15 pounds a plug, or 20 pounds a plug, so, they’re not that expensive. [Jaz]Is this different to the one that I have in my clinic whereby it’s a cube and then we sometimes cut it into two and put it into the mesial root and the distal root. But I don’t think they’re, these ones are that expensive? I mean, not that expensive rule, but it is much cheaper than the 20 pounds. So, are they a different brand, a cheaper brand, you think? [Diyari]I think the cubes are made in such way, they’re very sponges. Whereas if you have the two of them and you play with them, you notice with the cube, if you squeeze it, it becomes like a almost like paper. You know, you can squeeze it all the way. [Jaz]This has flattened. It’s like flattening a carbo box. Yeah. [Diyari]This one is woven in a different way, so it has a bit of a resistance. I mean, some of them go as far as they’re woven in such way that even if you press it, it’s almost like it bounces back a little bit to its shape and that’s something you need compared to those. Listen, at the end of the day, something is better than nothing, and even the cubes, probably half of my career, I used to place those cubes and they’re fine, but just leaving a socket. But one thing is very important. We’ve done the extraction, we’ve done everything, and I hope, sincerely, I hope that everybody grabs that curator or something and just clean the heck out of that socket. That’s the problem. Sometimes we take the tooth out, it took us half an hour. We are shattered. We just wanna send the patient home. No, clean it. And nowadays we have these saline in a little kind of injectable tube kind of thing. I don’t know. It cost probably pennies. Just kind of wash it, rinse a few times, and then put this thing maybe couple of stitches, maybe not. And then you send the patient home. Everybody happy. And they thank you later. And Plantologist will thank you. And going back to our- [Jaz]Diyari at the moment, I use just a basic, something basic, the spoon end of a Mitchell’s trimmer. Something as basic as that. And I really spend my time to clean it. And I feel as though over the years I’ve got less dry sockets. Since I started to clean the socket, and this is something that I didn’t always know. It took me five years I’ve done school, a neurosurgeon. I met who helped me taught me to do this. And then because it was over the shoulder teaching, I then inherited it. And now I passed it on to the other dentist. When I went by the chair side, I said no, we are not done yet. Pick up the Mitchell’s trimmer, get the spoon in, clean it. Do I need anything more fancy than that or is that okay? [Diyari]That’s perfectly all right. And I think you’re doing a great job there. You just mentioned a word that I forgot. I, since I used the new Piezos, which is about seven years now, or eight years for every extraction. I haven’t had one dry socket, none, zero. Because- [Jaz]See, before I would never believe that. But now that I’ve had such a decrease in myself, I totally believe you. [Diyari]The thing is, it is not, it’s not me. It’s a technique. It’s a device. Because what happens, because it has this antimicrobial property whereby the microorganisms cell walls break down. Remember through that cavitation, through that micro boiling, so your chance of success is much better, much higher. Now, I must admit that maybe another reason I don’t see many dry sockets is because probably eight or nine out of my extractions end up with an implant because that’s what I do most. And therefore, by the time they’re referred to me or they’re in my chair, but you asked Dylan the same thing and he will tell you the same thing. I don’t think I’ve ever heard him say about dry socket at all. So yeah, these are the things. So, if anybody is using just forceps, that’s a big no-no. So, the takeaway from here is that either follow your technique, which is amazing. The separation. I still do it today. Or you can add another tool. And hey, we are dentists. We love tools, we love gadgets. You know, anything that you could plug in a wall and use it, I’m all for it. So, try to get to any company really. But one of the good ones is, like I said, is the cube from Acteon. There is- [Jaz]I’ve had great things about Acteon. I mean if I’ve always considered, actually before when I was doing a more root canals, they had these really cool instruments for tips for root canals and stuff. So, if I buy a unit, for example, if I was to get a piece on unit for example, from Acteon, is there a such thing as you use it for the surgery, but also you have restorative uses as well, cuz or is it exclusively for surgery? [Diyari]There are so many tips that you will probably fall in love with all of them. I mean, you’ve got prep, smoothing tips. You got this tip you got, obviously I use it a lot for bone. [Jaz]Now we’re talking, now we’re talking. [Diyari]So for prep, smoothing for perio, you know, for root planning, for all kind of stuff. Every time they come up with package of these tips. I’m like, oh my God, here we go again. So now we have to get more tips. So, but it’s seriously, it’s unbelievable. It’s unbelievable. My sinus list, okay. All of them are done with a cube. So why I call it the Jackie Chan, you know, it does it with a smile, but it’s very powerful. It does everything from the small thing to the big thing, so it can kick one person, it can kick a whole gang. So, that’s on atraumatic surgery, so I hope, and because of that, obviously it’ll be atraumatic for the dentist. Hopefully, you know, that’s what we said. [Jaz]Yes, and more predictable and less failures and less dry sockets as you said then that’s good. [Diyari]So next time, next thing. I think if somebody finds in a dental show anywhere. Go speak to them, talk to them, see what they have, what they show you. And then maybe they run courses. There are courses all over the place for these kinds of things. We run it as well. So go and get that technology. It’ s not expensive, it’s just a bit more expensive than a top end descaler really nowadays. [Jaz]No, I mean, it is great. I mean, I knew there were users, for endodontics and preps and stuff, but then the way you described this is all new information in terms of the 360 technique and how much of a difference it can make. So, I’m sure lots of dentist listening have gained from that. You mentioned your courses and stuff. So, Diyari, tell us about Implant teaching that you do. Whereabouts do you do that? How is it run? There’s lots of courses out there, but what is special about yours? [Diyari]Sure. No, thank you for that. So, I’ve been teaching and lecturing all over, and for the last probably 10, 15 years, I lost, I think probably I’ve been talking over 250, 300 times in different places, both in the states here and all over Europe. Mainly it was about techniques, you know, certain techniques I teach or certain things. And I always had this idea of this academy at the back of my head. So, it’s been, my academy’s been in the making for 10 years now, and I thought if you do something, which is part of your legacy, I better do it perfectly and not just half the league. So, it’s been 10 years in the making. And finally, before Covid I started the academy, but then Covid happened, and then, because most of the things I teach there are all hands on. So, I found it very difficult or challenging, rather to do it online. And I thought, I just wait. I know this will pass. So, to kill time, I wrote a book that became a bestseller. It’s called Business Not As Usual during Covid, and that went on Amazon. [Jaz]Wow. I didn’t know this. I had no idea. Is it specific to the dental niche? [Diyari]No, this is for small business owners. You know what to do in times of turn down economics and stuff like that, because few years before that I did an MBA, and right now I’m halfway through my PhD on the back of that. So, I thought, you know- [Jaz]Like you said the learning never stops. You are a perpetual student. [Diyari]It never stopped. No. So basically this, so then I spoke to a few friends, and I said, listen I need to do something that I always find in courses. There are many courses out there, like you said, and there are some amazing courses. But what I found a lot of time there was this information, fire hose and then you go back and it’s like, okay, now where do we start? What do we do? So, I thought first and foremost, I’m gonna give the each one a roadmap. what is expected to do till next session so that they start doing it, number one. Number two, the other problem with some courses, they last six months or seven months or eight months now, I mean, God knows I’ve been on in courses for that last of the year. I thought I need something that it gives enough breaks to people, but before they forget the knowledge before, we need to get cracking again. So my course is done within five weeks, so like three weekends, Fridays and Saturdays, and then two weekends you know, there’s a break and then Friday. But there’s some work to do in between and that way the information stays fresh. So that was my next thing. So, I had to look a lot into teaching because I used to teach well, currently I’m a faculty, I’m an adjunct faculty at University of Illinois, at Chicago, at the Periodontology department. And also, I did some stuff with work as well after, you know, on the master course. So, I had this ability to teach and make big things, smaller pieces. But then I thought, how do we do this in the accelerator format? So I’ve kind of created this method where, you know, I just give you enough information that is super, super important. That’s used rather than just kind of painting this entire picture for you. Because people can get that information. They wanna know what can I do i n the safest possible way. And again, few I’m expert witness for Implantology as well in course of England and Wales. I did that law certificate few years ago, so I thought, okay, and what is it that keeps ’em out of trouble? You know, let’s do this. So, combining all this knowledge, basically it’s an accelerated learning format for the busy dentist. As long as they dedicate six weekends of the span of five weeks. That’s what the course about. So, at the moment, it has many courses in there on the DA Academy website, and that’s just DA Academy [Jaz]I’ll be sure to share that in the comments below and on the show notes so for those who wanna check it out. Can check it out. Did you get to place any implants? [Diyari]Well, at the moment, I was about to say that. Now, at the moment, the pinnacle of the whole thing is this accelerated dental implant course that we are doing and the way it works, that I will distill every knowledge that’s out there to be given in practical terms. So, we are ready to place implants. Now in this country, what we do, we place implants on real models. So, these are not human beings, but these models are so real that you have soft tissue, you have to cut it, you have to do all these things, you have to suture it. They’re amazing models. Very super expensive ones. And then from there, the idea is when people want each one, each candidate is actually invited to be with me for a full day looking over my shoulder and they can ask as many questions as they want, we have cameras, we have screens. They’ll be right above my shoulder. They can assist me if they want to and that’s one of the best learning. [Jaz]I a 100% agree. That is the most powerful learning I’ve had. It’s always been over the shoulder. [Diyari]And you know, they’re not stressed. They’re not stressed. Them doing it while not sewing. And you have to have all these codes between each other. You know, go left, go right, do this, do that. They watch me do it. They learn everything in five weeks, then they come and wash, redo it. And I try not to put two people together. Every dentist will has the right to come for a full day by himself or herself. So, they get full benefit of this. I mean, that is priceless. And then, because sometimes people put two, three people together now on top of that, then if they wanna place implants, I encourage either if they’re close, they can bring their own patients to us and then they can place the implants while under my supervision, which I think is brilliant because we have all the tools and everything around. Or we can arrange to go to their practice for the first few implants. Obviously, there’s some that’s outside the course parameters, but I encourage anybody who wants to place implants the safest possible way and predictable way to go and visit this, you know, the Accelerated Dental Implant course. And you know, Jaz, I’ve always heard great things from Dylan about you. Seriously. And when I met you my respect just grew. And I know this community is very close to your heart. I know that. And now they’re- [Jaz]Absolutely the Protruserati. You’re very welcome. [Diyari]I would love to extend obviously we have the super early birds on normal pricing, whatever the price is, I would like to extend 10% discount at any stage they wanna join. To them, as long as they mention your name. That’s my gift to all of them, and I hope they take on. [Jaz]Amazing. I really appreciate that. It’s funny, actually my buddy Clifton I went see him in Brighton and he said to me ‘Jaz, do you get a lot of course organizers and dentists who teach? Do you get a lot of stick from them? Do you get any hate from them? Because the things that you gave away on the podcast, I paid so much money to get that information and you are giving it away for free.’ He said I said, ‘Listen, I think the podcast serves to help identify people who realize, you know what, I’m inspired, and I want to learn more. So, I actually think course organizers have benefited from the podcast because it’s inspired people who’ve identified, and you know what I want to do better? I want to do different. I’ve now decided that I want to niche in this respect. So, if anyone’s looking into the implant world than I’m sure you’ve learned a lot from Dr. Diyari today in terms of what is possible in an accelerated program and from his wealth of experience and your very interestingDiyari, I have to say with the MBA and this Emmy producer Award and authorship, you are a very fascinating man. So that’s pretty cool. So, just tell us the website again. I’ll put in the show notes. [Diyari]So the website is Accelerated Dental Implant Course. That’s the main course at the moment we are running. You can also go to daacademy.co.uk that has different courses, and we are working on the days, but the main one’s accelerated dental implant course. And by the way, you can also give them my email. I’m more than happy to answer questions. And the other thing we do after the course for an entire year, we run this diagnostic and treatment planning WhatsApp kind of connection so that if somebody’s stuck on something, they can always ask me anytime and I’ll be more than happy to plan the case with them. So, my main thing is I want the way I was taught by some people and they made a big influence and impact my life. I want to impact lives of my dental colleagues. [Jaz]Absolutely. And that’s very clear. That’s very clear. Well, thanks so much for sharing all that we ran out of time for peri-implantitis. We’ve can definitely in some months but yeah, absolutely. But atraumatic extractions that was really fun. I learned a lot. I’m gonna be looking at the Jackie Chan of the Piezo World. I’ll be finding the Cuban and having a look. Actually, you’ve definitely piqued my interest there. More for, yes, the surgery sounds amazing, but as a restorative geek, I’m remembering all the tips, the preps tips that I saw to take my preps to next level. So, that’s got me very excited actually. This one more thing I can now justify to my wife. Anyway, thank you so much, Diyari. I really appreciate you coming on. Thanks for time. [Diyari]My pleasure. Thank you very much. Thanks for having me here. It’s been a pleasure and a privilege. Jaz’s Outro:Thank you. Well, there we have it guys. Thank you so much for being a true Protruserati and making it all the way to the end. I always really appreciate you. If you’ve resonated with what Dr. Diyari Abdah had to say, and you have the appetite to learn more from someone who’s so experienced and fascinating as Dr. Diyari Abdah is, then check out his academy, daacademy.co.uk again, I’ll put all the notes in the show notes so you could check out his complete range of courses. Also, the case that I shared with you on Instagram and Facebook where I showed about the whitening case with Enlighten Smiles. That case actually also did a canine riser. So, I’ve got full video showing exactly how I did step by step that canine riser, and dunno if you remember, but I’ve gotten occlusal series every month I’ll send you one occlusal tip. Over 400 of you join my email list for that. It’s completely free and the way you join that occlusion.wtf. The website is actually occlusion.wtf. You just type in your email address, and I’ll email you the tip. So, when you get the email for the canine riser, I’ll also include the video that you might have missed, the very first occlusal tip, which was how to adjust a resin bonded bridge after you re-cement it for the correct occlusion. So, RBB, recementation and occlusion. And then the next one coming is canine riser full-blown technique. I’ve checked out the whole of YouTube. There’s nothing this clear and this on canine rises out there. This is gonna be quite comprehensive and I hope you enjoy it. So do check out occlusion.wtf to sign up for that and be sure to share this with a friend if you found it interesting. Thank you so much.

Half way in to a tricky extraction you hear a voice…”Maybe now is a time to raise a flap?” You ignore this voice and keep sweating with the luxator in hand, because it has been far too long since you raised a flap and you dread the nurse’s reaction. If this is you, then we got you. I brought on Consultant Oral Surgeon Dr. Sami Stagnell to share his tips and pearls in Oral Surgery, specifically WHEN and HOW to raise cleaner flaps, as well as what types of flaps to consider for each situation and when NOT to consider extending beyond an envelope flap. https://youtu.be/cx6HvrZtjcw Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Nice and Clean Extraction Sites – Use the spoon end of Mitchell’s trimmer to clean the surgical site for 30 secs to 2 minutes. Highlights of this episode: 1:27 Protrusive Dental Pearl: Nice and Clean Extraction Sites 13:43 How to gain confidence in raising a flap 21:51 Envelope Flaps 30:09 Guidelines regarding relieving incisions 37:32 Raising a nice clean flap 41:45 Guidelines in lifting the papilla 44:56 Blades – 15 vs 15C vs 12 blade Improve your Oral Surgery Sectioning with this speed-increasing electric handpiece at Incidental Limited. And get 5% OFF their entire products with the code ‘onions‘! Check out the Oral Surgery Course that Dr. Sami Stagnell will be launching in 2023. If you enjoyed this episode, check out Make Extractions Less Difficult: Regain Confidence by Sectioning and Elevating Teeth Click below for full episode transcript: Opening Snippet: /Sami/ So the first word you said was purposeful. And that is it like you're doing everything with direction and purpose and meaning. You're doing it for a reason. So get your blade down to bone, to hard tissue, be confident in where you're putting that blade and know where you are, raise the papillae first. So I tend to sort of raise the outer edges and round the margins because those are the bits that tear. And those the bits that you then don't want to sort of have to try and repair if they don't want it. /Jaz/ What instrument are you using to raise the papilla and beyond? Jaz’s IntroductionHello, Protruserati. I’m Jaz Gulati and welcome back to another episode of The Protrusive Dental Podcast. This time, Oral Surgery specifically how to raise cleaner flaps and the principles of raising flaps in oral surgery, for exodontia. I’m joined today by Dr. Sami Staggnell. I know you will love his humor, and his humility. He’s a really humble guy. He’s a consultant oral surgeon, but he’s so down to earth. So I know you’ll enjoy all the tips and pearls he’ll share with you. The main themes that we’ll cover in this episode are like, when should we raise a flap like I’ve been in the past struggling with a difficult extraction, I’m thinking, it is now the best time to raise the flag? Or should I just keep going? Should I keep luxating, elevating and maybe the truth will come out? Or should I really start getting my handpiece in and start raising a flap, I mean, nowadays, I’m raising less and less flaps, I mean, I probably section 80 to 90% of all molars, and I do it flapless. So it’s something that I’m having to do less and less. But obviously, for third molars, I’m raising flaps. And so I had lots to learn from Sami as well, in terms of how to make my own flaps cleaner and nicer. We’re going to revise the different types of flaps and when to consider an envelope and when to extend beyond an envelope. And also, we talked a little about blades, are all blades build equally? Are there any that you should be avoiding? It was a surprise that he taught me today, which I’ll be sharing with you as well. The Protrusive Dental Pearl, it only has to be oral surgery related. So one way I feel I have zero evidence for this maybe it exists, but I haven’t read it, is how to reduce dry sockets. I was taught by this oral surgeon in Singapore, a very simple thing, like I think most oral surgeons do this and they pass this on to us when they will make learning from them as students. And I guess we fall into bad habits and we don’t do it, is once you’ve removed the tooth, do you actually clean the site, even if you haven’t raised the flap? And so something like Mitchell’s trimmer, you know that spoon end of Mitchell’s trimmer? My nurse knows, Zoe knows that after an extraction, I’ll always ask for it. So when we started working together a few years ago, she was surprised at how every time I was doing the extraction, I was asking for Mitchell’s trimmer. And then now she knows it’s part of the kit when I do an extraction. So every time I take a tooth out whether I’m raising a flap or not, I’ll use a spoon end of a Mitchell’s trimmer, and scrape, scrape, scrape. What am I scraping? I’m scraping the adjacent papilla you know there’s plaque there, right? That’s causing inflammation, that’s not a optimal healing environment, I’m going to scrape the inside of the socket, I’m gonna get rid of any potential debris, any granulation tissue, I’m just giving it a good clean for, you know, 30 seconds to two minutes if I find that it was one I had a section and then maybe there could be some bits of amalgam in there, you never know. So make your surgical sites clean and nice using something like a spoon end of a Mitchell’s trimmer. And using this, I’ve had like two or three dry sockets the whole year. So now it’s August and eight months, I’ve had three dry sockets, so it’s not like I’m immune to them. But I do feel since I started doing this a few years ago, I get less and less. So now let’s join the real expert in oral surgery, which is Dr. Sami Stagnell. I’ll catch you in the outro. Main Interview: [Jaz]Sami Stagnell, welcome to The Protrusive Dental Podcast. How are you my friend? [Sami]I’m very good, Jaz. Thanks for having me, man. [Jaz]I’m so buzzing for this. Oral surgery is always a popular topic when it comes to Protruserati, we had some great ones in the past. And we’re gonna delve deeper into flaps. But before we get into that, tell us a little about yourself. Where are you in your training pathway? What kind of work really, what part of oral surgery that you love to do? What’s your niche within that? [Sami]Yeah, for sure. Training is a long term thing, isn’t it? But as far as training goes, I’m a specialist now. So I got through specialty training about five, six years ago. I’m also a consultant. So I work at Eastern hospital two days a week, the rest of the time I manage things between general practice. So doing IMS type work, so specialty referral and through the NHS as well as balancing private referrals as well. And then subspecialty interest in implantology. So I spent most of the last 10 years building that as my niche. So traditionally a lot of oral surgeons would sort of just put implants where the bone is, but I have a background with a Master’s, restorative masters and a few other bits and pieces up my sleeve. So yeah, a few tricks to sort of help make me a sort of better implantology. But that’s effectively the sort of the general day to day so yeah, it’s quite good fun mixing it up general oral surgery and implantology [Jaz]Do you restore your implant as well? [Sami]Yeah, I still do. Absolutely. And I think I’ve always, I’ve never given an up totally. I’ve got a prosthodontist who I absolutely love, and she’s amazing. She makes me look good in so many ways. But I definitely think you’d have to keep your hand in and I know, Pynadath George, who’s sort of been on your podcast before. He’s one of those people who inspires me in so many ways and I do look up to him a lot. And he’s a polymath, and I sort of, I’ve always been comfortable in that zone and I think until in the last few years, took a while for people to get okay with people being polymaths and I think as an oral surgeon as someone who does the surgical side you’ve got to understand the restorative and the the outcome orientated aspect of it because otherwise it’s moot. It’s completely lost, I think. [Jaz]It raises an interesting point. I mean, firstly, I respect so much from an oral surgery background, that you respect the fact that is restoratively driven. That’s amazing. That’s the way it should be. But when it comes to Implantology, as a non specialty, there is no specialty of implantology, there’s no specialist in implantologist, really, it’s a made up term. When we have people with perio background claiming that okay, you know, we are the drill experts in implants, then you have the restorative folks, prosthodontic folk and the oral surgery, how can you get it and even GDPs who do implants, I guess what I’m trying to ask is how can we be more integrated in our approach, when all these different sub specialties are dabbling in implants? [Sami]You have hit the nail on the head with that question. I am totally on board with how that question gets asked. Because I think it’s asked often by the wrong people in the wrong circumstances it’s often asked is how can we control implantology? And it tends to be like you say, specialty specific people who are asking that question rather than people ask them holistically. And one of my other sort of sideline jobs is I’m a council member on the College of General Dentistry and we rent things like the training standards and implant dentistry that are due for review. And it’s a question we constantly ask ourselves, how do we improve that? How do we change? How people approach implantology because when I got into this about 12 years ago, when I placed my first implants as a undergrad, I was quite lucky over to do that as part of my sort of general upcoming as a dentist. You know, I got taught by a prosthodontist, who’s daughter now is also a prosthodontist, as well, who I work with on the younger itI and [Sami]Must be Emily Abraham? [Sami]It was yes. Well spotted. Yes. [Jaz]Another Sheffield alumni. [Sami]Yes, Sheffield. Absolutely, though, the Sheffield group. So I think it’s one of the few things in dentistry, that means you actually makes you have to be raise your game and everything. I think implantology doesn’t give you any leeway. Like you can choose other specialty areas. And even just if you’re just doing basic Oral Surgery minor or surgery, you can get away with sort of understanding, is the teacher restorative, is it not? You can tread lightly around the edges and sort of get vaguely whether or not it is or isn’t. But implantology, the deeper you get, the more your knowledge base has to grow, the wider your sort of scope for it has to be. And I think there are lots of people claiming stake in it. But in the UK, we’re the only country in Europe that has specialties in the way that we do almost there’s not as many specialties as many other European countries. And I’ll be corrected on that if I got that wrong. But if you go to someone like Germany, people orthodontics and surgery, you go to Austria, so I spent a year doing ITL fellowship in Austria. And there’s no specialties, it’s simply an oral surgeon by virtue of the fact that you work in the oral surgery department. So when I was out there for a year, all the faculty were mixed on one floor, so everyone had their offices that we shared with prosthodontists, perio guys, the was the president for the European Federation of Perio was in the office opposite view, which was amazing. So I spend a lot of time with those guys raising my perio game. So I do connective tissue grafts, I’ll sort of assess phenotypes, I think about the current conditions and things because that was so important. And what they brought to the table was crucial. And I watched these teams, everyone handed off to everyone, everyone knew where their cutoff was. And everyone knew, right, this isn’t for me. Now I’ve got a handle on. And it just meant that no, but there wasn’t infighting, and it’s somewhere I really want to get us in the UK because I think there is so much to be learned from that sort of background, from that way of thinking. And that’s much more open and collaborative approach to it. And then the only people that are going to benefit other patients. And then when they were not going to run out of work, we still place relatively few implants as a country. So there’s loads of work to be gleaned. We just need to approach it the right way, I think. [Jaz]Thanks for explaining that. But did I catch you right that you placed your first, technically you place your first implant as an as an undergrad? [Sami]Yeah, I was a fifth year. So Neoss was running an undergraduate program in King’s at the time, because I think the founders of Neoss were partly related to King’s. So when I was a fourth year, there was sort of an option out there to sort of get involved in implants. Now, I’ll take this story back even further. And I try not to bore your listeners. But a lot of people asked me when I sort of got into dentistry what I wanted to do Dentistry, I wanted to do it from a young age, no family or anything. I just my dentist didn’t hurt me. I went to the doctor for jobs, but my dentist was always nice. And then when I did work experience, I ended up doing my work experience with Andrew Darwin, who is sort of one of the gods [Jaz]Oh, my goodness [Sami]In anhtology. So 16 year old me on Harley Street has no clue about oral surgery, has no clue about dentistry. It’s just been told all the standard Spiel stuff that you get at the UCaaS sort of forms and all the rest of it. And I’ve walked in and I spent a week with these guys, and it blew my mind, absolutely blew my mind and I sort of knew that oral surgery of some kind. I was like, if this is dentistry This is then I’m in you know, sign me up now because I’m all on. And by the time I then got to 40 I sort of, I was toying with the idea of do I maybe do medicine as well and maxfax and I think you know, at that stage of your career, you sort you’re flooded with ambition and enthusiasm and you sort of you haven’t had enough clarity, have seen enough things yet to make good decisions. But this opportunity came up to, you know, who wants to try and do implants. And because it wasn’t really a mainstay thing in dentistry, even like 15 years ago, it was happening, but it wasn’t sort of something that undergrads were really talking about. Most people were trying to busy fill their quotas with composites and root canals, let alone trying to get anything else done. And I sort of me being something I struggle with saying no to things. So I was like, yes, struggling. So I then had to go to Prof Abraham, who sort of would work up the case with me, and I had to present him do all of that other stuff. So my finals case process, I placed two implants. And it was one of the nurses working in King’s at the time, it was her dad, I got to do the implants on so yeah, so it was already [Sami]That is so cool. You talked about quotas. And you know, when dentists are trying to do their one quota for that molar root canal, you went ahead and place two implants. I love that. And I think it’s so important to appreciate everyone’s origin story. And I repeat this theme time and time again, with every guest, I might spend a few minutes finding out how you fell in to where you are in the world at the moment in your journey. And I think it’s so relevant that, hey, you had that experience with Andrew Darwin in Harley Street, you met some people who took you under their wing to help you go above and beyond to help you as an undergrad. And you showed that interest. And then that spiraled into where you are today. So amazing, I hope people find some value from that journey and can can model it and look up to it. So don’t be, undergrad all over the world, don’t be upset that you didn’t place an implant. That’s the norm. But appreciate that When opportunity comes knocking, take it where you can. And if you already have an interest from before, then then go with it. So I’m glad you shared that. [Sami]I’ll add to that, if you don’t mind. Like I think you know, I was listening to a podcast really recently that was talking, you know, some people talking about luck. Luck is simply preparedness for when opportunity arises. Like you’ve just said, that opportunity comes you jump on board. And I think at the early stages of career, you’ve got to take those steps, you’ve got to take those leaps. And you’ve got to put in the mileage because all of a sudden, one day, kids come along, mortgage comes along, the world approaches you in a different way. And you may not have the energy and the enthusiasm. But if you can be inspired by what you’re doing, it makes a heck of a difference. And you’ll sort of find the drive. And often it’s motivation comes from seeing the results. And it’s simply being able to dedicate the time and the discipline to dedicate yourself to some of the ventures to begin with and understanding patients in those early formative years. I think so many people want to jump into implants, and I see young people come to it all the time. And hopefully this segues on to what we’re gonna talk about today. But people come and go, I want to do implants. Okay, great. How many surgical did you do? They’re like none. I’m like, Oh, my. Okay, no, no, no, do not pass go and like so what years have you done? Have you done any surgical? Have you spent any time in the hospital? No, but I’m on an implant MSc and I’m like, The only people winning here are the universities like they are the ones taking money. And I’m not, that’s not a go at the universities because the universities have phenomenal teachers but you’re not you haven’t seen enough composites fail. You haven’t managed enough patients, who didn’t enjoy their perio treatment, you haven’t screwed up making immediate dentures like you haven’t done enough of the stuff that will make you good at the rest of it later down the line. So take inspiration, but be patient. And that’s a really tricky balance, especially in today’s Go, go go sort of lifestyle. [Jaz]Sami, that is real talk right there. And I love the way this podcast started because it was very warm and fuzzy and uplifting and the story and now we just hit them hard with a real talk. I love that. Let’s because people now are getting little bit nervous because we’re into the podcast now. And we haven’t mentioned the word ‘mucoperiosteal’ yet so there we are, we mentioned it now. So let’s move on. Let’s talk about flaps, my friend. So the first question I have for you really is I am not afraid anymore to raise a flap like go back four or five years ago maybe then the thought of raising a flap was very much like okay, it’s been half an hour, the tooth’s not budging. I look at my nurse, I’m sweating and like okay, get me the blade. And then that means to her, okay, there’s no, I’m not having a lunch today, basically. So that was the kind of sort of background. A lot of dentists are like that okay, I’ve run out of options here. And I don’t want to refer in the middle of an extraction. So let me remember what they taught me in fourth year of undergrad and try and pull up some sort of flap and drill some bone and figure it out. Now whilst I had better mentors and stuff, and now I’m very happy to Section teeth and that for me, and we’ve covered this before as well, sectioning teeth, for me was so important in getting higher success rate and confidence and now things don’t faze me as much and having those failures behind me, those painful faces behind me that taught me valuable lessons. And even when I was at Guy’s hospital doing an oral surgery post, I saw an upper canine humble a consultant, Oral Surgeon. So that showed to me that actually, sometimes when you have these patchy areas, the way explain it to me you have these patchy areas of ankylosis and you can’t predict that sometimes and those are just gonna be really difficult. So don’t you know don’t be too upset if you can’t get it out because chances are if you’re struggling, most people would struggle [Sami]You won’t ever know. And I remember seeing this as an NHS as well. Watching a maxfax consultant who I absolutely like, put on a pedestal. And I watched him walk into an EMT theater where they were doing a cancer operation to take out some pre molars and he spent 45 minutes doing it. I’ve watched as a registrar, one of the like, the greatest surgeons I’ve ever worked with who’s at cleft maxillofacial surgery, he made everything look easy. And, you know, we walked away after an hour and a half doing four wisdom teeth, and he just turned to me was like, Well, that was like glass bottles in a concrete bed. I was like, Yeah, and I was assisting, I wasn’t even doing it. And I was sweating. And it’s totally that this having respect for the foundation, I think. But it’s the tightrope between fear and respect. And a lot of that, and the difference is experience. The difference is simply putting yourself out there, but most people, they don’t see it as a means to an end with oral surgery, they don’t see a means to an end with surgical extractions. You’re doing you know, when you started doing verti preps, and you might do crown lengthening, you’ve got an outcome because you’ve got a bigger thing that comes after all of that, you’ve got something else that supersedes it. Whereas in oral surgery is just getting the tooth out and I say just, but actually, you know, the thing that causes most fear and problems for most patients, most of their bad experiences are root canals and bad extractions. So surely, if the PRA, ever the PR exercise needed to be had in dentistry, it’s about good root canals and good extractions. You know, people come in and like the other dentist had any on my chest, I’m not that agile for one. And secondly, I don’t know, a single person teaching that technique, the sort of amount the patient style of removal of tooth. And, but when I speak to most people, and then especially on the implant courses that I teach on, where are people getting hung up on with raising flaps with approaching these is they don’t think far enough ahead. So the biggest start of stumbling block is often planning for the unexpected. So I have a plan A, but I have B, C, and D, hopefully in the background somewhere, that means that we’re not going to get stuck somewhere, we’re not going to come unstuck. And if we do, I’ve talked the patient through it, I’m not keeping it from the patient either. And I think again, it was a medical legal lecture, I went to the British Association of Oral Surgery conference a few years back, and there was a barrister talking, he was like, people need to stop getting worried about owning risk, because it’s not your risk to own, it’s for patients don’t. So if a tooth is risky, if there is a three that’s going to be ankylotic and different, difficult. I just talk people through my experience, I will normally tell people look, this is how I expect it to go. These are some of the things that can happen, the 30 seconds of telling people that tends to mean that you’re just sharing your experience. And if it happens, then they just look at you like you’re sort of you had your crystal ball on you could tell the future. And if it doesn’t, then they just think you’re good anyway. So you know, telling them after it’s just an excuse, that was always the way it was told to me, you know, just for warn. I think a friend of mine, Richard Moore, who runs an oral surgery podcast, he just did one on complications as well, which is worth a listen to for any of your listeners as well. And Judith, his colleague, I forgot his surname now who is a friend and colleague of his as well trained Richard initially used the phrase forearm is forewarned, and I think that is such an important that hope I got that away, right. That is such an important phrase. But I think listeners will hopefully get it that you can make assessments but people don’t treatment plan with oral surgery, so they just in their head go the tooth going to come out. But they don’t think about the anatomy, they don’t think about if I’m going to raise a flap where I’m gonna have to put it, do I have all the kit ready, I get the nurses to get stuff out at the start of a session. Because the nurse, 10 quick turnarounds, between getting things up, because you can adlib for 20 seconds, we’re just gonna get some more kit out, we’re just gonna make this a little bit quicker, we’re going to try and speed things up because it’s not playing ball. So I want to make sure that we go the right way with this as quickly as possible, versus trying to talk holiday plans for 20 minutes with whilst the nurse remembers which where water tubing goes in and the like. And all you do is sweat more and feel worse and then just that hiatus ruins your momentum. But it’s that’s the experience factor. And I think the more people do it, the more comfortable they get raising a flap and I think you’ll see that now like you say you’ve raised a lot of flaps, you’ve done a lot of these now. So you start, I put luxator on to tooth and I’ll tell straightaway whether or not I’m going to bother trying to just continue luxating or not, I’ll sort of use feel and in the same way that you’re sort of apply a certain tactility and experience to cram perhaps or looking at aesthetics and assessing whether they’re right or not. And actually now we’re going to do something different, but people aren’t used using that experience, and then it becomes a vicious circle. The more you avoid it, the less likely you are to do it. And you just keep going and then 10 years down the line you refer everything out and it’s actually it’s not that’s not a practice bill. [Jaz]Hey guys, this is Jaz again, just interfering with this important message about extractions and how to make them easier. We did a few episodes previously talking about speed increasing handpieces, electric handpieces and how I love them to Section molars without raising flaps, it reduces your risk of surgical emphysema because the bur itself is not driven by air. So if you’re looking to get a handpiece whether it’s the normal straight one and you want to use it for restorative and for extractions, or if you’re going to get that angled one, which is primarily for awkward extractions, but you can also use it restoratively, then check no other place than Incidental Limited. So incidentalltd.co.uk has got all these hand pieces. And if you use the code ‘onions’, that’s ‘onions’ with the plural, you can get 5% off and the crazy thing is a speed increasing handpiece is just 360 pounds that includes VAT. Screw all the companies that don’t quote with that. Okay, so iIncidental Limited run by Chris, one of the good guys, they always quote with VAT. So it’s 360 pounds, including VAT everything, and you get a speed increasing handpiece, there’s no reason why in 2022, your practice should not own a couple of these in every surgery. So check it out, go to incidentalltd.co.uk use onions to get 5% off on their entire stock, you know, stock up on rubberdam, wedges, tor VMs anything you need, but it expires on 30th of September. So buy before then pass it on to your practice manager or whoever does ordering at your practice to do a bulk order to take advantage of this time sensitive discount. Anyway, back to Dr. Sami. [Jaz]You’re so right. And I love those communication gems you shared. I love the humor there. And in case you are multitasking and you missed it, the whole glass bottles and the concrete. I love that. What a great analogy, what a great visualizations about some of the trickiest teeth that we’ve had to remove. So yeah, I mean, I am not so worried anymore. So just reflecting back on my journey in evolution in oral surgery as a GDP. But when I, even when I am raising a flap, quite often my go to flap is an envelope flap. So if you don’t mind, Sami just explaining to those maybe younger grads, what an envelope flap is. And I just want to know, in your practice, when you are raising as part of your let’s say, Plan A, you’re going to do a flapless maybe and then plan B if you need to raise a flap you will do this kind of flap, what percentage of times are you ending up doing? So we’re talking non wisdom teeth here, we’re talking anything but wisdom teeth, What percentage of times would you just raise an envelope flap? [Sami]Yeah, so I think envelope flaps are the way so those watching the video, I’m gonna apologize for telling my back and those listening, I’m just gonna tell you that and I’m drawing some badly drawn teeth at the moment and a broken root. And so, you know, assume typically this is sort of in that sort of four or five region or sort of the lateral that sort of breaks off, you know, after post core crowns tooth. Envelope flap is just what we traditionally typically called the single sided flap. So it’s that first incision, where you sort of use your blade to gently sort of trace the outline of usually the adjacent teeth, you can take it crestally, so sort of if you’re looking from it, top down, and, you know, the incision is in the midline, along the crest. And I often think that it’s quite useful putting fingers either side. So if you’re holding the buccal and palatal or the lingual and the labial, you get a feel for where your distance is. So you can place your blade in the right place. And often, a lot of people look like a sushi chefs, when they’re sort of doing this the way they’re sort of trying to sort of filet things and you’re like, Well, hang on. No, no, no, no, just raise the flap. And it’s almost I think it comes from this tentative nature of wanting to do it properly. But all you do is traumatize the flap. Unless you’re a periodontist raising a split thickness, flap, go to bone, go down to firm contact, be is sincere and sort of direct with the movements that you’re making. Because.. [Jaz]Be purposeful [Sami]Yeah, that’s it perfect word. And then that’s it. Because if you’re not, all you’re doing is traumatizing tissues, the more trauma there is the more bleeding, bruising, swelling, soreness, discomfort people are going to get later. So that all forms part of what you’re doing. But typically, for most procedures, I think probably for 60 to 80% of stuff an envelope works. Because often you can get enough reflection. And the other thing with raising flaps is you want to start and give yourself enough leeway because a lot of people will do flap, and then go, right I was taught two sided at dental school or whatever it is. And like they’ll do their flap. Now something else breaks or now you have to take away more bone. Now, you know, for example, if this had a big perio defect on that tooth and the tooth in front, whatever, all of a sudden, you’ve now put your flap on compromised that area that’s never going to support it when you put your… [Jaz]Your relieving incision [Sami]hen you put periosteum Well, you do a couple of things. One is you damaged tissues around adjacent teeth. And I think again, in an era of aesthetics, if you’ve got nicely done crowns, you know, this is why I get my prosthodontist provisional crowns on anything that we’re operating around for months before we get to the final things. So we can connect with tissue graft to do whatever it is that we need to do to make things look nice because if those margins are going to change at all, and I’m responsible for that change, the last thing you want to do is in on really nice looking crown and the same for some of the older population. You already have great margins and already fed up with that, but don’t want to go and replace some of the stuff. Why make that situation worse for them. So often you can maintain those flap margins quite nicely reposition that replace things to where they are, because that’s it, you’re starting with the money, this all has to go back to where it was when you started, if you’ve got solid bone, and is this concept of a periosteal cuff. Maxfax guys used to talk to me a lot about this, and they never understood it until they had loads of infections. And they often try and give themselves like a 5 to 10 mil cuff of margin. In some cases, I think that’s too much. And you’re probably encroaching on their anatomy. And actually, I think we can be a bit more minimally invasive of the concept stands. And again, it comes from autogenous, grafting and Frank Zastrow, who took the quarry bone split technique a little bit further, he talks about this, and I think it’s because you get this periosteal attachment to bone natural will stick to natural, you will get that and here is the Hemi desmosomes or behavior that you want to sort of reconnect to tissues, you’re not going to get that if it’s on the mind, but more so again, it comes back to the planning, if that’s going to break or I’m going to need to take away more bone and then all of a sudden I’m in a difficult situation, start minimal, give yourself freedom to extend but no way you’re going to take it to. And I think that’s [Jaz]So it’s a perfect good thing to start with an envelope and just follow the adjacent gingival margins, you know buccally usually, and then as and when your plan changes, you may then need to put a relieving incision make it a two sided three sided as appropriate. But as you said, 60 to 80% time when you are raising a flap and just out of interest, what percentage of your referral cases for like in an upper first molar or lower pre molar, some tricky extractions that you might get, What percentage of times I even raising a flap? [Sami]Very few. Because sort of failed extraction. But often like people have done the same thing, again and again, you can always predictably do. People look at you like you’re 30 When you sort of tell them, Did you put your applicator here? Did it then break like this? Did you then look at the fast handpiece in the long diamond. And people look at you like were you in the room. And you’re like No, but people do these things predictably. And often it’s because of the fear takes over. So the bad behaviors creep in. And then like no one will know if I just picked up the fast handpiece. Or I’ll just you know, I’ll just dribble some water from the three in one and the acrylic bur, we’ll see if that works. And might, because people cut corners because they haven’t set up, they haven’t got themselves ready or prepared. They didn’t anticipate it would break. And no one is perfect. Stuff still goes wrong on me. But it’s how you carry yourself in it. And I think you know that candor of being able to say to a patient, look, this isn’t going how we expected it to be. Hold fire, we’re going to reset and we’re going to restart. And we’ll come back to and often just having the authority about yourself and the confidence to say it’s not going right. So what I’m going to do is this. And you talk about referring and often like I think people are either afraid to refer because they think that we sit in our ivory towers as consultants just casting in Shame on those who send in? No, we don’t, because we’ve all been there. But there are some things we know that are avoidable. And often I think you get the fear stories, then people come in and go oh, my dentist said I needed to be asleep for this. And it probably didn’t. If you the dentist just lead with actually I’m not confident or comfortable doing this. I’m going to end and I say to patients my backup because I say to patients And I said to my colleagues all the time that being a GDP is probably the hardest job and it ends up on my doorstep. It’s only going one place in the bin. So I got a really easy job. Because I only do one thing. Being a GDP is probably one of the hardest jobs you can do hands down, I think. So if you turn around and say to your patients that your GP isn’t going to try and manage your dodgy ticker, are they going to send you to a cardiologist, I’m not going to manage this too, because actually, it’s outside my skill set. And you may need someone who can manage it, if it goes wrong. Most people are fine with that, and they will respect you for it. So don’t feel bad to say that to people. But I think it’s their sort of when people skirt around the subject. But in terms of, you know, again, I say this to the juniors who come through training. And I don’t say it to sound arrogant, but the difference between me and one of the juniors is 10,000 teeth, because I’ve spent the last 10 years you know, 5 to 10 years doing it. So in that time, I’ve amassed enough screw ups. You know, Michael Jordan talks about his failures quite openly, like he made, he missed several 1000 shots, he screwed up a number of games, it’s the same thing for me, I’ve done the mistakes enough times to know how it feels often when those broken teeth end up in my chair if I put a luxator on it. I have a sense of fear that other people won’t do in the same way that you will look at a splint Jaz and know whether it’s badly adjusted probably without even putting articulating paper. Because you’ve seen enough of that and you’ve done enough for them and that’s all that it comes down to in the same way that some people will be great and GDP is great with Invisalign. They’ll look at a case and straight off the bat go no you need fixed. Go see this guy and that’s just experience. That’s all it comes down to. But again, I go back to the point, if you do avoid it, you’ll never get that experience but for most stuff, you can avoid it. And then again, like if you’re going to add in throw in distal relieving through the motor, you know, chuck it further back, chuck the distal relieving incision. [Jaz]Let’s just make really tangible for those listening in case they’ve forgotten exactly what we have on the board at the moment. So we’ve got, let’s say, we’ve got a canine, premolar root, second premolar, and molar and then the first molar is broken, it’s subgingival we’re going to be raising an envelope flap and now somebody’s going to suggest it. Okay, when might we need to extend that to a relieving incision? [Sami]Yes, I’ll put the relieving incision distally always to start with, because I think in the lower arch, it’s less of a problem, scarring is less of a problem. Because people you know, nobody has a high lower lip line, you know, very few people show off gingiva in the bottom to be honest, then you end up with recession problems. So, again, most people have thin phenotypes anteriorly, around lower central incisors. So that’s always going to be a tougher place to manage those. So, you know, stick those distal relieving incisions in there rather than mesial ones. And often, again, the longer that envelope, the initial envelopes, if you’re taking a one, two up to two and a half units, then you’ve got enough, you don’t always need to take a papilla. And I think that’s one of the things that most people are sort of fallible for. So you know, I’ll sort of drawing the papilla on my shonky drawing, yeah. But for those listening [Jaz]Just to make it clear, I mean, you’d start, I’ll usually start off with the envelope first and see where you go. You then would add the relieving as and when required? [Sami]Yeah, totally. That’s all it is, like, you know, see what you can see, if you can’t see enough, what are you going to need to see more? And if that’s going to fail? Or what are the light again? So going back to the idea that if I can’t see at this stage, where am I going to get caught out? And where am I going to need? What am I going to need to see? So say, around lower premolars, you may well need to see them in terms of if you’re really getting down that low, hopefully not. But if you need to see it and protect it, then you know, it means you’re relieving incision may be a benefit just past the canine. So you avoid the anteriors you can you know you can include that, you can avoid the papilla. So the sort of sparing type flap, so you basically imagined an oblique incision, next to sort of one of these lower incisors, sort of angling the blade at almost like a 45 degree angle down to the bone at the level of the papilla. So you sort of leave the papilla intact, because between the two and the three, and then you can take the rest of that incision down and that will often spare because it’ll have blood supply from the labial aspect as well. [Jaz]So that’s one principle, don’t cut in the middle of a pillar, either either include the entire pillar, or would you say it’s okay to stop short of the pillar? [Sami]I think you can stop short of it. Because often like and you’ll see this, this has come more from the perio guys than anything else. So say you’re around the tooth, say imagine you’re on that lower four or five spaces again. So you’re sort of round the three in and then you’ll include the papilla, and then as you just compose the ability to then go to the midline of the tooth. And then when you’re sort of because again, you’re thinking forward to when you’re going to repair that as well like how am I going to put that back together? So do I have the right sutures for this? Am I going to be able to reconnect keratinized tissue to create nice tissue mucogingival junction to mucogingival Junction, use anatomical landmarks and make sure you safeguard those anatomical landmarks because again, it’s all starting with the end in mind. So you thinking forwards to what am I going to send this patient away with? And what am I going to have to deal with later when they come back? If they need a new crown? If they’re going to have, what’s the next stage? If it’s just having a tooth out, you know, are they going to walk away with scars or deficits around crown margins those things? [Jaz]Well, I think the reason I mentioned some of those points there is just to give some principles and foundations to dentists who are revisiting refreshing Oral Surgery flaps and I think what this podcast can’t be because you really need to be go to a proper courses. Okay, this is a two side, this is a three side, this is how you raise it. That’s wasn’t the plan. But the plan for just a main message I guess we want to send is a mistake that I would have made many years ago is okay, I’m gonna raise a flap now the flight or flight responses is inside me. Again, the whole sweating, find the blade 20 minutes are talking holidays, the blade comes, you’re gonna miss lunch, and then automatically you go for okay, I was, the only flap I remember from dental school is a three sided flap. So let me just go and raise a three sided flap. And that’s a common mistake that GDPs might still be making nowadays. And I just want to save everyone for everyone from that. Maybe start with an envelope first. Get some training, get some refresher course under your belt, start with an envelope first and then see if you need to extend it and I think some of those foundations you covered well, good there anything else want to add to that before we talk about how to make the flap cleaner? [Sami]Yeah, I think the two things that I add into what you just said are Yes, go on courses, get some mentoring and I think mentoring is becoming something that we’re shying less and less away from we’ve got more and more comfort with getting someone else on board to come and give us a hand and watch us do some cases. And you know I know some absolute you know pillars in the industry who will still get their mates and they’ll still pick up the phone to and you know, I have no qualms over going next door and speaking someone’s I’m still a new consultant in the grand scheme of things, I’m still very junior in my career. And just because I have the name badge doesn’t mean they know everything. And at some point, I have to be able to go, you know what, it’s not safe. Actually, I want to just sense check what I’m doing. And that’s, you know, that’s consciously incompetent. And that’s the safest you can probably be because you know, your boundaries, you know what your standards are, don’t be afraid, I think to go and ask for help, get some mentoring. And if you say to your patients, look, you’re a bit more complex, I want to bring in a colleague who can help me I’m sort of training up to make sure that I’m better at these cases, again, very few people mind because you’re open and honest. And if they don’t like it, then we’ll find them refer them anyway. So save yourself the headache, and because they’re probably not the patients you want to try and manage when it goes wrong anyway. And the other thing is instrumentation people go cheap, you know, people will spend 1000s on the weirdest stuff, like apps, like, they’ll buy a scanner that they use twice, or something like that, you know, and then then I’m not really buying to digital, but it’s the same thing at surgery, people won’t spend two, three grand on a decent surgical deck, you know, again, if you’re going to get into implants, you do those other things that will pay dividends. Same goes for things like Piezo, yeah, I use my Piezo for more than just taking teeth out, I do it for all the implantology work that I do as well. And so it’s got multiple uses, and blog rabbits in my line of work, it’s great. I’m not saying go out and buy a Piezo, but they’re a great addition. But a good surgical day. Good hand pieces that work that are going to get looked after that are gonna get oil. And then again, you don’t need the hue, you know, the top of the line, finest, you know, hand instruments, but you can get really decent sort of German made ones for not very much money. And again, like Hu-Friedy, Zepf, devemed, like there’s some great lines out there that, yeah, they’re a bit more of a premium, but they don’t fall apart. I’ve used cheap and cheerful and that stuff last minute. And by the time you’ve bought it for the eighth time, you spent what you would have. And actually you would have had something that worked much nicer fell better on your hands didn’t constantly like lose grip, didn’t lose teeth, didn’t drop Needles, Scissors that cut, you know, stuff like that was just like, again, because you’re there hacking away. It’s like you’re trying to start a campfire. Just it again, it’s the small things that just make the whole thing miserable. It’s marginal gains, but from a different viewpoint, I think. [Jaz]Brilliant. Now, when we come to raising a clean flap, any top tips that you can give that okay, we’re gonna be raising either two sided or maybe an envelope flap. We don’t want messy flaps, it looks like a dog’s dinner, it looks like a facial trauma injury. Any tips I can give on raising a nice clean flap, full thickness mucoperiosteal. [Sami]So the first word you said was purposeful. And that is it like you’re doing everything with direction and purpose and meaning. You’re doing it for a reason. So get your blade down to bone, to hard tissue, be confident in where you’re putting that blade and know where you are, raise the papillae first. So I tend to sort of raise the outer edges and round the margins because those are the bits that tear. And those the bits that you then don’t want to sort of have to try and repair if they don’t want it [Jaz]What instrument are you using to raise the papilla and beyond? [Sami]So often enough of the very least, the Mitchell’s trimmer does wonders. But it’s something that if you don’t have one of those sort of medium sized excavator works, because actually that the shape of that will get right under the papillae, you can put them in contact with a bone just peel up edges ever so slowly, and that works really nicely as well. Or a curette is a sort of more spoon like version of an excavator, isn’t it. Again, you can get dedicated papilla elevators, things like that. And those are, again, reduce for instruments. General Medical has a really big range. And I’ll pick up the general medical guys because they’re very good for the substance. And the so you can use any range of things. And again, like typically the ones that are fine, and we’ll have it sort of like a sharp or fine point on them that you can get between the teeth, you can sort of really put that sort of arrow head type almost configuration in underneath the papilla, just try and gently sort of like flick it up and flick it open. And then as you sort of work your way down the flap, you sort of the width of the instrument can get wider because as you get into the meat of the flap, what you’re potentially doing is tearing, if you’ve got a very small fine instrument from that you’re putting a lot of pressure through a very large space, because the periosteum will give eventually and so then you can sort of key help that your flaps and things and so again, that’s more repair work that you don’t want to sort of do unnecessarily so, and keeping these instruments in contact with bone, not on the flap because so Pynadath George again is great at this. We’ve had long conversations about it. I think you talked about it in the local aesthetic podcasts he did with you. So listeners can rewind to that one. But he talks about hydrodissection. And giving yourself enough time for [Jaz]Man, that’s changed our practice in terms of when I’m doing with wisdom teeth, I love that so much. [Sami]But it’s so i And again, like, when I’ve got many trainees with me, they sort of look at me really funny when I sort of walk in numb up, and then go and make coffee. And then I was he gone. And because like, I’m going back to rethink and look at the scans and look at the x rays and replan make sure that I’m happy in my head with everything. But I’m letting the local get to work, because it’ll take 10 minutes for the adrenaline to get to work and to create that vasodilation and give you that sort of cleaner field that you need for them to be comfortable. And then you can come back and redeliver more anesthetic. In that time, the team will prep the patient, get them ready. So when I walk in and scrub in, I just get started. And actually it saves time, because again, it’s small talk that you don’t really need to make with them. And it can feel almost awkward. And if they’ve been given that time to go numb when you get started, they’re properly numb. And they have a bit of time to forget. And sometimes I’ll do it. If I’m dealing with sedation, it’s like numb them as I’m as they’re sort of getting started as they give the first bolus of the dazzle and so tends to be a very patchy haze. And then the anesthetist will get them really comfortable. So by the time I come back again, they’re properly sedated, we’re good to go. So yeah, using good local and good local technique is a big part of it. And that helps with the cleanness of the flap because I definitely think you can see a difference. And we’ve seen it, you see it across oral surgery. Now is so vascular, but whether it’s orthognathic or otherwise good time for your local to work makes a huge difference with how you can then handle flaps. [Jaz]The right instrumentation, being purposeful, keeping your instrument on the bone, like you said and correct LA techniques is a good summary of that. But it’s want to just hone in on one point we’ll go to next question, the intrument. Let’s say we’re going to use a medium size excavator, can you just guide the dentists who may be visualizing this, if we liken that excavator to a spoon, that spoon is now going on to papilla, are you using the outside of the spoon? Are you using the inside of the spoon when you’re actually lifting up the papilla? So I curbside or the? The convex side or the concave side? [Sami]So I’ll often use the convex side against bone when I’m lifting the papilla first, because you’re almost trying to scoop under it, you’re trying to sort of gently lift and flick it forward, and then spin it around and get a toe, or there’s sort of a tip of that spin down onto bone and sort of gently sort of tunneling. And what I tend to find as well as most people will stick into one area of lifting that flap. And that’s when they get tears and things because the rest of the flaps not mobilizing. So sometimes it’s worth going around to other areas of the flap and seeing what will start to raise and what will start to move because as you start to get more mobility in the flap, you’ll get more of it raise. And I’ll often use tissue forceps. So the same as you would be doing for when you’re suturing. I’ll use those to sort of hold up leading into the flap, again, it’s about control. So making sure that you’ve got control over where that flap’s going. And as you sort of hold it, and you gently apply some pressure and pull, you can get your elevator down onto that bone and squirrel in underneath it. And that will again help to sort of push up to raise it. So you gently working your way around it and taking some time. And I think people underestimate, you know, again, it’s knowing where your patients there. So some of the perio patients, if we’re doing sort of clearances and then coming back to them for full arch work or whatever. Some of those patients have got such inflamed tissues that by the time it all heals, it’s really scarred up. It’s really tethered. It’s very rare. And again, even in the ones that are sort of you look at the ones who have been wearing dentures for years and flabby ridges, similar sort of stuff, these are sort of quite traumatized tissues. So sometimes it can be quite hard. So don’t underestimate how difficult that can be to raise the flap because no tooth extractions necessarily the same. And that will sort of have an implication what’s underneath and again, it goes you know, if you’re raising a flap and you’ve say you’re raising the flap, and there was a socket there, you know, I talked about putting your blade down quite decisively. But often what scares people is they put the blade and suddenly it drops into where the socket was. But again, that’s where it you know, I mentioned earlier on putting your fingers either side, or where the pallet is in, say that buccal bone is. Knowing where that midpoint is okay, fine, you’re going to be safe, but it’s okay to go to bone and to use again, you can use a caret to try and scoop something out. There’s Danny Boozer from Bern, he talks often about you know, if you’re doing an early placement with an implant, for example, you’re raising that flap, that’s tissues really immature. So taking that out of the socket moving it bucally, he calls it the free gingival flap, because you know you’re not taking it from anywhere else, you’ve got that tissue and it adds to the bulk buccally as well. So use that tissue if you can, if you need to. [Jaz]Brilliant. And the last thing I want to cover through the wrap up is, talk us about it, I mean, I think we can do a whole another episode on suturing that kind of stuff, but that’s we’re just focused on armamentarium, the blade. Is there just the one for GDP? Is it just a 15? And can you just talk about 15C versus 15 Normal? And and How about one more thing, which I actually people have asked me for is, you know that I usually call it the putty knife, but it’s actually a blue sterile blade that comes in a packaging. I use it for my putties. But the first time I worked in this practice [Sami]Do you mean the 12? Like a sickle? [Jaz]No, that’s what I use for composite. I mean, an actual, it’s actually 15 blade on a plastic handle, right? It’s sterilized, got an expiry date on it. But first time I was reblading for this practice, the nurse handed me this, I’m like, No, I want it on a metal blade. And I want the blade open from a package and stuck on. Now and that got me thinking Hang on a minute it. Am I just being very old school? Are dentists actually using this disposable blade, which I use for putties? Is that acceptable? I don’t know. [Sami]I use them. Because again, not everywhere has them. And it’s, I think it’s being versatile. And again, sometimes like, I’ll be honest, they’re not the most comfortable. I prefer round handled blades. And unlike a certain feel to like the pen type ones, I find that the feedback is much better. And I can be more dexterous with them, I can sort of change the angles in a nicer way. I don’t shy away from them. I think if it just gets you going and doing it again, then great. They don’t make 15C thing [Jaz]Sure, No one’s ever taught me to use that. I was just unsure. And I don’t want to do the wrong thing. So you know, already. You’re raising a flap you wanna do it well, so I was like, no, no, get me the proper surgical kit out. Let me use the blade I’m used to using but it’s good to hear, have that reassurance that if you have that pre-sterilized number 15, Blue, that’s usually the one I use light blue in color. You can use that right? [Sami]Yeah, you can definitely I mean, there’s the you know, the people will use them in a&e will use them all over. Like, it’s not wrong to use it. But again, like, you know, to go out and buy a nice scalpel handle will set you bet like 30 to 50 quid. You know, I know people who spend more on coffee in a month, you know, I just think there’s that, you know, if that makes your life easier to just buy one. And then you can use any blade you want as well, because they’re all universal, sort of, like, sort of fittings. So just, you know, there’s no, you can shortcut it. And if you want to get used to get out of this, so what and some practices if you work in lots of practices, and some might have different things. But again, if you’re moving around working lots of practices, you might want to start investing in your own kit anyway. So I think, yeah, the scalpel blades, 15 C is my preference, because I think it’s a fine blade, it’s the same shape as a 15, just a smaller width. So it has a smaller cutting to the length on it. And the smaller tip, so it’s just shrunk down 15. And I prefer those, I feel like you are in a much more finer way you’re managing the flap and a much finer way and raising that nicer. So that’s my preference. I started using, I’ve now gotten forgotten the number whether it’s at 11 or 12. I think 11 is the sharp pointy one. And 12 is this sort of curved, sickle one whatever I’ve got. [Jaz]Super curved [Sami]Yeah, and they’re quite useful. Because again, if you start getting into like implantology, and you’re doing lingual flaps to sort of raise for bone grafting, you can’t get in there otherwise. And same for things like taking connective tissue from the tuberosity sometimes are quite useful on the palate, if you ever do things like ectopic canines and flaps there. So it’s worth having a pack like I seem to collect packets of sort of blades and things and then you can get into Microblading sorts of stuff. But again, that’s more sort of adventurous. I think 15 C will cover you for the vast majority of stuff. And I think that that’s totally okay, just get started with that. [Jaz]Well, I learned something new today that you can use that blue blade, and I will apologize to my nurse when I get there from an afternoon shift of it as the first thing I do. So thanks so much for sharing that with me. And honestly, you gave so many communication gems. You’re very funny. I enjoy your humor today. Please tell us where we can follow you on Instagram. You mentioned about implant courses. Please tell us about your involvement with that. Tell us how we can reach out with you. [Sami]Yeah, thanks so much. And like you said, the armamentarium side, I think we could keep going to I’ll hold you to this and I’ll invite myself back. We’ll do another one if you want. But in terms of reaching out, you can follow me on Instagram @mr_ oral_surgery. So Mr. Oral Surgery And I’m on Twitter as well @samistagnell and also you can heckle me there and on LinkedIn as well. And as for courses, I am in the midst of setting up some new oral surgery courses, I’m going to be doing them with a few colleagues of mine. And we’re looking at developing, mentoring network because everything we’ve talked about today is sort of the real struggle. And you can go and implant courses. But the feedback that I’ve had from a lot of this senior guys the big names in implantology is that most people aren’t doing the basics. So for me my tagline you heard it here first is you know being better at basics. That’s what I want people to be. I want people to get the simple stuff, right and then progress and then grow and elevate themselves from there. But just come back like you said before, touch base, mentor, refresh. You can do that umpteen times and you’ll never sort of tired from it. And again, learning it from a few different people which is why we want we’re building this mentor network because we appreciate the fact that there are more than one way to skin the cow or there’s more than one way to elevate molar. So I think you want to hear it from a few different people and find what works in your hand. So you get comfortable with that. As for implant courses at the moment, predominantly, I’m teaching on the Paul Tipton year one course, which is really good. So definitely recommend that. And I contribute to a few others here and there. So if you follow me online, you’re sort of [Jaz]definitely well, I’ll put the link to to follow you on Instagram and LinkedIn. But also, if we need to know when you have any links, so you can send to me, Sami I’m gonna stick them in the show notes, so people can just quickly click on, that’d be great. I really enjoyed our chat today. And I think we’ve got what we wanted out because it’s unrealistic to explain through a podcast format all the different types of flap, but I think people will walk away just thinking bit more about the plan for oral surgery. The fact that knows even just learning you as an oral surgeon, the percentage of time that you actually using a flap and when using flap, what’s the main go to flap, I think that’s going to hold a lot of value for a lot of people. And then just little nuances about blade, which I discovered today. Thank you so much for that. And the communication stuff you shared today was really valuable. Thanks so much for your time today. [Sami]That’s a real pleasure. I think my absolute takeaway is going to be just plan, you plan for everything else. Don’t stop planning in this plan, the complications, plan your approach, plan your escape, and those are things that are going to sort of make things more comfortable, because when it happens, it’s not a complete unknown. So there’s definitely but Jaz, thanks so much for having me on. I’ve really enjoyed it. It’s been really good chatting. [Jaz]It’s been really fun. Thank you. Jaz’s Outro:Well, there we have it guys, you can use that blue blade after all, and I shouldn’t have corrected my nurse. So there we are. Now I know. And I hope you found value from that it was great that those who were watching, you managed to see him draw. For those who are listening, I’m sorry that it was a little bit of a visual episode that we didn’t get to explain certain elements of it. But you can always go back on YouTube to check out exactly those parts where he’s drawing certain things. I think that might be helpful for you. If you enjoyed listening to this episode, if it was helpful to you, please do give it a rating on your app, whichever app you listen to, or if you’re watching YouTube, do hit that subscribe and a thumbs up button. Leave a comment any questions you want. I always do get the guests to come and support you guys on YouTube. Or sometimes if I know the answer, I’ll always try and help you out. Thanks so much and I’ll catch you in the next one.

My worst nightmare: a patient complaint. We share with you a story of triumph as one of our colleagues SUCCESSFULLY defended a complaint. We reflect on the lessons learned and how to manage complaints (including the emotional side). Dr. Gulshan Murgai spoke about a long and arduous case that was resolved in his favor, demonstrating that he has patience and determination in spades. We will also discuss the importance of attending risk management lectures and how to deal with this nasty situation you might face with unhappy patients. https://youtu.be/v342FiEete0 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: The scenario that led to the patient’s complaint 8:41 Insurance-based scheme 16:40 Patient’s Complaint 19:07 Legal narrative 22:08 Dealing litigation emotionally 31:29 Emotional help for dentists 34:45 Importance of risk management courses 38:32 Lessons from the case 41:27 Head over to Confidental for Emotional Support for dentists in distress. Connect with Dr Gulshan Murgai If you enjoyed this episode, you will also love 10 Habits of Highly Successful (and Most Valued) Dentists Click below for full episode transcript: Jaz's Introduction: I haven't been sued yet and I say yet with a sense of realism because it's a sad state of affairs that we live in. That litigation is extremely high, especially we are in the UK and under my US colleagues will also agree that this can be a real issue. Jaz’s Introduction:The issue that really is at heart here is the emotional trauma that dentists can go through when a complaint happens and when it proceeds to the courts and whatnot. And we are talking a lot about that today. And we’re going to be sharing today a triumph, an actual triumph, because this is what we need. Our profession needs to hear it from someone who’s been through a very long and arduous case and come out the other side with a victory. I hope it leaves a very pleasant taste in your mouth at the end of it. But also what I want to extract today from our guest, Dr. Gulshan Murgai, is while the human emotion sides, because I’ve got colleagues who’ve been through complaints, formal complaints, and it cripples you. It really cripples you. It makes you doubt your judgment. It makes you lose your enjoyment and fulfillment. Personally, I haven’t been sued yet, and I know it’s going to come, right? It’s going to happen. We have to face off, and when that happens, I really hope that I’ll be robust enough for it not to affect my mental health. And one of the things that I’m supporting with this episode today, is the charity confidential. I’m going to be leaving the phone number in the show notes. If you need support emotionally because the themes that will be discussed in this episode resonate with you and you need help. Please don’t be afraid to pick up the phone to call confidential, who are an independent charity dedicated to your emotional health as dentists to help you overcome these nasty episodes that we may sometimes have to endure. Hello, Protruserati. I’m Jaz Gulati and this is an interference cast, something nonclinical, and I just cannot wait to get this out to you. I think every single dentist in the world should hear this story to hear about the challenges. Because one of the themes that we cover is just because a patient likes you doesn’t mean that they won’t complain. And when that complaint lands, it can really turn your world upside down. Now Gulshan, our guests, very robust man, very forward thinking, amazing how he handle it. But we’re not all built like that. And so sometimes we may need more emotional support. So if anything, I hope this episode inspires you. I hope this episode gives you hope. I hope this teaches you something about the importance of going to risk management lectures and understanding what it takes to come out the other side when something as nasty as a complaint and having to go through that process is just sickening. So I’m hoping this will help you in some way.Let’s check out the main episode and I’ll catch you in the outro. Main Episode:Dr. Gulshan Murgai, welcome to the Protrusive Dental Podcast. How are you, my friend? [Gulshan]I’m good, Jaz. Thank you very much for the invitation. I really appreciate the platform. [Jaz]No, I really appreciate you making time for this. And I just want to start by saying thank you for allowing this to happen, because you have to think about the fact that you’re exposing yourself, you are sticking your head above the parapet and stuff like that. And therefore, it’s not easy for anyone to go and do that and share this story, which involves negative themes like being sued. And I really appreciate the fact that you are happy. Talk about this. That’s a huge step, and I feel our profession needs this now more than ever, which is why when I saw your Facebook post of that triumphant victory, now we see the triumphant victory. But what people don’t see is the years of heartache, sleepless nights. I don’t know. You tell me. We’ll talk about that. Background, what happened? And I’m sure, I know you’ve been having lots of messages, but over the years it hasn’t happened to me yet, but my colleagues, they get suicidal thoughts. They get really crushed, crippling fear going into work. And I’ve seen what is done to my colleagues and a lot of some of these colleagues have completely gone non-clinical now. And I don’t even trust myself, Gulshan, that if I was to get a serious complaint, it was to go in that direction. I don’t even think I’m robust enough to really overcome it in the way that I would want to. So that’s what we’re discussing today. So, Gulshan, before we dive in to your story, just tell us who are you, where do you work, what are you about? [Gulshan]So, you know my name’s Gulshan Murgai. And I’ve been a practitioner since 2001. I’m a graduate of the University of Birmingham. I’m really proud of my teaching from Birmingham and what it’s allowed me to do. The way I was taught, and what I learned was such that. When I got out into practice, so we’re talking VT now. I really didn’t enjoy my VT job within six weeks. I was like, what the hell have I done? This is not right for me. Long story short, I had to get out of the situations quick cause I could obviously finish VT. And then I was looking to buy a practice because I realized, you know what, I’m not going to be forced into doing things other than the way I was taught five years of teaching. And you’re taught to do things the right way very strictly, pass the exams and then all of a sudden you’re in practice where you’re making money for someone else and then later on for yourself. And I thought, you know what? I’d like to keep my good habits. So I did my VT job, did a short stint as an associate, and very soon bought the practice. So where I’m sitting. I bought this in 2003, so- [Jaz]Wow. So straight after VT, this is your venture now. I know you qualified 10 years before me, therefore you are in the cohort and we always have this thing in dentistry where we look at the new generation and we think, ‘Ah, this new generation has it so bad. We had it good or whatever.’ Or the previous generation before you had it even better. So, 10 years ago before I qualified, you’d like to think that you had far more clinical exposure at dental school than I did, and then the new guys coming through have far less than I did. Did you feel ready clinically to take that step into your own practice clinically? [Gulshan]Clinically yes, because my VT job, I was busy, I was really busy. But let me put things into context because of where I was practicing. So I was in, sorry, a reasonably affluent area. And what you need to know is the end of vt, my income was 55% private, right? So vt, so we’re talking 2001- 2002. [Jaz]That’s quite rare. [Gulshan]So when I joined this West London practice as an associate, I already knew what I could do and I was lucky. I was living at home. I had no outgoings, right. I was able to buy a new car and all I spent my money on was the car that I bought and education, right? So it’s important for you guys to know that I only entered dentistry to follow a surgical career path, right? Some people will say, I’m a failed medic. I can put that to rest. Certainly not. But all of our family, friends, everyone I knew growing up was a doctor or a surgeon, albeit my parents are not doctors and surgeons, right. It just so happened to be our circle of friends. It’s all I knew. So I wanted to follow the surgical career path. I went into dentistry to basically go down a max fax route. But probably six months into undergraduate years, I was like, no way. I’m not going to do any more than I need to. So what I did was as soon as I could, I got out of VT and finished that. I started looking at surgical courses and things like that, and I remember my first few, I remember being at these very expensive courses. That I was paying for out of my own pocket, and there was me and a friend of mine that I qualified with from Birmingham and everyone else in the group was 50 something, practice principals and Jaz, they wouldn’t even talk to us, right? They were like, what are you doing here? You’re below us. And I carried on with it. So I placed my first implant in 2002, so the year after I graduated. [Jaz]Mm-hmm. [Gulshan]And yeah, I haven’t stopped since then. I needed a practice where I could continue that, so I then borrowed a large amount of money from the bank and I bought this practice, which was an existing practice that had a pedigree of implant dentistry that used to be owned by one of the World College tutors in implant diploma. So that’s what I did. So I kind of went into that and kind of, it’s been implant dentistry first. So my history in digital dentistry goes a little bit further back, but I had to pause and then I kind of kick that off as well. So- [Jaz]So, what’s clear from that little thing. So what’s clear is, A) your mindset is like very much growth. You have very much a growth man’s mindset. It is very clear to me. The second thing is you took massive action. I do feel that in our careers, you have to, at one stage take massive action and it’s very clear you did that. And also you are the master of implementation and you did it well on these courses to be able to apply it straight away. And then you control your own environment by making your environment conducive to that. So that’s super clear. Can we now get to the story where the main reason for this episode. We’re going to do a second episode, by the way, for those listening and watching. We’re going to talk about which is the best scanner, and that’s coming very soon. But for this one, just tell me from the beginning about this complaint issue. What happened that led to the complaint, and let’s go from there. [Gulshan]So it’s kind of good that we’ve gone through the history, right? So imagine 2003, I’m buying this practice. 2004, I moved in already. Made some significant changes to the way it was going to be honest, I had to just start from scratch. I was missold this practice. It was a big financial plunge and long story short, I turned it around. So we’re into the end of 2004 now. It’s almost a year since I bought the practice. I’ve got already some history in implant dentistry and this new patient comes along and it was November, 2004. Just a standard new patient to the practice. And yeah, she lived relatively locally, standard new patient, did whatever she needed doing. So it was restorative, ground, bridge, whatever it was Later on in that things changed in that, it was clear that bear in mind this was a private practice. She was being seen under private contract, right. What she would do though, is she would go to other dentists for her NHS kind of let’s say routine care examinations, et cetera, and then she’d rock up here when she needed any treatment. And that was a bit unfair because it was like, okay, well what happened in between? So you need to know that I was treating her, just looking at my notes for nine and a half years as an irregular patient, right? [Jaz]Mm-hmm. [Gulshan]So when I stopped seeing her, it was 2014, so like nine and a half, 10 years, right? And in that period, she was seeing me and seeing other practitioners as well, but she was based locally around here. What happened after that is where everything changes. And this is what your listeners need to know because- [Jaz]Can I just stop you? Ask a question, at that point, like, was she pleasant to you? Did she like you, would you say between 2004? Cause she keeps coming back to you and she obviously trusts you to know, to work in her mouth and not the other dentist. So that shows me that she trusted you so she knows you and likes you and trusts you. At this point, you got so much more rapport now. And so it’s important to state that, because some people think and please correct me if I’m wrong there, that if a patient likes you, that they won’t sue you. That may or may not be true. What do you think? [Gulshan]Yes. Doesn’t work like that? We’ll go into that probably later on, but I’m kind of trying to set the tone. You’re absolutely right, Jaz. In that, I said this to my legal team that were involved that, hold on a minute, because other parties are saying other things, and bottom line is, as you’ve said, this woman’s trying to sue me. Right? For clinical negligence, this is basically a personal injury case. It’s all about money. And in order to get that money, the other side have to prove that I had a breach of duty of care. So my point is that, like you just said, if that was the case, why don’t you keep on coming back to me, and paying me money to do stuff. But let’s just say this patient had a complex mental health history. I know her so well. Obviously I can’t mention names, but I know her so well that when I was having case conferences with my legal team, I didn’t even have to go to my notes because we had a rapport. This lady has cried in my surgery because of things going on in her life, and you don’t forget things like that, you know? So, yeah, you’re absolutely right. So we had a rapport. She spent good money with us, and she was very complimentary of the service we’ve provided at the time. [Jaz]Mm-hmm. [Gulshan]But the big problem, and this is what your listeners need to know, is when that gets tainted because of comments made out of context, right by our so-called colleagues, and that’s what’s happened in this case, right? She’s been going here, there, and everywhere because of her changing financial situation. So when she could afford to have her treatment done with us, she was wanted to, but it got to the point in 2014, what changed was that she had disappeared off for a few years and she’d come back and a whole bunch of her upper posterior teeth had gone. And I was like, what the hell? What’s going on? And she told me, and it’s not too important, but what is important is that because those upper posterior teeth were gone, my lower implants that I’d placed for her some years before had no opposing contacts. Right. But the last time I saw her was she came to me having seen her NHS dentist for options to replace these missing teeth. And I gave her the standard options, denture implant over denture, implant, retain, bridge, or keep your gaps, but then you’ve got no posterior function. Gave her options and that was it. Right? Obviously, we followed up on it maybe some days later, and we were told she’s decided to go elsewhere, right? She’d already told me that someone else was cheap, and I was like, sorry, that’s my fee. I can’t change what I’m. And basically that’s when the problem started, in my opinion because now that I’ve, through my legal team, had all of the records from all of the different people, you can start building up a timeline and bear in mind this case kicked off for almost five years ago. Right. And in that time, obviously I didn’t see her, but she was seeing other people. And before- [Jaz]So I just want to make it really tangible, so this is between 2014 and about 2017 she was seeing other people. And then she actually complained in 2017, is that right? [Gulshan]Yeah, that’s right. So it was, no it was 2016.She actually came to us. She’d move it out of the area. So she was in Lincolnshire. And this is important because she’s contacting us about, what implant she’s got, her general dentist in Lincolnshire being seen on NHS basis is just saying, gimme some information. Give us some screw loosening. Now, bear in mind when I’ve last seen her, she’s got my opposing teeth. So if they’re screw loosening, something’s changed. [Jaz]Mm-hmm. [Gulshan]Hey, that’s fine. That’s her prerogative. She’s moved on. Right. No issues with that. And I’ve got a whole email chain between me, her and my practice manager at the time saying, yeah, no problem. We’ll help you. We’ll do this and that. But what happened was she wanted help for free. She wanted to be seen for free. She made a big deal about the fact that, oh, it’s going to take her five hours to travel from Lincoln down to here in Watford. And I was like, sorry, but you’ve moved, we’ll help your general dentist, no problem. So we’ve got a paper train to show that we were doing everything we could to help. Then she requested her records. I was like, okay, yeah, you can have your records, but is there a problem? And yeah, she put it in writing that she wasn’t happy and she wanted to make a complaint. So as soon as someone says that two things can happen. What should happen according to UK rules is that you should say, no worries. You are allowed to make a complaint. Here’s our complaint’s procedure. Right? So we send her our complaint’s procedure and wait and wait and wait, and we don’t nothing back. And then she says, and this is months later, she’s like, okay, I don’t want to use that procedure. I’m going to lawyers. Okay. Soon as that word gets then indemnity gets involved. And so the complexity there was that I’d changed my indemnity provider from when I was treating her many years before to that particular time. This is now 2017. [Jaz]Mm-hmm. [Gulshan]So I ring my indemnify and say, what do I do? And they’re like, well, you weren’t with us when you were treating her. You’ve gotta contact the old lot. So it gets complicated here. [Jaz]Mm-hmm. It gets very messy when you change. But there’s something called a retroactive cover. Does that not apply? [Gulshan]I had all of that. It was not a problem. I had all of that and I’ve gotta say massive thanks to NPS Dental Protection. They were my old indemnify. I hadn’t paid them any subscriptions, premiums, whatever you want to call it for years. And yet they supported me according to their contract. Obviously part of the original contract, but that’s scary to think that I’m paying this guy now and they can’t support me. You can understand why, because now I’m on a insurance-based scheme. [Jaz]But just educate me Gulshan because I’m now with an insurance based scheme as well. When you join an insurance based scheme, is that not something that you do to say that if I sued from a case in the past, you’ll also cover me for that? Is that an add-on? Does that exist? [Gulshan]That does exist with some providers, Jaz. So, good question. So there’s basically claims made and which is one type of policy, and then there’s another one. So you’ve gotta speak to your existing indemnified to say, look, this is where I’m with you right now. I’m looking to move to that. Do I need anything such as what’s called runoff cover? And so on. It gets a little bit complicated, but there’s basically two different ways of having cover one’s claims made and I forgot the other term. [Jaz]Sure, sure. No problem. [Gulshan]Regardless, I had cover for historic claims. [Jaz]Mm-hmm. [Gulshan]Bear in mind that in the UK, if someone has treatment done 10 years ago, and then now today they find out that they’ve got a problem with work that they’ve done, had done in the past. From the time that they find out that they’ve got a problem, they’ve got three years to make that legal challenge, right. And that’s how this went on for so long. Unfortunately for new people entering into the profession and people like me 21 years in, doesn’t matter how long you’ve been here, you need to know that there’s litigation risk, right? Whether your NHS private mix doesn’t make any difference and therefore, I’d like to share with you and other people listening what I’ve put into place over the years, because this is not the first time I’ve been sued. [Jaz]Mm-hmm. [Gulshan]But every time you do get a complaint of any sort, whether it’s a little internal thing that you resolve. Or something litigious like this, or GDC or all of the above. If you don’t learn from it, you are going to just get into bigger and bigger trouble. And I can tell you for sure I’ve changed huge in huge ways from when I bought this practice, when I qualified to how I am now in terms of what services I offer, my record keeping and my conversations with my patients. All of that has changed. But getting back into this particular case, 2017, it starts and the minute the word lawyers has mentioned, you go to indemnity and then basically they represent you. So it starts off with them looking through your case. And the number one thing they’re looking for Jaz is vulnerabilities. Right? And there’s different types of vulnerabilities. Clinical and then record keeping. Apart from that, well, unless they see the patient, they don’t know. [Jaz]Mm-hmm. [Gulshan]So this is what’s really important. [Jaz]Can I just clarify that, Gulshan? If you continue, because it’s really important for the story is that, in her own words, in her one sentence, why does she believe that you were negligent? What harm did you cause? What was the thing that she’s claiming then? [Gulshan]So what happened in 2017 was this, it was a bit of a surprise. So bear in mind, 2016, we’ve been trying to help her, right? We’ve been saying we can provide a screwdriver, this, that and the other. It was screw loosening of an A button, right? And we were going to help her general dentist sort it out for her because she didn’t want to travel down here. It’s soon came to light that she’d be happy to travel as long as we paid for. Now I’m like, you haven’t been a patient here years. Why am I doing this? Anyway, turns out that outta the blue, I’m at the end of a long day, six, seven o’clock in the evening. My front of house basically tells me there’s a patient here who wants to see you. Is it possible? And they mentioned the person’s name and immediately they mentioned this person’s name. I’m like, I know exactly who this is. And my team at the time, they weren’t here when I treated her years ago. So I stopped with my patient in surgery and said, gimme a minute. Let me just go and chat to this person. And long story short, she’s in my reception area with an implant bridge in her hand in a sterilization pouch. So clearly she’s been somewhere, right? [Jaz]Mm-hmm. [Gulshan]And it takes her about two minutes to tell me that she’s come down here to Watford, my town, wearing my practices, and she’s seen a practitioner around the corner from me. And that basically, the implants that I placed for her have failed. And she’s thinking that what she’s got in the sterilization pouch is her implants, right? And she’s aggrieved at that. And she’s saying, you place these for me? What are you going to do about it? Type of thing. [Jaz]Mm-hmm. [Gulshan]And I’m like, you know her name. I say, what you’ve got in there is not your implant. I said, would you mind opening, let me just have a look. She opens her mouth and I can see two implants sitting there, lower left sides. And what’s in the pouch is two a buttons and a bridge that’s been chopped off. And I said to her, whoever you’ve had chopped that off, it’s now their responsibility and yours because they did it. And I said, it didn’t need to be chopped off. It could have been pulled off because it was cemented. [Jaz]Mm-hmm. [Gulshan]And had they actually conversed with me and asked me, I would’ve been happy to help, but now you and he have gone into that scenario, it’s nothing to do with me. And I asked her politely to. And then after I finished with my patient, I spent a long time documenting the conversation. And I knew then this is just going to kick off and be huge. Obviously then I knew who she was seeing, which is the practitioner within five minutes from my prac, my place. And I thought, now it makes sense. But what really hurt Jaz was the fact that she’d been lying to me, for months from 2016, telling me she couldn’t, she didn’t want to travel from Lincoln. And it turns out that she was coming backwards and forths to Watford for a long time. She was having treatment here. [Jaz]And, just to touch on that now that we know that, and you reveal that part of the story years later in terms of you obviously when we come to the end, triumphantly overcoming this case with success, was that part of the narrative significant that she was actually lying? Was that significant for the narrative? [Gulshan]Massively. Because you gotta remember this case is snowballing, right? So it starts off with a complaint, right? Everything gets sent to the legal team. Now, when I say everything, this patient’s got six dental implants that I’ve placed over the years. Multiple Crown Bridge. There’s photographs, there’s X-rays, there’s CT scans. There’s nine and a half years of clinical records or type right? It’s too big, quite frankly, to just, well, I wouldn’t print it because it would be. . So what we did was we created a digital dossier and we handed it to our lawyers who handed it to theirs. Right. Obviously that then went to our side. And when the other side then says, right now we’re armed with something, they start building a case against me, whoever it is, right. And in doing so, they hire an expert witness. So they give my dossier records and this patient’s complaint, this patient is obviously their client. They’re acting on their behalf. They give it to an expert witness who, again, is one of our colleagues, right, who basically takes everything apart and puts their spin on it, right? [Jaz]Mm-hmm. [Gulshan]They shouldn’t because an expert witness is meant to be totally independent. But it’s clear that this case was a dental law partnership against me. And everyone in the UK knows who TDLP are, right? [Jaz]Mm-hmm. [Gulshan]And they have a host of expert witnesses who just act for them. And a lot of people will say, well, if they’re just acting for them, how can they be impartial? Yeah. [Jaz]How is that independent? Is that legal? How does that work? [Gulshan]There’s ways of getting around the system and they do. And you can see this because the same expert witnesses come up for TDLP and IWiN Mitchell and all of these other big law firms that take on these no win, no fees. Independent kind of legal cases against medics and dentists around the country. [Jaz]Is there a list of these dentists who back for the other side? [Gulshan]It’s not difficult to put it together, Jaz. And actually if it did happen and it went public, there would be I think a bit of a backlash, but obviously these people are independent practitioners in their own right. Some are retired and it’s their way of making money. And some are still practicing and it’s something they do on the side. They’ve done further qualifications. [Jaz]I’m just saying if you’re going to, if you’re a dentist, you want to enter the expert witness world and do some legal work, good on you. But just by back for the right team back for justice, I mean justice, some patients may deserve, and some dentists may be negligent. We can be negligent as a practitioner. [Gulshan]Absolutely. [Jaz]These patients need protection from that. But the whole, it’s one of those things, isn’t it? It’s difficult to swallow. [Gulshan]Yeah. Absolutely. And obviously I know who the names are and so on, and as soon as they’ve got an expert witness, we get an expert witness. Right? So that’s when things get a bit scary because now all of a sudden, this person you’ve never met before is looking through your records and checking, did you do things the right way? Okay. And obviously, I’m going to suggest that. In this case I know that I did right. It might not been a hundred percent perfect, but it was done correctly. And I’ve gotta hold my hands up that we don’t get things right every time. Like I said, we’re all human, right? And when I talked generally earlier about vulnerabilities in the case and the amount of people that have contacted me since I’ve made this case public, a lot of people have said, can you help me with this? Can you help me with that? And the first thing I say is you have to look through your notes. You have to be honest with yourself, and say, number one, did you do things the right way? And there is no, ‘Oh, but it’s NHS. Oh, but this, that.’ This is no excuse, right? Because when we qualified, we didn’t get stamped on our head saying, NHS dentist or private dentist, right? You learn how to do dentistry properly. After that, it’s up to you. So the first thing that Alaska colleague is, do you feel you did everything by the book, number one? And that includes consent and giving people options. Remember I said left VT 55% private, right? [Jaz]Mm-hmm. [Gulshan]That’s simply because I gave every patient every option that I could deliver, as well as options that I couldn’t deliver, right? And then people surprised me. People who were exempt and on benefits went away for 3, 4, 5 months and saved money and came back and had things done with me privately. And that’s what I’ve done for 20 odd years. It’s been what’s made me successful. So back to this expert witness gets hold of your notes and you’re waiting to see what do they find?And in my case, in this case, they’ve cited with me, so letters written to the other side to say, you need to cease and desist, right? Because there is no case here. But they didn’t, and they carried on. Now, for some reason, the law firm that my indemnity we’re using changed over everything handed to another law firm. I then ended up with another expert witness. [Jaz]Gosh. [Gulshan]The good thing is the second expert witness also backed me. Right. And that expert witness- [Jaz]And this expert witness didn’t already know you? As independent to you? [Gulshan]No, no. [Jaz]Okay. [Gulshan]No, they’re not allowed to know you. They’re no contact whatsoever. It’s your legal people who it is that they use according to the type of case. So if it’s crown and bridge, they might choose a prosthodontist if it’s all implant related. They might choose someone who’s got a history in implant dentistry, but it needs to be someone that can give relevant experience. Here’s where some other cases fall down Jaz, because we’ve already mentioned this term expert witness, but there’s a bunch of people out there who are qualified to be expert witnesses that cannot necessarily qualified to make comment on work that you and I or any of the practitioners done. Mm-hmm. [Jaz]So it’s like me commenting on someone’s implants, but I’ve never placed an implant. Well, I have, but like, I don’t do implants basically. I’m not in that field, but me commenting, is that- Okay. [Gulshan]Yeah. It’s a really big deal. I’ve had this kind of situation in the past as have colleagues where the case is getting very serious and the person on the other side who’s basically coming at you with all of this information might not have done or been involved in the type of treatment that you’ve provided, and therefore, how can they actually make- [Jaz]There’s no credibility there, in my opinion. [Gulshan]No. They might have qualifications, they might have loads of letters after their name and sometimes I get controversial online and I say about all of these diplomas and things that are quite frankly, a waste of time. I’ve got a diploma, which is mostly a waste of time, right? It’s my implant diploma from the Royal College of Surgeons. Now, hardest exam I ever did. Right. And it means a lot to me, but that’s all just me. No patient gives a damn whether I’ve got a diploma from this Royal College or that Royal College in implant dentistry. What it might help with is a case like this where if someone tries to sue me and I can show that I’ve got this, that, and the other qualification, which was independently examined, right. Then it might help. [Jaz]Okay. [Gulshan]Yeah. But if I’ve got this qualification, and I’ve been doing implant dentistry for let’s say 20 years, but I’ve only placed 50 implants. Do you see what I mean? About how well, where’s the value in that diploma qualification? It’s the same for an expert witness. [Jaz]Mm-hmm. [Gulshan]So they’re qualified as expert witness and making comments, but they don’t actually actively provide that treatment, then you’ve gotta ask, where’s the credibility? And that’s one of the ways we want this case, because later on through the case, when it gets more and more serious and then there’s barrister involve, because then there’s talk about going to court as soon as talk about going to court, because of the other side won’t cease and desist. Things get expensive. There’s big meetings. I’ve spent hours and hours. Conference calls with four or five other people to defend this case. And the bill is just going up, and up, and up. [Jaz]Now, for you, it’s costing you your time, your precious time. [Gulshan]Yes. [Jaz]That’s the most valuable thing we have, but am I right in thinking that because mps their protection, were protecting you, they were paying all the legal costs and everything. [Gulshan]Everything. That’s why I have to give massive thanks and praise to them because- [Jaz]Can you claim back loss of earnings just out of curiosity? [Gulshan]No. [Jaz]No. Okay. [Gulshan]There is a rule which my lawyers told me about afterwards, because many people who commented online after I put this thing out publicly on Facebook, many people said, you must count to, so you must do this, you must do that. And I’d love to. But number one, NPSs obviously won’t pay for it. And the second thing is that even if I did choose to pay for it, there’s protection for the patient, right? In a personal injury case in the UK, a rule was introduced in 2013, which means that a patient is able to make a personal injury claim, against medical dentist, whatever without recourse. That means even if they lose, sorry? Yeah. If they lose and you win and there’s no case to answer, it doesn’t matter how long it took, you can’t go after them. Because the law says that if you could, then these big insurance companies and agencies would basically prevent patients from being able to complain. Okay? And you’ve gotta see it from that point of view that there’s some huge agencies out there, which people are scared to go after hospitals and this, that, and the other. And they’d never get caught out. So it’s there for good reason. [Jaz]It makes sense. I think, and when you put it like that, I think, that protection makes sense. Otherwise, I will say we need to start, start a crowdfund right now. And I know that you’d get a big amount to do it, but because of the nature of it, we can’t do it. Can I just ask you on the human emotional side, like, I’ve seen you lecture live for, you’re a confident guy. You’re a great speaker. You are very successful in what you do, which is great. And I love that. And, I just look at you and I think, wow, this guy could handle it. Did you have any low points? Because for me, I mean, I get like a whiff of a complaint. I’ve never had a formal complaint yet. Touch wood and I say yet, because it’s coming. And I know that, but. Even when something fails, a temporary crown really falls off, just for me as my personality, it affects me a lot. And so, and I know lots of dentists who get crippled by this, absolute crippled by this. So how did you cope emotionally? [Gulshan]So, that’s like two separate questions, Jaz. So one thing is, I’m massively passionate about the clinical work I do, right? I take it personally, if I can’t satisfy the requirements of a patient, whether they’re new or old, it doesn’t make any difference. And actually the best thing about my work and my practice that I’ve developed is that my regulars, they recognize that. They recognize that I go all out, day and night to try and to do what I can. And I did for this lady as well. I honestly hand and heart did, and my legal team know that, I got emotional a few times in some of the case conferences. Where it’s really difficult to know what someone’s saying against you, and you know that they’re out for money, right. And you’re thinking, but I did this, this, this, this, this free of charge. So one little aside, this isn’t the first time I’ve been sued, right? But I’ll tell you one thing, every single time someone’s come after me, sadly it’s been the people who I’ve done the most for, right? [Jaz]Mm-hmm. [Gulshan]The people who I’ve gone out of my way for. It’s often been those people. So that’s one thing. The second thing is that, how did I feel personally about this particular case? I felt angry because nothing more than that. Just angry because like I said, as I knew her for nine and a half years, I knew her type of character, and got on really well. I knew a lot about her family, her situation and there was some degree of, I felt sorry for her situation, which is why I was trying to go out my way to help. But there’s only so much you can do, Jaz. We’re all human and I come to work to earn some money. I’ve been in a lucky position where I’ve been financially successful for a long time, so I can afford to go out and do things for people for free whenever I want to. Right. And in this particular case, I was trying, but we’re going to take it so far when you know that they’re irregular tender, that in my opinion, kind of disloyal. So yes, I was angry. I was angry at the fact that she had taken it legal that this was going to cost me time, money, and effort to fight it. But because of that anger and that determination, and having gone through all of my records multiple times, I thought this is rock solid. [Jaz]Mm-hmm. [Gulshan]So what you need to know is, I said to my legal team right at the start, under no circumstances and like settle rules, right? So the legal team have to have your permission to settle. They’ll send you a standard letter. And before they even asked for my permission, I just told them straight, been through it, left, right, and center. I’m not giving up on this. That was years ago. Mm-hmm. . So that was my stance on this. [Jaz]But, someone who’s not as robust as you, someone who maybe has only two years into their implant journey, and imagine that happened to a young dentist. Right. And maybe got a different life circumstance, whatnot. I mean, let’s take a moment. Think of our colleagues who are at different stages, and young dentists vulnerable. And maybe that dentist whose record keeping that day wasn’t as good as it should have been. And then even though what you did was right, but your record keeping wasn’t good. Then you can’t help but feel helpless and really it can affect you. Now, your record keeping was good. You had this long history, you had some experience before you even treated her and whatnot. So I think that gave you the courage and the termination and the conviction that you needed. But what advice would you give someone who really needs some help? Emotional help? [Gulshan]Jaz, excellent question. And that’s the whole point of this. This is why number one, I publicized the post. And number two, I agreed to do this with you to help not just colleagues that are 21 years in like me, but also mainly for the new graduates, the people that are scared that this might happen. Because I do see the fact that a lot of new graduates are really quite happy just to refer out things, which really we’ve all been taught how to do. Right, and it’s because of litigation risk, I believe. So that’s going to be there. I’m afraid, guys. That’s the world we live in. That is the profession in the UK. So my advice would be that if there are vulnerabilities in your case and you know about them early on, then give yourself a break, learn from it, and basically say to the team, hands up. Yeah, I can see how there’s vulnerabilities in here. Why should the rest of the group of people that are indemnified by that agency, whether it’s insurance based or otherwise suffer and have their premiums go up because you are being egotistical about this, right? You’ve gotta put your hands up and say, you know what? My bad, I should have I clinically might have done things perfectly, but you know the rule, if you don’t write it down, it didn’t happen, right? If you don’t write it down, it was upset. And that’s why the notes have to be the way the notes have to be now, right? So if I go 15 years back, 18 years back and look at my records, I’m appalled. I’m like, okay. Yeah, that would stand up now- [Jaz]Because you’ve got the scars now, right? Because you’ve got the scars. [Gulshan]Exactly. [Jaz]And now you can criticize your former self. [Gulshan]Precisely. And if you don’t do that, which is audit, right? It’s you self-auditing and doing something to get better, to reduce your risk. So it’s risk management, basically. So it’d been on many of those courses. Now I’m in a position where I can teach it and look at what we are doing now, right? This is me through you helping other people mitigate their risk in clinical dentistry by saying, listen, there’s dos and don’ts and there are pain in the butt. Having to write reams of notes. So for instance, yesterday I did a 10 hour clinical day. I then spent two and a half hours afterwards at home writing up all of the records. Right. That’s crazy. But if you want to win the next case and the next case, because like you said, we all know they’re coming, right? This is not going to be my last case, right? Yep. We need to have that on our side. And if you have that on your side, and you can just dump that on the legal team and say, go guys, run with it. By the way, I’m not settling this one. Right. They’ve got some ammunition to fight for you. But if you don’t help them to help you, I’m afraid you’ve got to back down. And say, you know what? I’m going to take this one on the chin. Can you settle it for me without accepting liability? And then away you go. You carry on. But you don’t carry on the same way, Jaz. You’ve gotta learn from it. And you’ve gotta say, what did I do wrong or what did I not write down? Or whatever it is what courses do I need to go on? And off you go and you start learning and developing. [Jaz]And would you say Gulshan, one thing I feel is that then there’s all these composite veneer courses and fancy stuff, there’s not enough people going on these risk management courses, right? There’s not enough people going on the soft skills courses. [Gulshan]It’s not as sexy, Jaz. [Jaz]It’s not as sexy. [Gulshan]So what happens is, and I’ve been on these risk management courses and the kind of people that are on these risk management courses, they’re people that have been done already, right? People like me, people have been sued. People have been in front of the GDC, people who have been told by the indemnity organization, if we are going to get you off this right, you better be able to show you’ve been on this, this, this, this course. Right? Go and get the CPD certificate now. That’s what happens. So when you land up on these courses and you realize everyone around you’s got history and you can tell because everyone’s sad, no one’s smiling at these courses. And it must be difficult for the people that run them too. But you know what, they’re so, so important. It’s like when you get caught speeding. [Jaz]I was just going to say it’s a speed awareness course. It reminds me of my speed awareness course. [Gulshan]Speed awareness course, right. Someone I know went on one recently and said to me that what, it was enlightening. It was absolutely enlightening. [Jaz]I actually learned a lot from my speed awareness course. [Gulshan]Yeah. And this person who I’m talking about has been driving for about 15, 16 years, 18 years and said it was enlightening. It’s exactly the same when you go on these less sexy courses. So I was given a course here on Friday, and part of our course is a lecture on materials. And I said to my delegates, I said, when was the last time since uni you went on a course about material selection? No one does it. It’s not sexy. No one’s going to pay good money to go on a course to learn about materials. Right. But actually our feedback tells us from our day courses that we run, that’s the most popular part. So it’s about stepping outside of the box, thinking laterally about these kind of cases that occur, the kind of dentistry that you are doing and what you can do to mitigate your risk. Right. Because like you said Jaz, it’s going to happen to everyone. [Jaz]Mm-hmm. [Gulshan]So, I was told when I qualified from Birmingham that it’s highly likely that in your first X number of years, you’ll be sued twice or this many times. Yeah, it’s much, much harder than- [Jaz]The number I was told in 2013, Raj Ratan stood up and he said something like, you’re going to be sued five times your first three years or something. Complaint, like something crazy. And it was just at that time where the UK had become number one as a most literal, or number two, basically overtaking Israel or something at the time. [Gulshan]That’s right. [Jaz]It’s coming. And so, the key lesson we just shared just now is get those courses under your belt now, because it’ll make you a safer practitioner. But also when the proverbial hits the fan, not if, but when, it will also help you then as well. And just so I don’t forget, in the show notes, I’m going to put the phone number for Confidental, which is a charity. If you need emotional support, any point. These are guys who do great charity work and will help you emotionally, if you need it. Gulshan, can you just tell us, can you conclude the case? What happened at the end? How did it happen? And then, because you’ve shared already some lessons, anything else that you want to share in terms of lessons to people watching and listening? [Gulshan]So, the first thing is that when you get into a case like this and you choose to defend it, right? Because let’s say there aren’t so many vulnerabilities there are expert witnesses on your side. There’s lots of meetings to be had. So it got to the point and there’s several emails that I sent and saying, hold on a minute, why is this getting to court? Because literally legal documents are coming from court now to say this is what’s happening on this date, that day, and we’re getting deadlines from court. And I’m like, we’ve already told this person years ago to see some desist. So the lessons are that you don’t, once you get into it, you don’t stop and give up, because if you do, it’s going to get very costly. So once you are in this role and your indemnity organization is supporting you, you’ve gotta remember, other people have given up their time, money, and effort, right? So if you pull out, it’s a real slap on the face for them. So we kind of support each other. And, at the end of the day, they’re trying to protect my reputation. And the reason that we’re publicizing is to try and help other people know that you don’t have to roll over every time, right? So we go through and it’s getting to the point that there’s a court date, right? And I have to now give up three days of my life to be at court. I’m going to get examined, cross-examined. I’m going to be given evidence she’s going to be there. I haven’t seen her for years, you’ve got to know how to behave in court. You’ve gotta keep your composure, be professional, all of those things. And that takes some planning, preparation. Now, amongst other things, I’ve been to court several times as well. Pleased to say everyone, every single time, it’s not for everyone. It’s not for the lighthearted, right? [Jaz]Oh, I can imagine. [Gulshan]Not nice places to be. You only enter these things if you’re going to go all of the way. Right? Because if I said to them, yeah, I want you to defend this four and a half years, and then at the end. I choose not to go to court. Right? The whole thing falls apart, right? In this particular case, my own team had to subpoena me, which basically means I’m forced to go to court, right? I couldn’t say no. So that’s what they do and they apologize and they said, look, it’s a legal thing. We have to do this because you now have to it in court. And that’s happened to me in the past where I’ve had to give evidence in other cases and I really, really didn’t want to. But when they know you’ve got evidence to support that case and it’s make or break, you’ve got no choice. So that’s one thing is keeping your composure, keeping level headed. We’re all professionals and there’s many times in our careers when we’re put into situations where we’re outta our comfort zone and you’ve gotta roll with it. You’ve gotta have a support team around you. So the long drawn out answer to your question is having people around you, like you just said about Confidental, about emotional support. I couldn’t have done this without my support team at my practice, my legal team, their support, and at home. Because this stuff comes home with you. This stuff is in your head. You’re taking time out at lunch, before work, after work to be able to put all of this together. Um, yeah, it takes hours and hours to do. [Jaz]Because you’re so busy. You run a lab, you are so involved in education. You have a busy 10 hour days clinical practice, and then to have this on top, I mean, wow. Training. [Gulshan]Yeah. It’s my training, it’s emotional training. So I look at other people and I think, how the hell do they do this, that, and the others? Because I’ve taken on all of these other things in my life. So if you want to be a rock solid practitioner and be able to mitigate your risk of things like that, and sleep at night and have hobbies and blah, blah, blah, then you’ve gotta look at your whole big picture. You’ve gotta look at what’s common. You’ve spoken about work life balance. Mine’s messed up. Mine’s not great, but like I said, all of those people around me know me. They know what drives me. And actually I get bored very easily. So I’m not asking for more legal cases against them to stimulate me. But what I’m saying is that I need to be kept busy. So, because this case, in my opinion, my side was rock solid, I was able to roll with it. It’s when there’s vulnerabilities, Jaz. It’s when you know you didn’t say something, you didn’t give him an option, you didn’t write it down. Endo was crappy. You know anyone that sees it’s going to laugh at you. Yeah. You’ve got to just put your hands up and say- [Jaz]Acceptance and learn from it. [Gulshan]My bad. Yeah. [Jaz]Did you end up going to court then, Gulshan for this one? [Gulshan]No, it’s literally, what happened was they pulled out, so there was a deadline on this. This was just a few weeks ago. This was a deadline, a court deadline on the Tuesday that the other side and north side had to hand in the dossier. Right. So the court has to know upfront what all of the arguments are from each side because the court wants to know that their time’s not being wasted otherwise they fine you. The other side basically left it to the last minute. Tuesday morning was a deadline. Monday, four o’clock in the afternoon, they pulled out the case in time. That was it. So their vulnerability was actually their expert witness. Right. Their expert witness would’ve been taken apart by my lawyer and actually by me. My own barrister actually said that he wouldn’t want to go up against me. Not in this case, right? [Jaz]Yep. Yep. [Gulshan]I honestly know this lady from me treating her for many years. I form bonds with my patients, right? And that’s how they allow me to do invasive treatments for them, and they give me money for it, right? Yeah. People forget that- [Jaz]That’s a high level of trust involved to get to that stage. [Gulshan]Yeah, massively. I’m still, I’ll tell you shocked when someone comes to me for a full arch implant case and I’m like, wow, I’ve only met you three times and you let me just do that to you, and then you paid me for it. So, the level of trust is crazy. And I don’t know if I could do it. But these other people do, and this is what I try to get my team around me to appreciate that guys, these people that come and put their trust in us, pay for our lifestyles, pay for everything, right? So have some respect for the fact that they’re in this position. So it’s about looking at that bigger picture. Jaz. The other thing that made me angry about this case was that if the other practitioner involved in this case had just said, you know what, can you gimme a hand with this? I know she was your patient before, but she’s here now. Because I’ve done this for other people. Right. That practice and I have some history. And there’ve been some legal cases between us, so I’m not surprised. That’s why I believe this patient was kind of pushed towards- [Jaz]Spared on, you think? [Gulshan]Yes, definitely. Because it was all about money and what she had done by this other practitioner was the opposing full arch. And because the occlusion was totally messed up, hence early on. Exactly. [Jaz]Hence the cascade of events right? [Gulshan]Exactly. And we could prove that because we now had all of the records of all of the different practices, you could put together a timeline. And actually she was suing me for my implants that were in there for years. And they were successful, right. When the practitioner- [Jaz]And they’re still there? Also integrated? [Gulshan]Yeah. Some of them are still there. In fact, a practitioner that tried to take them out couldn’t get one of them out. Cause it’s so well integrated, right? But this other practitioner who spurred her on to complain about me. He placed multiple upper implants. I cleared the arch, put a full arch in there, right, immediately loaded it. They all failed, right? Then he went and placed more implants for her, and some of them are okay still, but this is what I don’t get. My implant was still there, but because of things that were said to her outta context, that’s where the problem is. So I suppose in closing, talking about this case, what I would say is, whether you’re an associate or a principal, whether you’re moving around practices, what’s most important is making sure that your patients stay with you, right? Do whatever you can. So customer service, whether NHS or private, makes no difference, right? The longer they stay with you, the less likely you are to get a complaint and the more likely you are to get the opportunity to fix things if it goes wrong, right? [Jaz]Mm-hmm. [Gulshan]And the first thing is saying, sorry. In one of my lectures, I talk about dentists and technicians and their egos. Right? And you know what? Even if you haven’t done something wrong to say, I’m sorry about the way you’re feeling, you mentioned Roger Rutten been to many of his legal lectures, and you don’t necessarily say sorry for what’s happened, but you definitely say sorry for the way they are feeling.Or have been made to feel that goes a long way to diffusing the situation. Now sometimes we’re given that opportunity, other times we aren’t. Right. In this particular case, I could show you emails where we said, ‘Hey, sorry you’re having trouble, but we’re here to help.’ [Jaz]Yep. [Gulshan]She just didn’t want that help. What she wanted was money to pay for the full art she had done somewhere else. See what I mean? [Jaz]I mean, what I want to know now is the last thing is those three days that you had booked off, please tell me you enjoyed yourself. You opened some champagne and you, you went away to, to, to, to put this behind you. Don’t tell me you went to work and you- [Gulshan]So the champagne was opened on the Monday night. When I got the news, it was an email late in the afternoon. I was with patients. My practice manager called me down and said, you have to look at it. You have to. I was like, oh my God, what happened now? And I go down and the lawyer sent an email and the subject line was in capital letters so that we didn’t miss it. And yeah, he said it all, and the relief Jaz, I just literally collapsed into a chair. And I was like, oh my God. I called all of my team. Whereas, a small to medium sized team, I called everyone. We opened the email together and read it. And yeah, I was just relieved. It wasn’t a problem having to go to court. That was a Monday, the following Monday would’ve been in court. It wasn’t a problem for me going to court in this matter. Right. Because I knew the case, it was hassle. Right. So, yeah. My days were blocked. The girls opened them up. Yeah. I’m afraid. I did go to work. I think one of the days I might have even gone to another practice and helped another colleague. But yeah, I had plenty of time to celebrate in between. [Jaz]I hope you did. And, I really appreciate you making yourself vulnerable. Oh, guys, we have to appreciate and salute Gulshan here because he’s sharing his story with you. How many other people are stepping up to share these stories? Okay. Not enough. And you’ve shared these lessons, you impart in some lessons. I really appreciate you, you giving your time for this and energy for this. And I really hope that this reaches all the dentists, whether they’ve been never been sued before, or they have been through it. Because I think there’s so much we can learn as a profession. And you’ve inspired me, Gulshan, to get some more guests on about risk management. I want to do more risk management kind of episodes to help our professions. And I have much to learn myself as well. So, Gulshan, how can we reach out to you? Please tell us about website, Facebook, all that kind of stuff that people want to connect with you, learn more from you. [Gulshan]Generally social media. So Facebook is where I’m kind of most prevalent. I’ve got various pages on there, but just search me up, send me a message. I’ll get messages from dentists and people in dentistry worldwide. I don’t need more of them. I see them. And- [Jaz]You run a few Facebook groups, don’t you? [Gulshan]I’ve got three Facebook groups with thousands of members, they’re all kind of focused towards digital dentistry, I’m afraid to. If that’s not your bag- [Jaz]We’re going to be talking about that next anyway, so if you want to learn more about digital dentistry, then we’ll tell you about those groups. But yeah, do reach out to Gulshan, please thank him. Please, if you found value from this episode, Please. Do you know you spent an hour with us there about, I think this deserves a thanks from our community. So, from Protruserati to you, Gulshan, thank you so much for sharing your story, my friend. I’m really, really pleased for you. I’m really pleased that you had the conviction yourself to fight this for encouraging your defense IT. And yeah, hats off to it. NPS, thank you NPS, for allowing this to happen. I think that’s credit where it’s due. [Gulshan]Absolutely. [Jaz]And I hope that wherever you are listening to this, if you’re going through a rough patch, I hope you get some inspiration from this. [Gulshan]Thank you, Jaz. Thank you for the opportunity and yeah, absolutely. Colleagues out there, several have already contacted me privately and didn’t want to talk about things publicly, but I was utterly shocked in the first 24 hours of putting this message out that had been successful in this way in the first 24 hours. I’ve got over 500 likes and comments. It’s still going up. It’s over 700 now. And yeah, it just shows that firstly, people actually occasionally read my posts, which is great . But also the fact that it rings true with so many people that they know that there’s this risk out there. And yeah, for years I’ve been talking about helping people to reduce their risk in political dentistry. Yeah, I put it out there. Feel free to contact me. Thank you, Jaz. Jaz’s Outro:Amazing. Thanks so much. There we have it. Guys, thanks so much for listening to this very special interference cast all the way to the end. If you like my non-clinical episodes, please do give it a rating on the podcast app that you’re listening to, or if you’re watching on YouTube, give a thumbs up to say that it made it to the end and I gained value from that. And please say thank you to Dr. Gulshan Murgai. Putting his head above the parapet, showing up, turning up. We have to always appreciate people who turn up and represent our profession in the way that he did. So thanks so much Gulshan for sharing everything that you went through, and I hope wherever you are listening, if you’re going through a rough patch right now, let it be known that it’s a group of colleagues that are here to support you. And if you need any support, please do click below in the show notes or scroll down and see the phone number for Confidental who are in charity that can help you so you don’t have to suffer alone. We are a community of dentists and we want to look after each other’s mental health. So please let it be known that you are not alone, my friend. I’ll catch you in the next episode of the podcast. Thanks so much for listening all the way to the end.

Being a dental student is tough – you’re learning a clinical and surgical discipline alongside all the challenges of relationships, studying and social interactions. In this episode with Dr. Lincoln Harris, we talked about three key themes relevant for dental students: overcoming fear, leveling up your skills, and being able to cope with failures. https://youtu.be/sl3CcLJYQUk Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “You only get confident once you DO the thing that you’re afraid of” Dr. Lincoln Harris. Highlights of this episode: Students pursuing growth vs Students enjoying uni life 12:07 Overcoming Fear 16:44 Coping with Failure 26:01 Discovery throughout Dental Career 31:36 For Dental Students who want to have a head start in their Dental Career, join us LIVE on Friday 30th of September with Dr. Lincoln Harris. Register Now! For Dentists who want to see Lincoln Harris LIVE in London for a full-day keynote lecture: From Class 1 Composites to Complicated crown preps. Email or DM us on Insta for a super special student rate. Check out Ripe Global, one of the biggest groups in Dentistry with 80,000+ members! If you enjoyed this episode, then do check out this 5 Lessons from Dr. Lincoln Harris  Click below for full episode transcript: Opening Snippet: The reason that failures hurt so much when you're a new grad is because you always think it's your fault. And you think it's your fault because you're no good. Jaz’s Introduction:This episode is specifically for dental students. So if you’re a dental student, keep listening. If you’re a dentist, I think you’ll actually still gain a lot from the latter parts of this episode. Who doesn’t love listening to Lincoln Harris after all, but if you’re a dentist and you haven’t checked out some of the big episodes, we’ve had this year, like Basil Mizrahi on Shell Crowns, we’ve had Ed McClaren on Ceramics, and of course, the other Lincoln Harris episode on Retraction Cords, do check those out, if you haven’t already. They’re huge. But if you’re listening today, about three things we wish you’d known as a dental student who wants to improve, who wants to no longer be scared, and who wants to be able to cope with failures, then this is the episode for you. Thanks so much for listening wherever you’re listening from guys. My name is Jaz Gulati. I’m the chief Protruserati and I’ve got Lincoln Harris, again, to talk about all those things I just mentioned, essentially about all the things that are all emotions I had as a student, so I want to help you guys out. So just to give you a bit more information about the three main things we’re discussing today is upskilling as a student, because what frustrations I had was that, as a student, you are just learning the basics. If you can just get the very, very, very basics correct, then the rest you can build on. I was really hungry as a student, I really wanted my composites to look nicer. I really wanted to know more about occlusion. And I just felt as though I didn’t have the access now. Now in this world we live in in 2022, with Instagram and etc. The education is everywhere. It’s actually amazing. We had such little to learn from when it comes to the big bad world of internet, when we were students, you guys, you students have got so much at your disposal. It’s actually amazing. But it’s also a little bit confusing and it can be a bit scary as well seeing all this dentistry on social media. And you can’t even take a bloody impression. And I know I’ve been there, right. So it’s one of those tricky things, which poses its own unique challenges. I mean, I think you’re in a far better position than I was, as student. I think it’s great that you can see what’s out there. It’s great that you can pick up tips from all these educators posting great stuff, great cases online for you to learn from. But at the same time, don’t forget that you’ve got your whole career and to enjoy your Uni time. So you talk a little about how I felt at that time, and how I want to do the course and my dental tutor at the time discouraged me from doing it. I’ll talk a little about that. Then we talked about overcoming the fear. Like I used to be really scared of giving ID blocks. I used to be scared of Crown preps for sure that just scares me the most. In fact, specifically with Crown preps, the thing that scared me the most was breaking the contacts. That was the most scary thing I could do during crown preps and then coping with failure. Like as a dental student, it’s funny actually, one of my mentors, Michael Melkers taught me is that one of the things we don’t get to experience as a dental student is failure in a way because you don’t get to recall your patients. So you don’t see those failures, the kind of failures you get are instant ones, ie failed extractions, failed temporaries, etc, etc. But you don’t get to see the real hard hitting failures a few years later. So it’s interesting when we talk about failure, but I suppose as young dentists, when you have failures, it really can cripple you. So Lincoln does a fantastic job of covering this. Now Linc is actually coming to London, 30th of September, and the 1st of October. Now 30th of September is an evening lecture just for you guys, students, whether you’re in Bart’s, King’s, or if you’re anywhere in the UK, or Europe, and you want to come to the free event on the Friday night, I’m gonna put on some pizza for you guys, then come on over. It’s an evening lecture, the way you can book that is if you go to protrusive.co.uk/students, it will take you to a blog post for this episode. And then I’ll put a link awakened by the ticket for nothing. It’s a free ticket, by the way, for the Friday evening. So you can come and join us and Linc will be there to talk about from graduation to a great career, what are the important things that are going to define your career in the future and how to maximize your time now. And then on the Saturday, it’s a huge event, there’ll be dentists coming from all over the country. And guess what, guys, you guys can come free. Now the Friday night is open to all students, the Saturday event priorities being given to fourth year and fifth year students because it’s just more clinically relevant for you guys. And so Ripe Global are sponsoring your ticket. What you need to do is get in touch, DM me, your student president should have already emailed you, all of this but if they haven’t just DM me on Insta @protrusivedental, and we’ll send you a linked typeform to fill in. And then that will eventually confirm your place so you can come on the Saturday. It’s a full day lecture at the Guys campus in London. Come and join us for both if you can. We get to see you guys and meet you and it’d be nicer for you guys to see what Lincoln has shared with you on the day as well. So I look forward to seeing some of you then. But anyway, let’s join Linc and talk about all these important things, all the struggles as students and how to overcome them. Main Interview: [Jaz]Lincoln Harris, welcome again to the Protrusive Dental Podcast. How are you my friend? [Lincoln]Very good. And thank you for having me. It’s an absolute pleasure to be on your podcast again, so. [Jaz]Linc, you absolutely blew everyone’s mind on episode 54. If you haven’t, if you guys haven’t listened to Episode 54 yet, five lessons with Lincoln. I love that theme because it was five lessons that I’d learned from you. But I wanted the whole world of dentistry to know and that was a huge hit. It’s probably up there in the top 10 episodes actually They have all time. So it’s a Masters of anyone. Linc, we were just having a chat briefly about education going forward, the one of the things you’re doing with Ripe Global. For the few people who listen who don’t know, you are, I don’t know, as anyone who doesn’t. But please, may perhaps some of the dental students coming through discovering this big world of dentistry. Who are you? And what do you stand for? [Lincoln]I’m a general dentist, and I work in a very small village in Australia, so and that isolation in that village has actually really shaped my entire career, it has forced me to learn more complex procedures, because I don’t have specialists nearby. In fact, I have an orthodontist, and no other permanent specialists of any sort within two hours drive. And so forcing me to learn sort of, I guess, more comprehensive and advanced procedures purely because my patients didn’t always want to travel two or three hours every time they needed to have something done. And then that led to teaching and teaching led to learning things on the internet, because it’s so far for me to go anywhere. And that has led to what we do now. So Ripe Global was really founded on the idea of giving people open access to really high level education. And to this day, we are the leading company in the world to deliver cloud hands on training of any sort, in any field, we were the leading provider of cloud education. So that’s where I am in a nutshell. [Jaz]That’s absolutely mind blowing. And for those who do know, Lincoln will realize that the way you answer that was extremely humble. I mean, you are the best in my opinion, and not just my opinion, pretty much most of the Dentists I know, you ask them, ‘Okay, who’s number 1 dentist in the world? Linc, whether you like it or not, like to hear this or not, they will say you, okay? And I certainly do. So you are someone I’ve loved enjoyed learning from over the years, your philosophies and how you make things tangible, your diagrams that you share on the Ripe Global Facebook group, it’s completely transformed how we learn and when, in fact, actually, next week, I’m doing a talk about social media and dentistry. And one of the first things I’m gonna talk about is how social media has enabled dentists from all over the world, every corner, to be able to learn from mentors that are remote, and our journey of learning has really expedited. And I’m gonna mention, the very first exposure I had was from your group that you set up showing full protocol photos, that for me change the game from before and after, to full protocol. And that was absolutely massive [Lincoln]We started that because at the time, there was lots of before and after pictures, and what people had learned is that if you showed the preps of your case, then you got criticized for prepping teeth. And so that if you just showed that before and the after, and you didn’t show the preps, then you didn’t get criticized. So all over the world, people were hiding their preps, and people would give them a lot of praise going, ‘Yes, lovely case. Lovely case.’ But it just wasn’t realistic. And so we were kind of all in denial that often to get a particular result that we really like you have to prep the teeth. And so and that’s really, I mean, that whole discussion about touching the tooth or not touching the tooth is actually people frame it as a clinical or a scientific discussion is actually a political one. It’s dental politics. And so more or less, you have like, you know, the left and right of actual politics and within dentistry, you have the left and the right of like enamel politics, really. So there’s another podcast for you. Enamel politics. We’ll cover that one next. [Jaz]I love it. Well, that absolutely shaped my career so far. All the course have been on yours and what you guys do with Ripe Global and I’m proud to be one of the educators make some videos for Ripe Global, it’s a great community. If you guys if you haven’t checked out Ripe Global, check it out. It’s such a fantastic platform, what you guys are doing now with making learning accessible through the new model, the hands on model, but remotely just briefly describe that because that is very clever, what you guys doing very much pioneering dentistry before we get to three things we wish we knew as a dental student. [Lincoln]So we actually, for a long time I’ve been passionate about education ever since I wanted to go to dental school. And there was doubt about whether my family could actually afford that. And so access to education is baked into me because there was a period of my life where I wasn’t sure whether I could afford to escape my life with education or not. And so, you know, that obviously, as you know, I’ve been teaching in one form or another since 2006. So this is my third evolution of education, you could call it so I started out at like luxury conferences, which were silly. And then I went into procedural training in a traditional sense. And now here we are, and but what’s interesting is that my brother has been at the forefront of technological advances in communication for all of his career, and he spent a lot of time trying to help some of the biggest companies in Asia Pacific, learn to be collaborative, so learn to use technology to enhance communication where people can just communicate all the time. And he spent a lot of time with universities trying to convince them to be build immersive collaborative education. Education where the students talk, and the students and the educators talk. And it all happens all the time. In 2020, I thought, Okay, let’s start a new company where we make education far more accessible. So we will use the power of the Internet to make education more accessible. And we bet we still had a traditional model that was like videos online. And then we would build training facilities, you know, in the UK, and Europe and the United States and wherever, and we got investors to help us do this. And then, in the middle of COVID, my brother said, we’re taking the education closer to the student, but we need to take the education right into their office. And so then we basically worked out how do we build this. And so we’ve built simulation kits. And we have built a platform and we connect the two together. And we can teach hands on education while you are in your office, so you don’t need to travel. And the thing that’s really interesting is that the students, the dentists who were training, they learned faster, and it’s not a little bit, they learn to 50 to 70% faster when we train them on Crown preps when they’re using their own equipment in their office on our cloud platform on a live class, but it’s a lot on cloud than they do if they’re in a similar app. So it’s amazing, because pretty much if you have the internet, you can join our hands on class and get ultimately very intensive education that you know, and our students that their careers, their offices are going crazy. It’s an amazing way to learn. And just if we’re like really calculating about it, cost is about 70% less than traditional education because the biggest single cost with education is closing your office, and they almost never need to close their office. So that’s amazing. [Jaz]The two reflections on that is A) You can do it anywhere with an internet connection, reminded me of an Instagram post you made of you know, someone on the beach during a prep, we don’t know they’re on the beach until they zoom out. And that was awesome. I love that and how fast they’re learning. Well, we have proof because on the Ripe Global Group, we’ve got the first cohorts of the fellowship. I mean, amazing. Let’s name, Stephanie, her I mean, wow, the development we’ve seen from her from Piatt, from Brett, from all these guys on the fellowship and just seeing that the quality of Dentistry you producing is really inspiring. So on the topic of development, the first question I have for you is just rewinding to when I was a student, I was a fourth year student. And I remember how awful my composite looked like even then I kind of knew that okay, this you know, my lower molar composite looks nothing like a little molar. So I approached one of my tutors, and I said, Listen, I see this leaflet here, there is a composite course happening. There’s nothing really there for students. But for dentists first few years qualified, it’s a reduced rate of 185 pounds, should I go? I think might be a good investment for me to make as a student, I didn’t have much money, but I knew I wanted to develop. And my tutor said to me, ‘Listen, you’re a student go drink some beers, go enjoy, you can do this stuff when you’re qualified.’ And I look back and I resent that because I could have had a head start, I feel. So what do you think about that? Do you think my mindset was right that I should have perhaps pursued some education, because I really wanted it. And I really, really want to improve my composites. And that was the only way I knew how because my tutors. The proof was there, my composites wasn’t helping me to the degree I wanted, or should students just be chilling out enjoying their uni life while while they have it. [Lincoln]I don’t Far be it from me to tell the university student what they should do during university. But if you are interested in attending further education while you’re at dental school do so. In fact, we have quite a few students who do because so you have to remember that universities do a terrific job with the constraints that they have. And they have quite a few they have a lot of regulation, they have a lot of government demands on them. And they have a captive audience and a captive audience sounds great. But what that means that they have to teach the dental students who are enthusiastic, but they also have to teach the ones who are like limping over the line with their total least amount of effort possible. And so whereas when you teach, when I teach, the only people who turn up are people who are motivated enough to like do something voluntarily above what they have to and this is very different. So if you’re a person who wants to learn more at dental school, go ahead. I have, I actually have an American dental student who has signed up for my full two year fellowship before he has graduated, because he says I’ve only done like a handful of Crown prep, so I don’t feel confident and I’m about to be released into the real world. He has a very good theoretical grounding, and like a theoretical understanding how to do it, but it doesn’t have a technical, like, I’m 100% confident that I can drive my hand around something. And so he has done that. And we’re actually working on programs like that, you know, for new grads to make education very affordable. So obviously, I can’t talk about that yet. So that’s still coming, but that is definitely possible. And I think more and more dental students are realizing and we’re getting contacted from a lot of them saying ‘Hi, we want to finish our degree and then we want to go into high level education, post degree.’ And you go well, what can we teach the dental schools. Dental schools are teaching you to a regulated standard. And that means a lot of making like a lot of paperwork to prove that you have met some type of standard. And that’s, it’s a difficult job. I don’t have to do it so thankful for that. And I, you know, it’s easy to criticize them with skills, but they have to take the great unwashed and turn them into dentists. And then I get them after they’ve done their job. And they’ve done the hard yards. And then from there, I’m putting icing on top. So what can we teach from there? I mean, we can then go into things with a much more enthusiasm and specificity if you like, these are real world problems. Not the theory. But how do you actually do it? Like the theory of class two composites doesn’t help you when your rubber dam clamp has gone ping. And while you’re waiting for it to land on the other side of the room, you’re watching the blood well up from the gingiva that was inflamed. And you’re wondering how you’re ever going to restore this subgingival class two, you know, that the theory of that is not really well covered, and the actual practical, how do you do it? And then even more, so, how do you feel? But that’s not covered. How do you feel when this is happening? You’re feeling like really stressed. So how does that? How do you manage that stress and emotion? [Jaz]I’m so glad you mentioned the stress and emotion, what I heard from that was that perhaps if I went back in time, I should have pursued what I really wanted. I was really keen I was executing, I should have pursued pursued what I wanted. And then of course, all these emotions took off when things aren’t going well and the daily struggles and when you’re a newbie, gosh, I mean that those emotions are heightened like you know my routine days now. I can only wish my days now, as I kind of coast sometimes your crown prep. I remember when I was scared of Crown preps. So my next question is about fear. Fear to prep, fear to extract, fear to give a something you talked about giving a palatal injection, giving an ID block. I’ve been through those phases, and eventually you lose that fear. So what advice do you have? Or lessons do you have to give to Dental students who are feeling that fear? How can they overcome the fear that is procedural? [Lincoln]So there is more or less the whole process of teaching is an exercise in fear management, because mostly what is holding us back it’s actually fear. And I need to stop at this point and point out that I also am afraid. So I’m afraid of different things now to what I was when I was a new graduate. So I’m not afraid of doing an injection or class two. But I was when I graduated, I was very, you know, like, I can’t remember how long it took it might have taken 10 years before I could just do local anesthetic willy nilly without being concerned about the fact that I had to do this nasty thing to the patient. But beyond that, there are some things that you can do. Now, in Ripe Global, we have spent a lot of time not only on the technology platform and the simulation kits and the collaborative communication between all the students and giving them a community that safe that they can help each other through their journeys. But we have also put a huge amount of effort into innovating and how to teach the way that most people teach is not necessarily the most effective way to be taught. And so if you look at that, why doesn’t it work? It doesn’t work, because it doesn’t take into account a thing called human factors. Now human factors is the effect of how you feel on your ability to perform. So if we look at that, what things affect how you perform? Obviously, we know that if we’re tired, we can’t perform as well as if we are not tired. We know that if we are stressed, you know, we know that stress makes us perform worse. And we know that fear makes us problem. So all of these things affect how we perform. And so you can do things about that the first one you can do is you can have the right type of training. And I’m not talking about theoretical training, I’m talking about training, that builds your skill that will actually make a huge difference to your fear. So like to give you an example, most courses that teach you how to do a crown prep, you do like occlusal reduction in the morning, and then you do mesial and distal cuts in the afternoon. And by the time you finish the day you have done one crown. Now almost none of us have eight hours to do a crown. We mostly have like 30 minutes, one hour, an hour and a half. And so we don’t do that. When we do our crown prep training, we do 17 in one day, we don’t stop for lunch. We stopped for like 10 minutes, because that’s what real dentistry is like. So we it’s not a simulation if it’s nothing like the real thing. So simulated training exercises can be significantly helpful to reducing your fear because you need to have the ability to do a procedure far in excess of what’s required so that when you are stressed you can still do it. So like if you can only just do a crown prep, when you’re relaxed, you won’t be able to do it under stress. That’s just because your stress levels, stress levels reduce your performance by up to 85%. So you need to have like this massive reserve of skill and competence. So that when you are stressed, when your ability to reduce, you can still do it. And so the one is the right type of training. Now most people don’t focus on human factors training. In fact, I think almost no one does, we do, because we’ve done the research into it. And so one is this highly intense simulation training, that helps a lot. The second thing is, there’s a whole bunch of mental things that you can do to help keep your mind clear while you do a procedure. One is the boxes, which you will have heard me talk about a lot of times. And I won’t go into that, but only doing your procedure in small chunks. And so a lot of the ability, like people focus on the theory far too much. And actually, our controlling our mental state, and having ourselves trained to a skill level far in excess of what we need is the way that you reduce stress. And that’s, you know, we’ve built a whole program around helping people get past this. And also you have to support people emotionally through confronting their fears. So you can’t just go okay, here I’ve taught you now go like, then they get to the first page and go, I’m afraid, which is normal. And you have to have that support. That is normal to feel afraid. And you’re not going to feel confident until you do it. Like people think there’s some secret to feeling confident before you do something that you’re afraid of but there isn’t. The confidence will only ever come after so yeah, that’s it. It is what it is. [Jaz]I think we’ll all, I think everyone listening, all the students, young dentists listening will take satisfaction, I guess, or there’ll be a little bit happy to know that you’ve been through the fear, I have it, we all have had it at some stage, whether it’s the first ID block or whatever. And I think the key lessons from what you shared there were, for example, an ID block, it really helped me to revise the anatomy again, and then get opportunities to practice it. So opportunities whereby I could get away with the buccal infiltration. Actually just do the ID block with some support might be a good way to go. or less, like you said about repetition. So if you’re a student, because I’m gonna probably get really tangible with students here, yes, watch all the videos in , log on to Ripe Global, see the preps on the forum and whatnot on the Facebook groups, but then find that dedicated couple of hours of space in the mannequin head room as a student and just prep prep, prep, prep prep, and get that muscle memory going. Don’t worry, I mean, yet, obviously do the theory. But try and get some sort of hand skills going to get used to prepping and prepping. And then on the day when you’re performing, it’s going to help you a lot and having that confidence that ‘Okay, I’ve just prep 17 of these yesterday.’ [Lincoln]Yeah, like. So I think a very important thing is to literally sit down. So when I say that I’m still afraid. The things that I’m afraid of are different, but don’t think that I have less, I feel afraid less often like building a company with investors is scary. Trying to develop a new way of education is scary. All these things are scary trying to move at the same time as all that building my office from a one dentist office to a three dentist office whilst I was doing the other thing that is scary, like literally, you know, at times terrified to the point where I can hardly copem, okay? So it’s not like the fear goes away unless you no longer progress. So if you are progressing, you will be afraid that is just a fact of life. But a good exercise to do is to sit down and go what am I afraid of? Don’t skirt around the side of the issue and go Well, no, I’m not afraid of anything. But then you actually are. Like literally sit down and go, ‘I’m afraid to do injections. Well, I’m get stressed about crown preps or whatever, root canals, okay? I mean, it took me 15 years before root canals felt easy. So you write down those things that you’re afraid of and then conquer them. That is the only way otherwise, it’s like the boogeyman under your bed. Okay, you’re lying there in bed and you go, maybe there’s a boogeyman under my bed. Now, you can do one of two things at this point, you can hop out of bed and look under the bed and you will conquer the boogeyman because you’ll see he’s not there, kay? Or you get too afraid to look, because he might bite me when I look under there. And so you lie there all night awake. And while you’re lying there, the boogeyman gets bigger and scarier and has bigger teeth and longer claws and by the time you wake up in the morning, okay, he is like the most scary thing ever. And so, and then daylight comes and he goes away. And so your fears about dentistry are the same, if you avoid them because you’re afraid they get bigger. So don’t avoid them, right? Like the problem is that sometimes we don’t realize we’re afraid and we’re subconsciously avoiding them. So like conquer those fears. Write them down, because I can absolutely guarantee you. Your confidence is only ever found on the other side of that fear. You never get confident first, and then the fear goes away. You only get confident once you do the thing that you’re afraid of. That is a universal human trait that you are only confident like, how am I not scared to public speak? Was I born this way? No, I was terrified. My knees used to shake. And now I’ve done it. And now I’m not scared. So the confidence was on the other side of the fear. I had to do the thing until the fear went away. [Jaz]On my public admission here, students, anyone listening, dentists, I am afraid still of Cobalt Chrome dentures, I just have done so few of them in my career, my demographics. So that’s my fear. I’m putting it out there. I’ve made it public. And guess what, I’ve got a fit next week. And I’m looking forward to it. So that’s I’m gonna get around it. And I had like a one hour mentoring session with one of my prosthodontic colleagues guiding me through it. Even though I’ve been qualified some years now. I still had that fear of something that you know, you think a denture is a denture but depends on how much exposure you got. I lost my fear of extractions a good while ago, since I got improved at sectioning and elevating, that was a big game changer. Loads of great tips that Linc shared on just general improving your extraction technique as well. So do check those out. Next theme is failure, how to be comfortable in your own skin with failure. And I’ll give you an example, which is not quite a failure on my part. Literally two weeks ago, I saw a gentleman root canal of his upper right canine everything was done. Yeah, it was necrotic, little bit infected. Everything was procedurally fantastic, use all the best stuff, rubberdam, hypochlorite. And then, a few days later, he’s in absolute agony. He has been taken to hospital, he’s had blood tests and whatnot. They can’t find any sepsis. But they find his inflammatory markers really high. He is just an agony. The hospital staff don’t know what to do. His because you’ve got some learning disabilities as moms on my case, his mom’s on the hospital’s case. And I was worried, I was generally worried for him because he was suffering so much that he was in a maxillofacial department hospital. But for me, even though the procedure was in success, it kinda was a failure, that he had so much post operative discomfort. And to this day, I get sleepless nights sometimes, and that kind of stuff, something like that one of your patients suffering because something you did, even though I would have done it the same way 100 times, there was nothing I could change about that. It’s just Sod’s law I think I generally think that after, I’ve speak on some endodontics, as well for, for clarification, it still bugs me to this day. And I guess when I was, you know, 5, 10 years ago, even the simple thing like a composite, crown coming loose that I done or something like that, it’d be like, Oh, my God, I’m getting major anxiety here. So when you experience some sort of failure, how can you cope with that? Because when you’re younger, and you don’t, you’ve had very few failures, because done very little dentistry, they really hit you much harder. [Lincoln]The reason that failures hurts so much when you’re a new grad is because you always think it’s your fault. And you think it’s your fault, because you’re no good. Now, I’m going to confess that I probably get the same number of failures in a month now, as I did when I was a new graduate, miss a few reasons for that. One is that the cases I do are much more difficult. I push the limits of dentistry probably a bit more because the cases are difficult. And also because the volume of cases I do is much greater. And the number of cases I have that are 20 years old is also much crisis. So just like pure statistics is going to bite me so but I get stressed now because I know I’ve done a good job and that sometimes just things happen. [Jaz]It’s a bit like that root canal I told you about, you know, if that happened to me, when I was just a dental student, or one or two years qualified, I would have completely been like, ‘Oh my god, what have I done that was all me.’ Apologizing profusely to the patient. I was still apologetic. ‘I’m sorry, this happened to you.’ But in my own skin, I was comfortable. That ‘Hey, you know, this wasn’t my fault. It’s one of those things.’ So you know, I definitely agree with that. [Lincoln]Look, there’s a lot of people also, like the last thing they do to you, just before you graduate is tell you that you’re going to get sued. Like usually like the people come from the Protection Society or whatever. And they go, right. Now, let me tell you about a person. He did a perfect filling, but they got sued and went to jail. Like this is like the last bit of advice you ever get as you graduate in almost every country. And it’s like, it’s so unnecessary, because the first thing is that almost no one gets sued in their first few years. Like me, it probably happened somewhere in the world. But the indemnity, there’s a reason why you get charged less for professional indemnity in your first two years than in your later years, because your first two years are the lowest risk for any sort of claim or complaint or anything like this of any of the years of your life because you’re not going to do anything complicated that’s going to be a massive problem. Like I mean, the chance of you putting a implant and then having it fall into their sinus and then you have to do surgery to get it out of the sinus in your first two years is vanishingly small, like because you’re probably not going to do implants in your first two years. And the first, the chance of you doing like some massive smile makeover and then they go to another dentist who throws you under a bus is also quite small because you’re generally not going to be trained to do this. So the fear of being reported for a crime against dental humanity is quite low in your first two years, so it’s probably more than unhelpful to have those lectures just before you graduate. Second thing I would say is that things just go wrong. Like, go home and try and bake 100 cakes in a row, and have all 100 workout, it’s impossible. Like, it’s just the law, it’s just the bell curve. The bell curve doesn’t allow everything to be perfect all the time. If you select 100 Random humans off the street, what’s the chance that several of them are going to have some sort of quite complicated disease? Very high. So it’s just statistics. Yes, your do a crown and it’ll fall off. I mean, I did a crown three months ago, and the patient had sensitivity, I had to cut the crown off and put a temporary on and then like, it wasn’t my fault, it was just the tooth. So that’s why failures will hit you really hard in your early career because you actually doubt that you’re any good and you doubt that you’re, you always think it’s your fault. [Jaz]That’s the crux of it. I totally agree. [Lincoln]And sometimes it is your fault. But like, you will continue to make the mistakes through life, I still make mistakes, it’s just that like, it’s not the same mistakes, it’s just different ones, you know, like I have a patient at the moment where I probably should have pulled their teeth out and done implants. But I decided after doing a course on saving teeth that I should save the teeth, and now it’s just so hard. I’ve done so much work to save these teeth. I’d be finished, if I’d done implants, I’d be finished six months ago, [Jaz]I can actually think of a very similar case right now. Anyway, Linc you’ve covered these main themes, I’ve got limited time with you today, we’re gonna bring you back on to discuss all the difficult stressful things that we do in dentistry, subgingival dentistry, difficult isolation, how to see difficult patients, we’re going to cover that theme as well. But if you can just give us one more lesson you want to give to a dental student that’s going to help them to want, to make perhaps make a realization make a discovery that’s going to help them throughout their career. [Lincoln]Okay, the number one thing I would say to dental students, and this is not a negative thing. So don’t think of it like that. Dentistry is much more difficult than you think. And the reason this is important to understand as a dental student is because when you’re a dental student or a new grad, you think that dentistry is difficult because you’re not good. Because you’re not good enough, you’re not trained, your skills are not good enough, you don’t know enough. And if only you knew all these things, dentistry would become less difficult. And I can tell you that after doing many, many courses, and hundreds and or even 1000s of repetitions, that I’ve come to the realization that dentistry is a surgical specialty, as difficult as ophthalmology, but unlike an ophthalmologist, we are not trained to competence when we’re released. So if we’re an ophthalmologist, we will be trained for about another six years after we have graduated as a dentist before we’re allowed to enter private practice. So dentistry is a surgical specialty. And but unlike every other surgical specialty, we are released, basically with the most basic training we’re not. Yeah, so it’s very difficult. And so when you go out and you’re going by ‘Oh boy, this is hard.’ It’s not because there’s anything wrong with you, you’ve just chosen a really difficult thing to do for your career, and it will get easier, it actually won’t get easier, it will get routine. Routine is the word you use for when something starts to feel easier, even though it’s technically very difficult. So that, you know, the rough timeline for myself. It was two years after I graduated before I could use a dental mirror without my hands still going the wrong way. It was probably five years before, I didn’t feel an urge to see what patients were in the book tomorrow so I can mentally prepare myself for them. 10 years before I could roll into work, knowing that I could just cope with whatever the day threw at me. And at 15 years, I woke up one day and I said, I think I’m actually good at this now. But that’s how hard it is. It took me 15 years before I felt good at it. So you know it is a very difficult technical profession because it is a surgical specialization, which is not recognized as one by most of the population. [Jaz]Amazing. It is not a race. Take time. So great to hear those numbers from you and your own story of that. I think everyone needs to hear that. Don’t worry if you feel like you’re really struggling because it’s super, super difficult. When we talk next time, when you come on the podcast, we talk about those really tricky daily conundrums, you know, not Instagram dentistry. What happens behind the scenes of the Instagram dentistry is what I want to talk to you about. So I look forward to bringing you on for that. Linc, as always a pleasure to have you on. I look forward to speaking to you again. Now, Linc really special thing that I know you’re doing is you’re coming to the UK, you come to London, you’re really speaking to dental students so I’m really excited for you to come and speak to dental students. I’m gonna make it very clear on my social media and the email list protrusive.co.uk/emails when I sign up about how to get involved and meet Lincoln live and we’ll put on some drinks and stuff and a few lectures, followed by a full day course as well which students will be invited to which is absolutely crazy. What are you going to talk about on that Friday evening? [Lincoln]So the Friday night when I talked to dental students, I’m going to talk about your career. The title is from class one composite to first class career and, and the stages and some of the things you’re going to have to battle to get through and make a great career. And you can make a very good career in Dentistry, there’s no doubt about that. It is not easy. And there is, it takes courage, because it’s pretty scary. But that’s what I’m going to talk about is how do we go from our, because it’s very, you know, to some extent, it can be a bit dispiriting when you graduate, because you graduate, and you sit there and you look at the tooth, you’ve just treated and you go, that looks rubbish. And then you open Instagram, and you see, like a tooth that looked like a nuclear holocaust. Okay, you know, it looks like a nuclear wasteland. And then the dentist has sprinkled fairy dust on it. And it now has all of its fissures, and it has tertiary anatomy on the composite and all of this stuff. And you look at it and get that like I don’t even, I can’t even comprehend how that is possible. And so that can sometimes be a little bit hard, like a little bit depressing. And so, and then like, even from a financial point of view, you’re a dental student, like you’ve just graduated, you don’t have any money, you’re got a terrible job, usually, your first job is going to be your worst job. And your boss has probably signed you up on some abusive contract. That’s usually what happens to new grads, because of the only people who fall for it. You know, like everything kind of, you know, you graduated with all this optimism, you’re gonna go into this great profession, and you’re gonna be like rolling in money. And then next thing, you’ve got a terrible job, you’re doing a million checkups a day, and you get all of the cases that the boss doesn’t want to treat. And then the boss rolls in, in his like, you know, Porsche GT3, that was just got back from racing, and your car has broken down and you have a repair bill. But the reality can be pretty hard when you graduate, and so it can seem an impossible chasm to cross. So what I’m talking about is how you cross that chasm. And it’s a pretty simple process. It’s not easy, but it’s simple. And why the chasm is not as big as it looks, it looks a lot bigger than it really is. And it’s not as big as it looks. And there’s reasons why it looks so big to it. So I’ll be talking about you know, basically how we start as a baby dentist, where basically we graduate with optimism, suddenly everything’s a bit rubbish. And then how do we get to a place where life is actually pretty good in a sensible way, and the sorts of thing the challenges that we will encounter and most of those challenges up in our head, not anywhere else. [Jaz]I love it. I love the theme and I think it’d be a great event to involving for dental students in the day after I’m a tease everyone a little bit more about that another time. But Linc, thanks so much for getting time I know you gotta go in the numb up the patient and then do the complex restorative dentistry whatever you’re doing. I look forward to seeing the case unripe. Thanks so much, Linc. [Lincoln]No worries thank you so much. Absolute pleasure to be here. Thank you. Jaz’s Outro:There we have it guys hope you found some value from that. Look if you’re dental student, let’s share the love, right? Send it to another student who hasn’t heard of Protrusive before and hasn’t found this episode. You’re going to help your colleagues and hopefully some of you can join us in London. So remember, go to protrusive.co.uk/students find the link, there’s two links there, one for you to book for the Friday night for free. And Saturday. You can also come free if you’re fourth and fifth year BDS. And I will sponsor your ticket. And you can learn from one of the best dentists in the world which Lincoln Harris so we’ll see you in London. But if you can’t make it then thanks for listening to this episode all the way to the end. I really appreciate it and if it’s the first time listening to the Protrusive Podcast, check out some other ones. I mean, some episodes may be a little bit too advanced for a student but there are some other fundamental episodes which I know you can gain so much from. So if you enjoyed it follow @protrusivedental, say hello, I like connecting with my listeners and watchers, and I hope to catch you in another episode soon. Thanks so much