Protrusive Dental Podcast

Are you living your career by design—or just letting it happen to you? Do you know what your ideal day as a dentist looks like? What about your ideal week? In this episode, Jaz is joined by Dr. Andrea Ogden to explore how you can design a career—and a life—in dentistry that feels purposeful and fulfilling. They dive into why many of us get stuck on autopilot, chasing goals we’ve never truly chosen, and how to break free by aligning work with your values.  Andrea also shares practical techniques to help you fall back in love with dentistry, so you can build a career that energises you—inside and outside the surgery. https://youtu.be/XDxlUFeEpbw Watch IC060 on Youtube Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 00:00 Teaser 00:21 Introduction 04:49 Guest Introduction – Dr. Andrea Ogden 06:05  Andrea’s Journey in Dentistry 08:51 Pivotal Moments in Dentistry 14:51 Trial and Error in Career Development 15:51 Current Role 16:59 Identifying Strengths vs. Enjoyment in Dentistry 18:18 Challenges for Young Dentists 21:51 The Importance of Career Awareness 24:05 Impact of Social Media 26:57 Understanding the Decline in Dentist Morale 31:51 External Factors Contributing to Stress 35:09 Internal Factors and Cognitive Dissonance 41:17 Practical Steps to Reignite Passion for Dentistry 47:32 Resilience Through Adaptation 48:59 Community and Support Networks 51:46 Enjoying the Journey 56:30 Outro Key Takeaways:  Dentistry is more than fillings and crown preps—it’s a career you can shape to truly excite you. Choose Variety & Joy – Build a mix of roles that energise you, not just ones you’re good at. Ditch the Comparison Game – Your journey is unique; stop measuring it against 15-year veterans on Instagram. Guard Your Values – Burnout often comes from a mismatch between what you believe in and where you work. Align the two. Create Space to Reflect – Slow down, think, and use SMART goals to plan your next step.  Find Your Tribe – Mentors, colleagues, and community will keep you inspired and resilient. Celebrate the Wins – Small or big, they’re proof you’re moving forward. Loved this conversation? You’ll also enjoy Passion and Values in Dentistry – PDP014 #CareerDevelopment #InterferenceCast #BreadandButterDentistry This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes  B: Effective management of self and working with others in the dental team. C: Maintenance and development of knowledge and skills within your field of practice. D: Maintenance of skills, behaviours and attitudes which maintain patient confidence in you and the dental profession, and put patients’ interests first.  AGD Subject Code: 770 – Practice Management and Human Relations Aim: To provide dentists with strategies, insights, and practical steps to rekindle passion for dentistry, align their work with personal values, and develop sustainable career satisfaction. Dentists will be able to – 1. Identify personal values and career drivers that contribute to long-term job satisfaction. 2. Recognise common stressors affecting dental morale and their underlying causes. 3. Apply structured decision-making frameworks (e.g., SMART goals) to career planning. Click below for full episode transcript: Teaser: There's a definite difference between doing more of something or because you are good at it and doing more of something because you enjoy it. You know your values are a compass. As to, you know, where you are gonna go in, in, in life. I think if you are listening to this conversation and you are really struggling, is that the first thing you need to do is you- Jaz’s Introduction:Hello Protruserati. I’m Jaz Gulati and welcome back to your favorite Dental podcast. This is the interference cast, like the nonclinical arm, but a very important arm of the podcast. One of the things that Andrea mentioned, is that when she was studying in dental school, that’s what it was all about. It was just about studying and becoming a dentist and passing your exams, and I resonated with that so much because our date was 6th of June. I knew that on 6th of June 2013, we were gonna get our results.  And I could not imagine life beyond the 6th of June. Like it was all about am I gonna become a dentist? This is what I’ve been building up my last sort of eight to nine years to do. Like I wanted to be a dentist since I was 14, but I couldn’t even think about the future and what it will actually be like to be a real dentist in the real world. Now, fast forward so many years, I have a lot of real world insight and I’d love to share it with you today along with Andrea. I love people like Andrea because they are all about helping us feel fulfilled in dentistry.  There are plenty of people out there who perhaps dentistry didn’t go the way they planned. They leave and now they want to coach you on your exit plan, which I understand, but what I don’t believe in is making permanent decisions based on temporary feelings and actually attempting to figure out exactly how to make dentistry work for you. Now, some things I didn’t discuss in the conversation with Andrea, because she was on a roll and I want to give her the space and time to talk about all the wonderful things, including the latter part, the end of the podcast, whereby she actually gives real techniques, is about five techniques she shares to help you feel more fulfilled from dentistry. But one thing I wanna just talk about while I have this opportunity in the intro is the following. Have you actually put pen to paper to write down what your ideal day actually looks like? Like you are actually allowed to have an ideal day. Have you thought about it?  I didn’t do this until a few years ago, and it made a big difference to my clarity of thinking and where I want to take my career. And the other one, of course is what does your ideal week look like? Once you’ve decided what your ideal day and ideal week looks like, then make that your goal, that’s your aim.  Why wouldn’t you make some decisions right now to make your ideal day and your ideal week become a reality. For example because I think examples really help. I’m someone who if I don’t exercise at least three or four times a week, I don’t feel like I’m living to my truest value. I become grumpy I don’t feel like I’m enjoying my life as much as I could be. And so I know in my ideal week I need that.  Now, I’ve had a few years in my career where that wasn’t happening, especially when we are building OBAB that was such a huge project. I had to wrongly sacrifice some health for that. But now I’m back on track. And so slotting that into the ideal week for me is really important, and you make it work and you make some key life decisions. And something that you do with your significant other, you decide that you design your perfect life how do you actually want it to look like, where you’re gonna live? What gym membership will I will have to make sure this all happens. And so it’s about living a life of purpose, allowing you to live to your truest values. And that was just one example of me making sure that I designed my ideal day and my ideal life to make sure I get to go to the gym 3-4 times a week. Another thing that was important to me is like I’m someone, I’m not good at multitasking. I think most, most of us aren’t, and we shouldn’t be multitasking. It’s better to focus on one thing, and I’m particularly bad and like sometimes I get distracted and I feel like really overwhelmed easily. And so when I’m in clinical mode, I’m in clinical mode. And because I love my clinical dentistry, it’s not a big deal for me to do a 12 hour shift. I know it’s not for everyone, but I’m more than happy to do an 8:00 AM till 8:00 PM if it means I can work less days. So for me that made perfect sense that I have a really long Monday and now I don’t have to work a Thursday anymore, for example. And this has only just come to fruition. It’s something that we agreed on about a year ago, and then we had to wait for my Thursday patients to diminish, if you’d like. And now I really consolidated my clinical days. This allows me to be in the zone on Monday. And whilst I don’t get to see my kids much on a Monday, I get to make up for it on the other days. because now three days a week, I get to do either school drop off or a pickup, or both. And the main point of sharing this detail with you, my friend, is that everything I’m trying to do is with great intention, it’s on purpose and it’s by design. And it doesn’t happen overnight. It actually took a discovery process first, and then you put your action plan, and you relentlessly chase that. And that ideal week may look different for everyone. But if you don’t decide what your ideal day or ideal week looks like, then you’ll never get it. If you don’t know where you’re going, how do you know when you’ll get there? Alright, that’s quite enough of my rambling. I’ll catch you in the outro. Enjoy, enjoy, enjoy this podcast with Andrea. Main Episode:So Doctor Andrea Ogden, it is absolutely a pleasure to have you on Protrusive Dental Podcast. How are you?  [Andrea]I’m very well, and I’m very excited to be here. So thank you so much for the invitation to come and talk to you today.  [Jaz]For those of you listening on Spotify, Apple it’s a sunny, beautiful day today in the UK for once. And Andrea’s looking bright and vibrant and that would really, I think be a great descriptor of some of the content I’m seeing from you, Andrea. And the top word I’d probably say is relatable. I reached out to you because I’m loving what you’re putting out to the universe. So much of the podcast over the last six years. Our tagline is Fall in Love with dentistry again, and I’m very much, when I do some speaking, I say, find your niche, find a way, and fight for it to make dentistry work for you. And everything you’re putting out there is just, I’m loving it and I think we can learn so much from you. And often with these kind of episodes, Andrea, I get so many messages saying, you know what? I really need that and that’s what I want everyone to achieve. And so to start with, Andrea, I wanna learn about your journey because you do reference your journey a lot in your posts and stuff, and I think you’ve got a really interesting one. So can we start with that, Andrea, and tell us about yourself?  [Andrea]Yeah, sure. I think if I’m gonna talk about my journey, it’s hard to kind of think, well actually, where do we start? And the reality is that I probably need to go back all those years to when I filled out that UCAS form, when I was doing my A Levels. And, I feel like there’s four places for the picked four random dental schools that didn’t really put a lot of thought into it. Just was like, no, I really wanna be a dentist. It’s the only way I’m gonna be happy and I’m gonna find fulfillment and achieve my potential. I sent the UCAS form off and I didn’t even get a single interview. So I was like, oh so it wasn’t like I got rejected, like not offered a place, like they didn’t even wanna interview me. So, I think when I look back at the fact that that happened and I went and did a degree in human biology and then applied again, I was successfully offered a place. But I suspect, in fact, I know that that failure right at the beginning, definitely played a part in many years while I was at dental school. There was definitely this fear of failure that I might not make it, that I wasn’t gonna graduate, that I might get thrown out. And looking back that was crazy because the pass away exams, but that fear was definitely there. And so for many years it was all about becoming a dentist, rather than giving much thought into what it would be like once I became a dentist. And so, that plus the fact that I don’t come from a medical or a dental background. I don’t have anybody to mentor me or explain the realities. I did a bit of work experience and obviously, you learn stuff where you’re at dental school, but I had no idea. And I think looking back at that time at dental school, I don’t have any memory of getting any careers advice or, even being given any kind of skills about the opportunities that are available to you once you have a dental degree. So when I graduated I think I was just kind of like, “Oh, okay, so now I’m gonna do what everybody else does. Which I’m gonna go and do well, it was vocational training when I did it, and then I got myself a nice little associate job and I really thought that if– [Jaz]MFDS and all that kind of stuff  [Andrea]Yeah. Did all of that, it was tick box exercise.  [Jaz]Yes, yes, yes.  [Andrea]Everybody does this, I must do this. And I really thought that what if you are a successful dentist, then you earned a practice. So I needed to acquire the skills that you need to manage a business, which you weren’t taught at dental school. So I was like, okay, so this is the plan, this is what I’m gonna do. And there were definitely a couple of key pivotal moments. The first one I remember when I was an associate probably, few years in as an associate. And I just had that moment where I was like, is this it? Is this what I’m gonna be doing for the rest of my working life? Being in this one room, working with a nurse and the patient and then I just had this sense. I had so many more skills and potential, that I hadn’t tapped into. And that clinical work in general practice alone was not gonna enable me to do that and to grow in those things. The second thing was when I had an offer accepted to buy a practice, and at the time I had a seven month old baby, I was driving, but this moment so clearly I was driving down the road, my seven month old baby in the back of the car. It just hit me how much additional responsibility I was about to take on. My husband’s not a dentist, my family aren’t dentists. There was that moment where I was like, hang on a minute just stop and think about this. This might not be the right choice for you, why are you doing this? Are we just ticking boxes because you think this is what you should do? Rather than what you actually want to do, or need to just take some time to think about it. And that really did set those two moments. Definitely set up a chain of reactions, chain of events that made me evaluate not just what I want out of my career. I want out of my life.  [Jaz]Andrea, did you go ahead and buy that practice in the end? Or did you make a decision that actually this isn’t for you after all? [Andrea]No, I made a decision that this wasn’t for me. I think the sale was likely to fall through anyway. We were literally at the very early stages. And then, something came up with bank valuation, all that kind of stuff that I was like, “Actually, no, this is my chance to get out, this is not the right decision for me at this time. Let’s just stop and let’s just think about this and take some time and work out where it is that we’re gonna go from here.  [Jaz]Have you read the book, the E-Myth or the dental version of the E-Myth?  [Andrea]No, I haven’t. But I’m gonna make a note of that so I can definitely reach it today. [Jaz] There’s so many things that you’re saying there because it argues like, for example, that yes, let’s apply to dentistry, but like one step back, and not even related in dentistry, but it gives an example in the generic book The E-Myth Revisited. It gives an example of someone who just loves baking. They’re just amazing at baking.  And then everyone says, “Look, you need to sell your goods. Your baking is the best, you need to sell.” And then eventually she opens a shop, and then she’s there like 5:00 AM, baking and stuff. And then she’s there serving customers. And then it grew and it grew. And then eventually she’s not baking anymore, she’s just doing the account. She’s managing people, she’s doing this. And the thing that she was in love with, right? Which is the baking. She was no longer doing anymore. And so that is like the the technician. Then we also have the manager and the entrepreneur. So these are three different roles, and as dentists, we get shoehorned into playing all these three roles.  As a business owner, you’re like the entrepreneur, you also become a manager, and then you also a technician. You still have to do the implant, still have to do the orthodontics, you still have to do what is very challenging work, and this can be a real source of burnout and stress because you’re trying to wear so many hats and everything is like brand new and like you,  Andrea, like I think very few people are fortunate enough to have clear mentorship, whether it’s family or close colleagues that they can rely on. A lot of people are just making up as they go along. And that’s scary. So what did you do thereafter when you decided that okay, a really good judgmental moment for you, really good insight that you had, potentially a good insight where you decided that this isn’t for me. How did you pivot from there?  [Andrea]I think the first thing I looked at was: What was it that I really enjoyed in dentistry? And I got into teaching very early on because my first associate job was in a foundation training practice. So the FD was often coming in. I wasn’t their trainer, but they’d often come in for a chat. I’d help them get bits of teeth out, find canals, and I got a kick out of it. I realized quite early on that to be part of somebody’s journey is a huge privilege and even if you’re just a teeny, tiny bit. So I think that was always kind of there and I thought, “Actually no, I need to do more of this. I’ve done my postgraduate certificate in dental education. I applied to be an educational supervisor in my own right. And then naturally it was kind of, so that was kind of already going on in the background and it was that moment actually after being in the car with my eldest. I was like, “Okay, we need to look at how we can take this further.” And around the same time, there was a job that came up to be a training program director in the East of England. And I didn’t think I was gonna get it, but I was like, I have to apply for this. Like, we have to see where this can go. And you know that was at that point. That was definitely, the biggest pivot because that changed my working week. I went from being five days as a clinical associate to actually doing three days and then two days was involved with foundation training and that kind of initial variety, that increased variety in the week and actually having to learn all the different skills of working, within a much wider team and managing budgets and dealing with the trainers and the FDs, all these skills that I didn’t realize actually, I didn’t know I had to acquire those and learn quite quickly. And I was like, ” I really enjoy learning stuff. I think most dentists do. That’s one you sign up to a lifelong commitment of continued learning. Okay this is something else I hadn’t realized about myself. How can we do that?” So it was definitely, as you said, most dentists, they don’t know and it is this kind of trial and error and just–  [Jaz]I think that’s okay, Andrea because I think it’s important to have you need to trial. I always say you need to kiss a lot of frogs before you find your prince charming. And in the context of finding out what your niche is or finding out if you should specialize or not, or finding out, what kind of career you want to have, and sometimes you need to figure out that “Actually I’ve done enough endo to realize I don’t enjoy this, and actually I really enjoy digital dentistry.” Like for whatever it could be. They get a kick out of doing the lab side. They get a kick out of Cerec. In contrast to you that you felt as though that this is not for you to do it for the next few decades with the nurse, whereas other people get a kick out of six days a week working in that room. [Andrea]Yeah.  [Jaz]And they just love their clinical tiny details of dentistry, whereas other people feel like they just want a variety in the week like you. So is that what your week looks like now, Andrea?  [Andrea]Yeah, my week is incredibly varied now. I think because after I finished working as a training program director, I joined the BBA as a member of their staff. Ultimately, that’s really the amount of things, different types of things that I do during the week, whether that is giving talks to foundation dentists or students, whether that is project work. I still work clinically. As a dentist, for me variety was always a key thing that I wanted to tap into. Like you say, for many people, if they absolutely love working, doing that clinical work, then that’s what’s right for you. The point is we’re all different. And it’s about understanding who you are and what makes you tick and why it is that you wanted to do dentistry in the first place, and how can you enable that? And you’re gonna learn stuff about yourself throughout, along the way. Like, I didn’t realize that I like teaching when I started doing dental school. That was the last thing I thought about. So you discover these things that you are like, “Okay, well that’s good. How can I, how can I do that a little bit more?” But I think probably one thing I probably need to mention is. I often hear people say, “oh, you need to find out what your strengths are.” Like let’s say you’re good at root canal site, you should do more root canals, I suppose, like your, the baking analogy that you were talking about.  But there’s a definite difference between doing something, doing more of something, or because you are good at it and doing more of something because you enjoy it. Because you can be good at something but not necessarily enjoy it, and therefore that’s not necessarily a strength. So I think the two have to come hand in hand.  [Jaz]I think usually they do, but there are instances where they don’t. But I think sometimes you are, you become good at something because you enjoy it, and then you follow that path, and then that’s the ultimate. You are in a very privileged position, Andrea, in the sense that you’ve touched the lives of main trainees. You’ve had to influence to mold them, to support them, and that’s a really special thing to do. What have you learned from that experience in terms of what are the struggles? What’s the plight of the young dentist nowadays? In what ways some of them potentially feeling not so fulfilled? What’s keeping the mup at night? What would you say to our colleagues listening and watching right now that might be relatable? Kind of like the content that you’re posting out. What are the main challenges we face as dentists?  [Andrea]Well, I think, there’s two main challenges that people have after they’ve graduated and particularly after they’ve finished foundation training. And the first one, I think it’s a very similar experience to what I had, is that if you don’t have the information about career options, you end up just doing what you think you should. I mean, when we look at people that go into dental school. We’re high academic achievers. The vast majority of people have kind of gone through A levels, then they’ve gone into dental school and it’s all mapped out. So if you do very well at your A Levels and you apply to dentistry, you’re successful, then you progress to year one, and then you pass your exams and you progress to year two and so on and so on. And then you do foundational vocational training and then all of a sudden. Unless you do DCT and specialty training, like there’s—  [Jaz]Which is why so many do it, Andrea, I, I think so many are doing it because they feel like, “Well, this just seems like a path and therefore I should do it not with any sort of real conviction or enjoyment of it, or actually a desire to do it other than. I think this is the next step because it kind of is a path that’s already been made, but it’s not necessarily your path. And then some people do it because they’re afraid to go into practice and they’re afraid of the, the, the big bad worlds out there.  [Andrea]Yeah. I think that can definitely, definitely be a factor, especially because you know you’re gonna get more support. Whereas you don’t necessarily know you are gonna get that continued support in practice. I think that is a huge jump to go from that a structure to that autonomy that you have. I mean, it’s hugely exciting the fact that you are in control. You make the decisions as to where you want to take your career, which postgraduate training you are gonna focus on. But because it is such a huge leap, I think it can feel tremendously overwhelming. And again, as you say that can be a factor as to why people choose the more prescriptive route, at least initially, just to, to help them with that.  [Jaz]I mean, I can definitely relate to this, Andrea, because when I qualified, I did the DC- the DF1, then DCT, and then DCT2 because at the time I thought I wanted to go down the specialist route, and so I was keeping my options open. I was keeping my hand in practice at the same time at the Saturday job, so I wouldn’t descale, and then thankfully, that gave me enough knowledge and experience to know that, “Okay, I actually don’t want the hospital pathway for various reasons.” I joked in a lecture the other week that if you had to just convert hostile dentistry into a Disney character.  Then, the sloth from Zootopia, right? It would be that. So for me, it was just like, maybe it’s the way my mind works, I’m like this is all over the place. I need to be quick. And so for me it was like, “Okay, private practice or, OR practice certainly is the way forward for me and I’m glad I look back now. I’m glad I had enough insight at the time and I knew that, okay, this really isn’t for me. I could do it, I’d probably be good at it, but it’s gonna be soul destroying for me to go down that path. Right. And so I felt really confused. I had no idea what to do. Should I join the rat race? Should I do an MSC?  I was considering at the time, I just made a bold decision. Me and my wife moved to Singapore. We worked in private practice there for 18 months and we came back because my wife got homesick, but then I never looked back because it gave me that foot into practice. And I love what I do clinically now, but that was part of my journey of confusion and figuring things out and doing something bold and everyone’s journey is gonna look a little bit different. [Andrea]Absolutely. But I think you touched on the key point: you kept your options open, right at the beginning. So you could gain a maximum amount of information from all of the people that you’ve met, so you could make an informed decision.  And I think that’s the issue that sometimes if you don’t have the options you don’t know what’s out there, then how can you just like when we tell our patients about treatment options, how can you make an informed decision about your career and your life? It’s very interesting. But I think that’s ultimately been one of my big passions through the work, through the BDA is to develop their career hub. Because it used to just really frustrate me that there wasn’t anywhere that you could put all that information in one place about these are all the jobs that you could do with a dental degree. This is what you need, this is where they’re advertised. You know, these are the kind of routes that you can go down if you want to do X, Y, or Z. [Jaz]I was just making notes there, Andrea, because it just reminded me that the whole thing as, as a parent, they say the days along with the years are short. And the other thing the reason I mention that is because in dentistry sometimes you have a really tough day and we think like really small in terms of the timescale but if you actually remember where you’re gonna be now compared to 10 years time, there’ll be a huge difference.  Think five years, think 10 years rather than think just next year. And you’d be amazed because if you, if you think that, if I don’t make this really important decision now, or if I mess up one year, then this could, the end of my career is gonna go down the really bad trajectory. That’s not ideal way to think because that’s not true. You can have a couple of bad years or a bad year or a bad few months, but then whatever that means for someone, I think people will be able to relate to what that means for them. But it’s not career defining because our careers got wonderfully long in a good way, and we get to mold and reevaluate it and reshape it at many checkpoints. Is that something that you think as well? Is that fair to say?  [Andrea]Yeah, I totally agree with that. I think the other thing I’d probably add to that is the fact that you don’t need to achieve these things tomorrow. Like it is, your career is long. And I think going back to your question about the challenges that new graduates are facing you know, I didn’t graduate in an era of Instagram and social media, and I think there’s something called social proof bias, which is in the absence of an answer.  You do what everybody else does. And I think when we are looking at social media in particular, there are some things that photograph a lot better on social media than others. So obviously, you know, cosmetic, whether that’s composite buildups or veneers or smile makeovers, photograph beautifully.  Whereas if you have a picture of a perfectly executed molar endo, it might not gain the same traction. So see the algorithm is, is gonna show you certain things. You’ve also gotta remember about the context of the post. Is that there to educate you or is that there to market to potential patients. And so it makes me think of this famous equation by a guy called Tim Urban that happiness equals reality minus expectation. So if you are at dental school and you are seeing a lot of these cosmetic cases, because that is what is coming through on social media and you think, okay, well that’s what I need to do.  So my expectations are that I’m gonna graduate and I’m gonna be able to do this. But obviously that takes time. That takes postgraduate training, it takes an all sort amount of resource. So when you graduate and you are not there, or you think, “Gosh, I’m so far away from that, then your reality is way lower than your expectations. So you are in negative happiness. And I think that’s a challenge that certainly I didn’t have. But I think I’m seeing that in a lot of new graduates.  [Jaz]Totally agree. And then the next question I had, which follows on so nicely from this is about stress burnout. And I’m gonna say it’s important to address these sensitive matters, but suicide in dentistry, we’ve lost a lot of colleagues over the last few years and we have been for decades. And so. Is there a net benefit of social media in dentistry? I don’t know. I think there’s so much good I see in social media, but comparison is a thief of joy, right? And so we are comparing, especially now someone qualifying and they’re seeing the work that’s been done by someone 10, 15 years, but they forget the journey. They just see their outcome and they think, I need to be able to do this. And everyone’s like in as fast paced. And that’s maybe keeping them up at nighttime. So social media could be a source of stress and resentment if someone falls in the trap of comparing themselves, right, and comparing what, where they are compared to where their peers are, for example, which is a, a dangerous thing to do. Why else do you think we are in a situation where many of us in some of the BDA polls, you know, are quite striking the percentages are feeling disgruntled or upset.  [Andrea]I think that’s actually on the surface of it. You turn around and you go, Oh, it’s because of a high patient, increased patient expectations, it’s because of increased financial pressures. It’s because of increased fear of litigation. But I think actually, if we’re gonna examine this question because we want to improve our wellbeing and reduce the amount of stress that we’re under then we need to actually understand it a lot better and break it down. So you mentioned the BDAs poll. So every year the BDA is part of its evidence that it presents to the doctors and dentists review body surveys, its members. And over the last eight years, the data has shown that the morale has reduced. From about initially 2015, about 40% of dentists said that they rated their morale as either high or very high. And in 2023 that had kind of gone down to about 20%.  [Jaz]Wow. [Andrea]It harped. And what I find really interesting is that back in 2015 about 50% of dentists surveyed would say that they would recommend dentistry as a career. And fast forward to 2023, that’s now reduced to about 35, 36%. So when you look at those surveys and you say, “Okay, well, what causes you the most stress?” Interestingly, for practice owners, like 90% of them said it is increased practice cost. And for associates it’s fear of litigation. And then the list kind of goes down. I think it’s, you know, and number two is staff. Like how easy it is to recruit staff. How, if you are an associate, what’s the staff turnover if you don’t have the same nurse all the time. And then it becomes about financial concerns. And then I think number four is hitting NHS targets. And so, we can look at those and go, “Oh yeah, okay, so that’s why, why dentist stress?” But I think it’s important to remember that they are external fractures. And so with external factors, you are limited as to how much you can control them. Then we’ve gotta look at the nature of the job, which if you are in general practice, it can be isolating. You could be in a big practice, but you could end up working in a bit of a silo if you’re, if you’re not careful and you don’t, you know, if there isn’t that kind of culture that, everybody helps each other out and you all work together. Plus like the huge amount of mental load that comes with the job. I think the fact that as a dentist as you said, you’re doing all of these things. It’s not just the one job as a self-employed individual, you are the accounts, you are doing the actual clinical work. You are, you know, and all you are making–  [Jaz]Communications with labs and patients and letters.  [Andrea]Absolutely.  [Jaz]And planning itself, the whole just, getting a decent treatment plan. When you are conflicting in your mind that what is the best thing to do, that takes up so much choice, fatigue and decision making skills in your head. [Andrea]It does. I mean, the list just goes on and on, doesn’t it? And I think, the problem is when you’re making decisions all the time is that your brain doesn’t get chance to shut off. And then when you leave work, you are still replaying some of those events and decisions throughout the day. So you can leave work, but mentally you are still there. And so when you don’t get that level of respite, and obviously you get home and you’ve got, you know, other financial constraints and pressures, whether that is a mortgage to pay or the kids to pick up or who, we’ve all, got whatever— [Jaz]Life, just everything else in life. [Andrea]Exactly, so it’s really, really fast paced and I think because we don’t get that time to, if we’re not careful, to just pause and just, reflect and think, “Okay, you know, I just need to take some time just to slow down and, I mean, I can’t meditate, but if you can, that’s great.” But whatever works for you, but you just need a time just to kind of slow down. And I think also, the kind of people that I’m naturally attracted to dentistry tend to be high achievers, people who we wanna do a great job. I mean, whether we’re perfectionists or not, but we wanna do a great job and we wanna help people. And so when things go wrong, as inevitably, sometimes they do, they don’t work out as as well as you’d like them to do. You know, if you are naturally, I don’t wanna say a people pleaser, but you wanna help somebody, then you can take that failure very personally. So I think that contributes to that. And then we’ve got the other internal factors which are really specific to you. That is when you’ve got a clash of basically internal stresses usually come from a clash of values. So that means that your action or your environment is conflicting with what’s really important to you, and that makes this kind of internal cognitive dissonance, which you might not spot. You might not even realize that it’s there. But over time massively contributes to burnout. And so I think, your values are a compass. As to where you are gonna go in life. And I think sometimes I meet people that are like, “oh no, dentistry is just not for me.” And you are like, well actually, is it? And when you really delve down into it and you look at the kind of things that are causing them stress and draining their energy, you are like, well no, actually it’s got nothing to do with dentistry. It’s just a mismatch between your environment and your actions. So if we can change that, then actually that will make the world of difference for you. [Jaz]I think I’ve never had an episode where my neck is hurting so much. because I’m nodding so much. It honestly is like the cognitive dissonance, I talked about this a couple of years ago, right? And I’m so glad you mentioned it again because like, I don’t wanna talk about specific scenarios because of the international audience, but let’s say an example I’ve used in the past is you go on a course, you learn how to find MB2, okay. And you learn how to find it. And now, when you are working and you’re like, you don’t have much time to do this endo, and everything’s rushed. And you know how to find the MB2, but now you don’t have the time or the tools to find it. That’s a source of stress. That’s a cognitive dissonance in itself. [Andrea]Absolutely.  [Jaz]Or you know that you should be doing things a certain type of way, but because of the environment you’re in, you are having to take shortcuts or just something that may have worked in the past few, but now because you know better or different or you want to be a certain way, but you’re not able to be your true self that eats you up inside. Especially like you said, for us who want to do a good job, and many of us do love our clinical dentist and we work in microns and we wanna be proud of what we do, but we’re not able to do it.  [Andrea]Yeah, I think that you’ve hit the nail on the head. I think you know that there’s lots of examples that I can can give of that and it could be something as simple as you really value family time, but you are having to work really long hours, you’re having to stay behind because you know, you don’t have enough time to do your notes and your referral letters during the day. And so actually that’s a massive conflict of your value. Like actually it’s got– [Jaz]I’m so glad you mentioned that non-clinical one. I’m very pleased. And the other one would be like, you value your health and fitness, but because your working so much then you neglect the gym. You have the gym membership. You only go once a month, but you are at your best. You have the most energy when you’re going three or four times a week, but you’ve sacrificed that for work or for something else. [Andrea]Yeah. And I think another example that something I’ve certainly experienced, and it took me a while to work it out, was that for me, actually autonomy is, is really important to me. And so, you know, if I’m working in an environment where I lose control of my list and that, you know, the reception are putting in patients here, there, and everywhere for one dentist that they might love that.  They might love the challenge, whereas I want the day to be separated into this is when I see emergency patients, or this is when we do this kind of treatment. And if I lose that sense of autonomy, then that causes me a huge amount of stress. So it’s about understanding what specifically triggers you. And you only really understand that if you’ve actually put in the work, which can be quite uncomfortable work, to be honest as to what is important to you and why.  [Jaz]Hard now is an easier tomorrow, as I say. So with with that, let’s talk about the final phase, which I’m the most excited for, right, is let’s talk about some practical steps every dentist can take to fall in love with dentistry again, and ensures that it fuels them and it doesn’t feel like it’s a chore or a burnout, and it helps us to reconnect with why we got into the profession. In fact, actually that reminds me of, there’s a book called Can’t Hurt Me. David Goggins, and then one of the techniques he uses is you reach into the cookie jar. So he’s an ultrathon runner, right? So let’s say he’s done like 80 miles and he is running and he is getting a little bit tired, and he is losing his energy, he’s losing his focus. He reaches into the cookie jar where he remembers, he searches inside, he remembers a time where he was successful or he conquered something and he tries to tap into that energy.  And something I haven’t spoken much about before, but is something I think is relevant to hear is many of us okay, the vast majority I think at some stage when you’re doing the UCAS form, for example, Andrea, at one stage you really, really, really wanted this, you really wanted to be a dentist.  Like if you tap back to that energy when you’re 18, 19, 25, wherever how much old you are, when in your individual journey at some stage you were like, you sleepless nights waiting for the results to come out, to find out if you’d become a dentist and that’s what you really wanted at one stage. And to remember that and to tap into that energy. And that’s our version of a cookie jar to help you, to ignite you to do the hard work that you need to do, like you said, Andrea, to help make sure that you carve a professional life you that serves you.  [Andrea]Yeah, . Tapping into to that original why is fundamental, but I think also it’s important to say that, once you’ve tried different stuff, that why actually might change a bit. And that’s– [Jaz]That’s okay. [Andrea]And okay.  [Jaz]Great. because I’ve seen so much practical stuff shared by you on Instagram, can you share your top tips that you give to your trainees or you educate on to make sure that someone listening today can really go away and I think that’s a great , I can apply these few things to make a big instant difference to my fulfillment.  [Andrea]Well, I think the first thing to say, just because we’ve touched on stress and, tragically increased suicide rates. I think if you are listening to this conversation and you are really struggling, the first thing you need to do is you, you must seek support and there’s lots of support out there, and that’s Samaritans BDA has, it’s a health assured counseling service. Your indemnity provider may have counseling support as well. So if you are really struggling, then there’s absolutely no shame. It’s, as we’ve talked about, it’s kind of an insane job when you think about it. And so we are all gonna go through periods of time where we are not doing too great. And what’s important is that, you access professional support when you need it. When we kind of, if we are just looking at how can we make life more fun. How can we, improve our life in practice? I think, we’ve kind of touched on this already. The number one thing you’ve gotta do is get clear on what is it that you liked industry, what is it that actually does excite you? And then look at how you can do. More of it, but to even kind of have these thoughts that we’ve been having. When we were talking about how rapid everything is and how our brains just are going a million miles all the time. I think the number one thing that I would advocate is that you just find a way of stopping. So I can’t remember who it was that I heard say this, but basically if you are looking about even making any kind of change. It could be a small change, it could be a big career change. I mean, who knows if you are driving a car, you can’t reprogram the sat nav while you are still driving. So you need to be able to have time just to pull over. And not saying stop working, I’m saying see if there’s a way that you can actually dedicate time during the week and put some real boundaries around it. Like, okay, well, you know, on a Thursday night between whatever, I’m just gonna, I’m just gonna sit and I’m gonna think I’m gonna do some work on this. I’m gonna do some Googling, I’m gonna,– [Jaz]It’s protected time.  [Andrea]Absolutely create some protective time. If you really are thinking that, you know, you’re not actually sure whether you dentistry long-term is for you, then actually I would, you need to think about maybe just having that protected time, but perhaps even just reducing either clinical afternoon or a clinical day. But these goals need to be smart, so there needs to be a time specific element to it. Otherwise, we just get carried away and we do other stuff. But if you are like, “Right, okay, in the next four months I’m gonna make a decision about where I want my career to go, or what kind of post-graduate training, or what kind of jobs I think I’m going to shadow, or what I’m gonna find out what’s right for me.” So create protective a time–  [Jaz]Finding a mentor of a certain kind was giving an example like, I want to get a mentor in implants and I need one local to me, could be your main thing that you’ve identified that’s gonna help you to, to go to a next gear.  [Andrea]Yeah, absolutely. But things need to be, I would say it needs to be time specific to make sure that you are actually gonna do it.  [Jaz]It’s human nature because if you don’t have any urgency, then everything else will just fill up and that will get left behind. So I, I totally agree. If you actually write down a specific date and specific time and where you’re gonna be at that time when you’re gonna make the decision, then that can be quite a powerful, like it just gives you your mind some clarity. [Andrea]Yeah. Absolutely. So having the protected time to be able to do that is going to really help you. So yeah, so we’re getting clear on our why we are creating protected time to kind of do go through that thought process and then putting the work of whether that’s, like you say, finding the mentor, doing the Googling, doing the research—  [Jaz]Doing the shadowing for maybe some areas that might interest you, that you think, okay, I could pivot my career into sleep, or I could pivot into endodontics and then actually doing your due diligence and, and shadowing. because you might decide, actually that wasn’t for me because X, Y, and Z. [Andrea]Yeah. And I think, for some people, if they’re in a similar situation to what I was and they like variety and obviously we get a lot of variety in practice anyway. But if you want variety as in different types of jobs, I think that dentistry is incredibly unique. Like I truly believe there isn’t a degree out there that gives you the amount of flexibility and opportunity that a dental degree does. The fact that I do clinical practice on one day, and then I might be talking to somebody else on another day, or I’m working on my computer, on a project on another. It’s actually, when I look at it, it’s all insane. And obviously that gives me a tremendous amount of pleasure. But the fact that I can even do that, I can’t think of any of my friends that have done. Other degrees and qualifications that have that level of variety to their week. So, you know, it could be that you think, well, do you know what actually, maybe I’d like to go and demonstrate at a dental school, or, you know, just do that as a general practitioner, half a day. A week just,—- [Jaz]Or even, i’m just thinking out loud here, dental charity work, dental aid- Absolutely. Some people have gone into that and they love that they get so much fulfillment from their career from that.  [Andrea]Yeah, no, there’s absolutely loads of things that,  [Jaz]Oh, business. But the business of dentistry, sorry. So some people get a kick out of owning three to four practices, and then for that reason, they only had to, I read someone from a colleague I really respect. He said, when you get to about four practices and you own four practices, you really kind of have to think about giving up clinical dentistry because it’s a big ordeal if you’re gonna manage to a high degree of success. But that might be different for different people. You know, you might still keep your hand in clinical, but certainly you might find that the whole marketing element and hiring and the, and the managerial stuff you get. Kick out of that and having a vision for your practice and employing the right, not employing, but hiring the right associates in your team and building that team. And it’s like a project development. That could be your calling.  [Andrea]Yeah. Completely. And I think another thing that we need to do is look at, you know, especially when we were talking about stress. because obviously we’re all under stress to some level, obviously, how much and what that stress is, it depends on you and your individual circumstances. But I think certainly when I was a younger dentist, I would hear this word resilience and I would think, “Oh, okay, well I’ve just got a tough up. This is what it’s like. I just need to keep cracking on and eventually it might get better.” And so there was definitely this misunderstanding between resilience in terms of toleration versus adaptation. And so it’s just if you are finding that some” Oh gosh, you know i’m driving to work and I’m feeling it today. Like, it’s an understanding like why it is. And then once you’ve worked out those specific stress triggers, how can you manage those? Like, if it is like the example I gave about autonomy and the diary, right? It’s actually quite an easy one to fix. You know, there’ll be some things that are harder to fix, and you might be like, actually, no, this is not the right environment for me. I need to change environments. But again, it’s getting clear about what it is that’s specific to you that causes you stress and anxiety, and then coming up with a manageable plan as to how you can either adapt to it or ultimately, if you can’t do that, then remove yourself from that. The final bit of advice is actually, no, there’s two. There’s another one that’s just coming to my head. So, community, community is a such an important part obviously you’ve built this incredible community through Protrusive and, but you’ve really going to find your tribe. And it is not just about finding a community online. It’s about finding people who you can pick up the phone to you see face to face, who understand what it is like to be doing your job. Because dentistry is so, so unique, it’s very hard to explain it to somebody who’s not a dentist what the realities of the job are and why it is can be very challenging sometimes.  [Jaz]I just wanna give an example of that, Andrea, my, my wife she’s a dentist, she’s a community dentist. She’s now pivoting into private practice pediatric private practice, got MSC in Paeds. Massive imposter syndrome. She’s being kept up at night.  She’s having this huge imposter syndrome, and I’m saying, Sim you can be absolutely great. You can be fine. But, then I got her in contact with the Dental Mums network. It’s a new network that’s been set up and she’s going to their, like inaugural conference in a couple of weeks time, which I think is wonderful. That’s like, she’s finding a real in-person event. The magic of in person, you can’t be replaced and she’s gonna go there and won the talk. Is all about Impost syndrome and these are really high achieving women in dentistry that’s gonna inspire her and to, to find that source of inspiration from, and then look, yeah, look online as well, but look beyond and look, find local as well. And be willing to travel or pick up the phone to find that tribe. Totally agree.  [Andrea]Absolutely. And that’s one example of the, many of these, these groups and I’m seeing more and more spring up which is fantastic. It’s the issue I would say that you just need to be aware of is that if it’s only like yearly or couple of, twice a year that you are going to these, these conferences, see if you don’t have a local network, see if you can build that, see the BDA have branch and sections events, there’ll be local dental councils. There’s lots of things that you can get involved with. And also by having that element of community, it’s not just about support, it’s about career opportunities as well. Think about, because we are such a tiny profession really, that the nature of many jobs don’t, they don’t even come to the online boards. So to find out about these kinds of. That’s in practice or these other kind of weird and wonderful opportunities that come along, you need to have a strong network in order to be able to access them or even know they exist. So community really is key. The final thing is that you need to enjoy the journey. And I think going back to the, what we were saying about tick boxing, it’s so easy to kind of steamroll it down this road of, I’m gonna achieve this or I’m gonna get this. Qualification without, and then you get it and then you’re like, okay, what’s next? What’s next? Let’s go, let’s go. And actually, you know, you have what you have achieved just to even qualify or graduate as a dentist is amazing. Like it’s huge. You have to be able to, if you are looking at the next mountain, you have to look at the mountain you are already standing on. And I think we can be quite bad at that sometimes. And just going, well actually, if you’d shown my 18, 19-year-old self. Who I am, it’s gonna blow their mind. But it’s having that kind of realization that, you know, well done. You like that. Just having, having that bit of recognition for yourself and it’s not even just looking at the big things. I would say if you were in just one of the massive things that will make a difference to you in practice is looking at your micro wins. All get really focused on. I don’t think that prep point as well as I don’t think I’d got the angle of this or like that could have been better and like we’ve become super self-critical. And actually you are like, no, what, what did go right today? What difference have I made to the people? I got this person out of pain. Or it could be something really simple but just by taking a moment to think about it actually. I make a difference on a daily basis. And so, yeah, what a privilege. What an amazing privilege that is. And you know, I think that really is kind of the message that I keep, I keep going on about, is that we are in such a privileged position. We have this incredible degree, we have incredible qualifications and so many people don’t have that privilege. And so the last thing we wanna do is. Is, you know, not utilize it and, you know, not be, not be happy. Because ultimately, you know, if you are happier in what you do, then that doesn’t just affect you, it affects the people you live with, definitely. But it impacts your patients. I mean, there’s a growing body of evidence to say that happier clinicians have better outcomes. So this is, it’s vitally important, it’s essentially, life is short. Let’s not waste it. Let’s think about things. Let’s give some intention as to what we’re gonna do with our career and our lives, not just for ourselves, but for those around us as well. [Jaz]I’m applauding. I love that. That was fantastic. I can’t, I can’t wait to share this with everyone. Andrea, I’m just gonna I guess, round it off by saying, I agree that this is truly a phenomenal profession, but if you’re feeling at this moment in time that, hey, actually it’s not, it’s not feeling like a great profession. Everyone’s saying that, oh, it’s so much flexibility. Then you’ve cornered yourself, you need to embrace the difficult period. Of either discovery or action taking, taking massive action, picking up the phone, writing an email. The worst thing you could do is just be stagnant and watch the entire world collapse around you and not do anything about it. One thing I have been good at over the years is taking it by the scruff of the neck and making. Brave decisions and key decisions and sending those emails and having that conversation with my principles wherever it could be to make sure I carve out life by design and by choice, and not wait for things to happen to me, IE being proactive. Okay. And that’s so, so important, Andrea. How can we learn more from you? How can we reach out to you? How can people send you a box of chocolates and flowers for the mood that they’re in right now?  [Andrea]The easiest way is yeah, if, if you wanna send me stuff that’s I’m sure we can provide some form of address. But yeah, the easiest way to contact me is actually through Instagram at Dr. Andrea Ogden. Then you can find out everything you need to know about me and the one-to-one coaching that I do.  [Jaz]Excellent. So you’re doing coaching and you’re sharing so much on Instagram, so I highly encourage everyone to follow Andrea. I’ll put her link in the show notes. Thanks for helping us to fall in love with dentistry again. I think it’s so important to do so much CPD on various aspects: cosmetic stuff, composite stuff.  This is the important CPD right here, reminding yourself how to get out of a tough spot, how to reengage and get refuel, reinvigorated from your career. This is an annual exercise, every monthly exercise. Okay? And so this is so important, and thanks for helping us put this together, Andrea.  [Andrea]Oh, it’s been my absolute pleasure. It’s been so lovely to talk to you. Thanks for having me on.  Jaz’s Outro:You as well, Andrea. Thank you so much. Well, there we have it guys. Thank you so much for listening all the way to the end. Look, sometimes when you are given advice, you enter paralysis or choice fatigue and you don’t know what to do. Listen, just do one thing. Pick one technique that Andrea talked about, or I talk about the intro and implement it. Maybe that’s gonna be writing down what your ideal day and ideal week looks like. Even if it’s so far from what your reality looks like at the moment. If you actually put pen to paper in some protected time to, to actually discover what does your ideal day and ideal week look like, and then for the next few years or few months, or wherever your timescale is that you choose, you relentlessly chase that, my friends, and feel free to share it if you’re on Protrusive guidance right now. Put it in the comments or start a new community post. We are all friends here. It’s a safe space, and we’d love to hear from you. This episode, by the way, is eligible for CPD or CE credits. Protrusive Education is a pace approved education provider, and now CP credits are valid all over the world, including us, Australia, New Zealand, you name it. We have two main plans that. All you have time for is the podcast, and that’s where you wanna get the CE for. Then we have the podcast plan, but if you also wanna access all our master classes that we have and some of the best dental webinars you’ve ever seen, I promise you you’ll never laugh so hard and learn so much from these webinars that we have. And that’s from our Ultimate Education Plan. So you can choose your protrusive flavor. I’ve put in the show notes, by the way, how to get in touch with Andrea and her Instagram link. If you like this episode, please let her know we need more people like Andrea in the world. And you know what? We need more people like you in the world. Thank you so much. For reaching all the way to the end. It shows that you are dedicated, it shows that you really want to make a difference for yourself, for your loved ones, and for your career. My friends, I’ll catch you same time, same place next week. Bye for now. And of course, thank you so much, team Protrusive for behind the scenes, all the hard work they do. Bye bye now.

Is gold really dead or making a comeback 2025? Are zirconia and biomimetic dentistry sounding the final bell for precious metal restorations? Is there still a place for gold in modern practice—and when is it actually the best option? Dr. Lane Ochi joins Jaz for a rare live podcast episode to unpack the current and future role of gold restorations. From skyrocketing costs and lost lab skills, to emerging alternatives like milled cobalt chrome, this episode covers everything you wish dental school taught about gold. They even dive into clever tricks for temporizing gold and discuss the surprising lab workaround that may save your patient money—without compromising function. https://youtu.be/QWhY2_Oghd0 Watch PDP236 on Youtube Protrusive Dental Pearl: You can achieve profound anesthesia for lower molars—including cracked, heavily worn ones—using Articaine buccal infiltrations instead of an ID block, even in dense bone cases. 🔑 Key nuance: Ensure blanching of the attached gingiva and infiltrate through the papillae for better effectiveness. Watch the detailed technique breakdown (including patient feedback): https://youtu.be/cCXacw5DE4M?si=gDmYTKiFYxhYvbj3 Articaine works—master the nuances!  Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Use gold in tight spaces, short preps, or when longevity matters. Simpler preps = better milling, easier seating. Burnish when needed—but focus on great impressions. Talk to your lab. Explain your margins, internal spacing, and cement plans. Treat the patient, not just the prep: comfort, cost, and communication matter. Highlights of this episode: 0:00 Introduction 2:06 Protrusive Dental Pearl 06:19 Welcoming Dr. Lane Ochi 09:40 The Resurgence of Gold in Dentistry 14:11 The Importance of Preparation and Cementation 18:17 Cost-Effective Alternatives to Gold 21:39 Burnishing Gold Margins 26:53 Partial Coverage Margin Designs 29:04 Retention vs. Resistance in Tooth Preparation 43:14 Vertical Preps with Gold 45:05 Immediate vs. Delayed Dentin Sealing 47:23 Challenges with Temp Bonding and Solutions 49:13 Recap 50:02 Lab Considerations for Gold Crowns 54:53 Perforated Gold Crowns 57:24 Temp Bond Troubles and Fixes 59:59 Gold vs. Ceramic Longevity 1:06:25 Gold Crowns on Implants 1:08:44 Wrapping Up and Final Thoughts  Unlock webinars like this one by joining the Protrusive App. Studies Mentioned in the Episode: Marginal Gap of Milled versus Cast Gold Restorations Marginal Fit of Gold Inlay Castings Longevity of the Tooth Restoration Complex : A Review Catch another episode from Dr. Lane Ochi: Cracked Teeth and Dentistry’s Tough Questions with Dr Lane Ochi – PDP175 #PDPMainEpisodes  #BreadandButterDentistry #OrthoRestorative 🎓 Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES). 🗓️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician” 📍 February 18–19, 2026 · Chicago, Illinois Don’t miss Dr. Jaz Gulati and Dr. Mahmoud Ibrahim as featured speakers, presenting on “Occlusion Basics and Beyond” This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes B and C. AGD Subject Code: 250 OPERATIVE (RESTORATIVE)DENTISTRY – Preparation technology Aim: To provide clinicians with a comprehensive understanding of the rationale, techniques, and clinical considerations for using gold restorations in modern restorative dentistry, including when and how to use them, cost-effective alternatives, and how to communicate value to patients. Dentists will be able to – 1. Justify the use of gold restorations based on their mechanical properties, clinical longevity, and adaptability under occlusal forces. 2. Compare gold with alternative materials (e.g., zirconia, cobalt chrome) in terms of fit, performance, and cost-effectiveness. 3. Explain the principles of traditional and modern gold preparation designs, including vertical margins, bevels, and resistance features. Click below for full episode transcript: Teaser: Zirconia is not turning out to be the product that we wanted it to be. It does break and you know, unfortunately, even three Y, it's not self-healing. Why do we still call it the gold standard? Because it works. Longevity is there. Teaser:Well, Mrs. Smith. What is your desire, longevity, or pretty? The beauty is that when they looked at the occlusal margins, the ones they could finish, the state acceptability was-  Jaz’s Introduction:In this world of lithium disilicate, and zirconia, is there a place for gold? Many years ago, it was agreed that nothing beats gold. Gold is the best because it gives you absolutely brilliant longevity. It’s kind to opposing tooth structure and you can burnish the margins. What does that actually mean? We’re actually going to cover it in this episode. What does it mean? Is there a place for Gold in 2025 and beyond? I’ll tell you, the last time I did a gold restoration about three years ago, I had to sell my left kidney to pay the technician. Gold is expensive. Are the benefits of gold worth that expense? Or perhaps, just perhaps, there’s a viable alternative to gold, what you’ll find out today. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This is a slightly different one. We did this live. This was a rare live podcast with one of my heroes and mentors, Dr. Lane Ochi, one of the geekiest and kindest dentists I know. And to see him communicate with us on Protrusive Guidance, our network. And every time we all get stuck and we’re like, oh, what do we do with this query? Or something like really obscure and geeky about material science or how things were done back in the day and we’d always tag Lane. Dr. Ochi is an absolute pleasure to have you as part of the community, and thanks for doing this live with us. So for those who are now listening on Spotify, Apple, or watching on YouTube, just bear in mind that I do lots of shout out when I do a live on Protrusive Guidance. It’s very much responding to the chat, engaging, serving. So you’re gonna hear lots of names being shouted out. Dental PearlNow, every Protrusive episode we give you a Protrusive Dental Pearl. This one is already spilling the beans. It’s giving the secret away of this podcast. It’s gonna blow your mind, right? Many, many years ago, this is probably the first meeting I ever went to, like maybe 13 years ago, it was the British Society of Restorative Dentistry Meeting. Maybe I’ve told this story before to you guys. I’ve been speaking to you guys for six years now. I can’t even keep track anymore of what I’ve told you and what I haven’t told you. Anyway, back then, we are moaning about the price of gold. Now I had a check, and actually since that meeting, the price of gold has doubled. So here we are in 2013, moulding about how expensive gold is, and now the price has doubled 12 years later. So we asked the restorative specialist, what should we be using? And so what this specialist said back then, which always stuck with me, is to consider the use of a milled cobalt chrome. That’s right. A milled cobalt chrome for your indirect restoration such as crowns and onlays. So since then when I’ve got second molars and I’m tight for space, I’ve been doing non precious metal crowns and onlays and I’ve been pretty happy with how they fit and especially with how much they cost. And did you know that something like cobalt chrome is so kind to enamel. So any opposing enamel, it is so kind to it, but is this like a forbidden cheat code and there’s a good reason why we perhaps shouldn’t be using this? Well, stay tuned my friends, because I asked this question to Dr. Lane Ochi and let’s see later in this episode, what he had to say. But as far as the Pearl is concerned, that specialist believe in it. I believe in it. In fact, recently if you’re on Protrusive Guidance, you would’ve seen me do a live, I treated a crack tooth case and I walked you through exactly why and how I prepared this for a cobalt chrome restoration. I show you the entire prep, the cementation, and this is available with CPD CE quiz. We are a PACE approved education provider, as you know. So if you’re curious about metal restorations for compromised second molars, when you’re lacking that space, check it out in the Premium Clinical Video section of the app. And speaking of the app, I just wanna do a shout out to Dr. Jamie Adamson. Jamie said on the app, thank you, Jaz, for the availability of your VertiPrep course. Fitted my first anterior VertiPrep crown today and just plunked it on loving the soft tissues especially. Appreciate your commitment to helping the Protrusive community. Well, Jamie, to you and everyone who’s started to do VertiPrep since doing VertiPreps for Plonkers, thank you for implementing what you’re seeing online. So I always worried when I created VertiPreps for Plonkers because I was like, can you actually learn VertiPreps online? Do you not need a hands-on? And honestly, with the loop mounted footage that I have, or it is very possible and we proved it. Dozens of you have been posting your preps and your cases and so we discussed the lab protocols, materials, troubleshooting, and because we have all that and the images and full protocol videos, it’s as good as shadowing someone. In fact, I had a student shadow me recently and she’d actually shadowed many dentists before. And the same thing that happened to me is that when I’m shadowing someone, I’m like over their shoulder. I’m trying to see what they’re doing. I’m trying to like make notes and what’s really carefully how this dentist is doing something so I can learn the nuances. But it’s actually very difficult to see what the dentist is doing. So what I do when anyone shadows me is I sit them on the sofa opposite. I give them an iPad on my laptop and I switch on my loop mounted camera and they can see everything and I’m speaking to them as I’m doing the procedure and they are absolutely gobsmacked at the end. It’s like, wow, what a powerful learning experience because your vision is so clear. That’s why my friends, you can learn VertiPreps online. You can learn Sectioning and Elevating online. You know this already because I know you go on YouTube and you type in certain procedures that you’re about to do, whether it be delicate layering of anterior bonding or certain steps and dentures. The University of YouTube already exists and does a good job. I’m just here. Pack a punch and contribute to this education. And the best of it happens on Protrusive guidance. A quick shout out to three individuals from PG who I just wanna give a lot of love for. You guys are just mentoring and helping out and contributing to such a huge scale. Mohammad Mozaffari, Richard Coates. Richard also did a podcast recently about finances, like how should we budget our finances? That’s a private podcast only available on the app, but you can check it out. And also Harpardeep Kaur Ratia, our friend from California, you three in particular, have just honestly upheld the values of the nicest and geekiest dentist in the world. Alongside our guest today, Dr. Lane Ochi. So thank you. And now let’s get to the main interview and catch you guys in the outro. Main Episode:It’s so great to see you again. How’s life? How are you? Tell us about just, just a flavor of life as it is at the moment. [Lane]Life is wonderful. It’s so fun. To, dabble in dentistry as an educator still. I am an associate for one of my mentees in helping them learn how to let go and bring in their own associates so they could spend more time with their family. And it also is a deep appreciation of why I really wanted to step away from full-time clinical dentistry to be a full-time grandfathers, it’s just this whole life balance. I’m glad I was young enough to make this decision to enjoy, so I’m probably the happiest I’ve ever been. So thank you for asking. [Jaz]That’s exactly why I asked. because I knew you were gonna say that. I’ve been seeing these images of you and your grandkids and honestly your fitness levels and how much you’re trying to maintain that. It’s an inspiration, so I think it’s a great to live up to like everyone knows you here, even on the podcast for everyone knows you. So many of us came to join you live when London, when you came recently. But just for a few people, can you just give us like a one minute highlight of like, imagine your career clinical dentist career was made into like a, an Instagram reel of 60 seconds. What would be in the highlights? [Lane]Yeah, that’s easy. You’re looking at the ultimate beneficiary of mentorship. So, I have been so blessed that so many doors were opened. And the doors were opened by generous souls like you. I mean, we don’t have enough anchors and mentors that invite people to come and learn, and that’s, you know, that’s basically it in a nutshell. So, God bless you, thank you so much for everything you do.  [Jaz]I mean, it is a real shame ’cause those of you who don’t know you just stumbled on, you’re a new grad and you’ve never seen Lane before, like if you just type in his name in Google see is an amazing plethora of educational things he’s done like even online that came later in his career. But what I’ve seen and what I’ve heard, and you have actually just even on Dental Town, the amount of forum interactions and amount of people who you’ve mentored is just amazing. And that theme of mentorship will keep coming up every time we meet. And you are the original Dental Geek. So an absolute pleasure to have you again laying your old nickname. We’ve got so many questions for you. Gold, right? We’re gonna talk about Gold. So before you joined, I dunno if you were there for that bit, I asked everyone in the chat, how many Gold restorations has everyone placed since COVID and I set about five, and most of the answers were zero. Miles said, yes, he has placed Gold he didn’t say how many, I don’t think. But the numbers are low. Okay. Now, because as a new grad, I was not really taught how to do Gold. I was more PFM and then I had to kind of learn it and to fair I kind of was making up a little bit, reading Shillingburg, and trying to my patients, like the whole thing about burnishing the Gold margins. There’s so much to talk about today, but the place to start is, maybe it’s a terrible place start, but is this is our conversation is this podcast the last goodbye for Gold. Is this like a farewell to gold? Or, would this conversation, can we see a indication for gold still in 2025 and beyond? [Lane]I think this is, you know my, one of my favorite ways to start a lecture is if you’re gonna quote me, please date me. Honestly, I think we’re gonna see a resurgence in Gold. Zirconia is not turning out to be the product that we wanted it to be. It does break, and unfortunately, even three Y it’s not self-healing. It just turns out that the crack propagation occurs very slowly. It is by its very nature, probably going to fracture in areas where we don’t have a lot of room, meaning the lower second molars, upper second molars. And as that happens, you’re always gonna find a subset of patients and doctors who want value longevity over aesthetics, especially second molars. And with that, I think, the beauty of Gold is exactly the polar opposite of Zirconia Gold strength is that it’s weak, meaning it wears, it adapts. Our bite is constantly changing. So the most bite forces we know is our second molars. So I think as the profession moves on, as we mature, as our patients get educated with us, that we’re gonna find a place for Gold again. Because people just don’t like replacing broken things every 5 to 10 years. They just don’t, I mean, those are from Dental School. I mean, talking other dental students we didn’t know S from Shinola yet they’re here 45, 46 years later. Cemented with crap water-based zinc, oxy phosphate, cement. [Jaz]Well, that was one of my questions, like, okay, so you’ve answered it already. And I love how you really explained the properties goals very, very simply. The whole self-healing, use the word zirconia, not being self-healing, but really we’re trying to say gold has those properties, it adapts with us. And, and the longevity and the data supports Gold long term. And you said an interesting thing that it was done by students, so inexperienced operators with cements which are not as good as the cements we have today, yet in your mouth, they’re still there, still functioning well. And in your career as you were doing, like, did you find, you had a phase where you tried some new ceramics and then they failed, and then you tried other materials and you were fine that they failed, but perhaps you were just seeing Gold just standing the test of time. What kind of recollections do you have written in terms of longevity of materials?  [Lane]So you know how long disilicates have been around? Can I ask. You know, when they were introduced.  [Jaz]Does anyone know in the chat, does anyone know in the chat when disilicates were introduced? Because my guess, where they were popularized was like early two thousands, but you are probably gonna tell me they’ve been way before that. [Lane]1980 Dicor disilicates. And I have Dicor machine in my garage. I was one of the first people to purchase it based on the recommendations of the ceramic expert at the time, Ken [inaudible] And they all failed miserably within like three years. So I kept the machine to remind me that, we have to be careful not to be beta testers. There’s a reason Legacy concepts are called Legacy concepts because they’ve stood the test of time. I mean, how long has gold been used for in our profession? I mean, generations. And it still has, why do we still call it the gold standard? I mean, because it works. Longevity is there. That’s why, why can you, if you, if we ask ourselves, you know, more modern materials, right? Why do we make a distinction between bonding and plonking on things with cement? So typically, my learning curve was with all ceramics. I bond by cuspids forward, I plonk and cement molars. And I based my material selection based on how I wanna do things. So Gold’s no different [Jaz]Nowadays I see those who are using Gold. I remember attending a Jason Smithson lecture and he was actually treating student, a dentist student. And the young dentist said, “Hey, this Gold you’re about to do for me, can you bond it?” So that scenario of the lower second molar where I will go for metal for cost reasons, I have been shying away from Gold. And we’ll come to that okay, we’ll come to that and alternatives in cobalt chrome and that kind of stuff, which I have been using rightly or wrongly, and I’ll get your advice on that. But when we have an option, like we’ve got a gold, we can either cement it or we can bond it. Is there any advantages? Because now young dentists are comfortable with bonding. We’re doing our lithium disilicate, we’re enjoying our rubber dam. In those scenarios, could the bonding give us additional benefits? [Lane]If I reflect on my first use of the word legacy. Because we use such crummy cement, you know zinc oxyphosphate is 10 times weaker under compression and shear than our resin based cements today. So our cements are far superior. And the thing is, is that our preparations for Gold were designed with intent to have resistance features, right? So, you try on a lot of these indirect restorations in Gold. Sometimes you couldn’t even take them off without cement. So we’ve probably modified our preps a little bit. I know I’ve modified my bonded preparations to take advantage of some of these resistance features like I do like potholes and isthmuses, and I think we’ve had a conversation about that in the past. But MDP is a very interesting product. It will bond metals and so I would not discount resistance and retention features. But yeah, we can bond gold and you know, Panavia is a wonderful cement. It gives us enough working time because I heard you while you were trying to get me up and live, asking about burnishing. That was the beauty of zinc oxide phosphate cement. We could manage the setting time by what we call delayed mixing and using a cold cement slab. So we had plenty of time to work with our margins. Well, resin, glass, ionomers, panavia all give us the same amount of working time, so we have much better products that can be utilized in the way that you mentioned. So we can bond metal, absolutely.  [Jaz]I think you’re saying all the, for me, what I was expecting to hear is that the word space, when you’re tight in space and you’re cramped for space, those small clinical crowns, that’s exactly when I’ve been turning to good old metal again, not gold for cost reasons. We’ll come to that, but I find the, sometimes, if I can’t put my slots and grooves in, or if I just have a doubt that okay, perhaps I wasn’t able to deliver as much retention and resistance form option to bond is quite attractive using MDP using Panavia. So I’m glad you’re not against it for any reason. I don’t know I worry about it going against the initial intentions of how Gold was classically used and I was thinking, “Hmm, is this like a forbidden cheat code that we shouldn’t be using?”  [Lane]Not at all. So again, every question in our discussion begets another observation. The reason that we can’t get away with subtractive milled restorations on short preps is that we can’t mill it fine enough to get in there. The simplest thing and one of the beauties of our modern cements are their film thickness is so thin because the thicker the film once our cement film thickness goes past about 50 microns, the retention of a crown, the sheer force strength, the sheer strength of the cement drops off the table. So subtractive milling unfortunately won’t get into all that fine detail on grooves and boxes and potholes. So again, this is where lost wax or milling differently. This is kind of an interesting thought, and I didn’t think I’d mention this, but we know from studies and a very good one was done by Russell out of one of my residents the San Antonio Grad Pros program looked at cast Gold restorations and milled Gold restorations for marginal fit. And it turned out that untouched, the milled Gold restorations fit better than the wax invested in cast Gold restorations. But when you cleaned up the inside of a cast restoration, it fit better than a milled one. But the mills were pretty darn close internally as well as marginally.  And so one of the cost savings we can look at is not only using lower percentage gold, or even non precious based metals, that they can be milled and the cost goes down because there’s less labor, there’s no loss of material. Technology and legacy are slowly coming together. They really are.  [Jaz]Well said. And so this brings us very nicely to, I did a live webinar recently where I just talked about how I treated this particular scenario of a second molar small clinical crown that was cracked. And as I have been opting for a base metal, I’ve been opting for a cobalt chrome milled. And I was told by a mentor many years ago that this is what he believes in. Because the price of Gold is getting extortionate. And well, he’s been getting good results and we know that cobalt chrome is kind to opposing metal and feel free to lay in to give me a slap on the wrist. And tell me that Jaz, perhaps you shouldn’t be doing this for whatever reason. I’m happy to change my ways, especially if you tell me to. What do you think? Because when I lasted a Gold restoration, my lab bill was approximately 400 pounds, and so that’s a lot. And it’s probably, I don’t know double that now based on gold, based on the pure gold weight, right? So that’s a lot. So these cobalt chrome onlays, which fit really well. I’ve been happy with them. How my lab are making it, it was about 160 pounds. So what do you think about this choice I have made? Should I stop?  [Lane]No, not at all. At $3,300 an ounce, that was Gold spot price this morning. US dollars, it hit 35 what, last week? So it is, unless you are willing to charge your clients the gold difference, and they’re willing to pay it, then it’s really kind of off the table. Now we can drop down, and still be in the precious metal world, I mean, we can have noble metals, less gold, more platinum, and more palladium, but you’re still faced with the same costs. There’s nothing wrong with non precious at all. I mean, I think it’s great as a metal. It sucks as a metal to support ceramics, unfortunately, with non precious for those of you who don’t know, we bond, we have to create an oxide layer on our metal. For the ceramics to bond to. And if you look at ceramic failures on PFMs and you see metal, it’s typically a non precious metal. And what happens is the oxide layer just continues to grow over time until it gets so thick that it breaks off. But as a metal itself, as for an onlay partial veneer gold, or got partial veneer crown, it is a wonderful material. The only downside to it is that we can’t burnish the margins as well as you could with high noble Gold. But you know, our ability to capture tooth detail, iOS or PVS and machine, you really don’t have to touch your margins. If you’ve captured a good impression, digitally. Or with conventional analogue impression material. [Jaz]That’s extremely reassuring. Now, Lane burnishing with the base metal option, like the cobalt chrome that I’ve been using. Firstly reassuring that if we do all our impression work scanning and we get good quality data, we can get good margins that don’t need to be touched. But with Gold, the whole burnishing, firstly, what actually is it and was it always necessary or was it when you felt as though, I’m going to do it here because I want to improve the margin that wasn’t good enough. [Lane]You really wanna hear the answer to this? But there are over 280 something ways that the crown won’t fit. It’s quite fascinating. And the burnishing came around from the concept of the MU angle, which is a bevel on a shoulder. And the logic is that as crown horizontally seated, if you had a bevel angle, it would seat. Faster than the horizontal component. Well, that’s fine in physics, but nobody took into consideration loot cement between the tooth and the crown. So you actually ended up with a restoration because we were prepping bevels, because that’s what we were taught.  Depending on how old you are as a dentist, as the crown seeded, it didn’t really fully seed on the bevel, so you had to burnish it to make it fit. And burnishing simply is taking advantage of the physical properties of Gold and manipulating it and pulling it from the Gold onto the tooth. And so it was an ends to a means because we did not understand all the interactions and our choices. And the other problem, again, with zinc oxyphosphate cement, even the most careful mixing, its film thickness is very unpredictable. There’s no measurement. You just feel, and so it’s temperature. So our castings didn’t always fully see, so we needed an out. And that’s where using higher percentages of Gold, this is where type 3 was typically used for onlays, type two for inlays because it’s softer. So we can manipulate the Gold. And it worked well, but you also had to understand what you were doing. And just like when you teach us how to finish our composites, we spin composite onto tooth. Well we have to make sure we do the same thing with Gold. We would take [inaudible] sand paper discs, course medium to fine and we would rotate it from the gold onto the tooth. So we’re pulling, burnishing and making up for all the little errors that went along the way. Remember, I referred back to Johnson that the cast restorations required work to fit as well as a milled restoration.  [Jaz]I’ll tell you something really embarrassing. When I was a baby dentist, I must have placed my first or second gold restoration and like one of the few in my career. And I’d heard, oh, you can burnish the margins. I had no idea what this meant. So I asked my nurse for a burnisher a ball burnisher and I just rob because I thought, okay, maybe this is what they mean, right? And there we are. So it didn’t mean that at all. I didn’t see a difference. I was like, what the hell is this? What’s all this fuss about? But obvious the actual, you’re dragging.  [Lane]You’re just dragging the Gold. And you know what? This where the first marginal fit, clinically acceptable margins came from. It came from Christensen. And if you don’t remember the study, Gordon just prepped a bunch of MOD onlays on by cuspids, fabricated restoration cemented them. He finished anything on, we’ll call it the occlusal bevel. So anything near the occlusal, he finished the proximal bevels, but he didn’t touch the gingival bevels and made sure his evaluators couldn’t see the gingival bevels. So, the most evaluators noted that a margin at the gingival where they couldn’t feel it was clinically acceptable at about, 50 microns plus or minus the standard deviation. But the beauty is that when they looked at the occlusal margins, the ones they could finish, the acceptability was about two microns.  [Jaz]Wow.  [Lane]When you can finish, get at it, you can finish it, it is evident. And that was, again, the beauty of gold is it adapts to occlusal changes. It’s soft enough that you can pull it and adapt it, you know, to the tooth. So it was again, an ends to a means. But now that we’ve eliminated a lot of these uncertainties, by milling. You have to remember what we were doing back then. You know, what were our impression materials? PBS was nowhere to be seen. Additional silicones were nowhere to be seen. What were we using? Hydrocolloid, you know, polysulfide. These are terribly inaccurate materials.  [Jaz]Fine. So I could see the necessity and why you would do that with the better scanning and pressing techniques. I can see how that equation’s completely different and in our favor. Which is great. So bevels are out. Does that mean that if anyone’s replacing preparing for their first or very few Gold restorations that we get to do that we should be opting for shoulder chamfer?  [Lane]Well, for partial coverage where you’re capping a cusp, you could follow what you do for ceramics, just a longer bevel, it could just be a shoulder, it could be a butt joint. Again, ’cause we, we don’t need to finish. Let me back up a step further. So, so the best closing margin angles when there is cement looting agent present, doesn’t matter what the looting agent is, is an exit angle of a either 35 to 45 degrees, which is just like a light shafer or 90 degrees, which would be a butt joint at the occlusal. So both of those, if you keep in mind, exit angles or angle that the restoration meets the tooth, if you have one of those two criteria, 35 to 45 degree bevel or just a butt joint, 90 degrees, those are gonna seat very well– [Jaz]In terms of angle. Okay. So is the angle of the finished margin, is it, regardless of the material? The ideal 30 to 40 and also the butt joint? [Lane]For my preparations actually are pretty similar, both gold and ceramic at this point. So, yeah, I would say that this is gonna be tough. Okay. Without pissing anyone off. Okay I don’t understand a lot of what we see in Biomimetic dentistry. To me, the design of their preparations and their margins are wonderful in the compression dome concept. This is gonna work. Their designs, their margin exits are perfect for maximum compressive strength to the tooth. The problem is, the off axis loads and understand all indirect restorations fail to buckle lingual off axis loads. So this is where I prefer a little bit of a coming over a cusp tip, a little bit of a shoulder or a shafer versus just that kind of butt joint. So think of it in terms of resistance to coming off. We know that retention is this way, the path of draw resistance is if you put a groove in the prep or you have shoulders, right? It’s preventing off axis loads and puts your cement slightly under compression, under those off axis loads. So when it comes to capping a cusp, I think this is what the question is. Do you put prefer a bevel or do I prefer a Shafer around it? It depends. Both will work. One, you may pick, because you don’t want to drop interproximally and get longer axial walls and say a groove or a box, right? Versus, I’m gonna keep this whole thing high water, so maybe I’ll put a little pothole in and a little circumference or shoulder. Again, up at the occlusal third of the tooth. [Jaz]With the slots and grooves that you might place. I found in the past when I was a bit overzealous with them and I was going for, at this stage again non precious metal, but I found that. Sometimes my seating wasn’t good, there was rocking, I’d have to use a clued spray and then figure out where to adjust to get it to fully seed.  It was a real ball lake. And then now when I keep it simple with just one sort of a groove, things fit more predictably. They still have a good retention resistance form. Is this a scanning PVS error, manufacture error, all compounding when they got too many intricacies? [Lane]I think it’s both. We have to find that sweet spot that works in our hands, but more importantly works with the lab that we’re using to work with. So, you know, how many of, how many of us actually ask for the proposal of a single unit crowd? Have you done that?  [Jaz]So a proposal, like for example, like an exocad design, would that count as a proposal? [Lane]I’ve talked about the internal: The milling proposal. The actual milling.  [Jaz]No, not at all.  [Lane]You’ll do that and you’ll be kind of surprised at where you need to change your preparations. You know, we think we round over things enough, you know, we think they’re smooth enough. But then you have to remember, a milling machine can only mill to the diameter of the smallest milling bur. And so if it’s too tight or a little too sharp, the only choice the milling unit can do is over mill, which typically if it’s in the wrong place, can actually lead to a little rocking on your restoration. It’s not an internal high spot, it’s just there’s more slop. I suggest everyone do that with their laboratories, ask for the milling proposal. And so you can get, see the cutaway of where it is has to over mill. You’ll actually be quite surprised and based on that, you might change your preparation design to be simpler as you evolved to Jaz. [Jaz]I mean, I did that for my Zirconias and when I went to Marco’s coast course in Sicily and he showed us all these issues with milling and the bur and how you have to keep in certain dimensions, otherwise you have these cement gaps and yeah, cost as is just point mentioned about Sicily as well, but I didn’t actually draw two and two together for gold and it makes perfect sense. If we’re going for milling for gold or or non-pressure metal, similar complications can arise. So that’s a very good point. The next question I had was. Again, a stupid one and shows my inexperience in this is inlays, let’s say a gold inlay, right?  Would the entire restoration be gold or would it be that you’d build up a very generous core and then prep back so you that you are using the least amount of gold possible and therefore saving the lab fee and therefore you don’t have a heavy bit of gold? [Lane]Foundation fillings all day every day to, to minimize Gold content. And it’s a very interesting, I heard you mumbling about Richard Tucker. Tucker Gold Foil Study Clubs and Tucker Cast Gold Study Clubs still exist around the world. They’re not as popular as they once were, but they still do. And I used to like look at Dick and go, either your patients don’t brux, or Yeah, you’re just the luckiest guy on the face of the earth. because he would always, base up an inlay, the pulpal floor. And he put a pothole indirect with more retention into the foundation filling. And what’s the point of that? Well, he understood buildups much better than a young lane did. And so yeah, you could do that. In fact, it’s so funny back in the days, I remember when I, when I graduated from well, let’s see, I started dental school. You’ll love this story on the board, professor, first, professor, oral surgery on, on medical history. Writes the number 35 on the board, never mentions it again.  Whole lecture goes by and at the end of the lecture, typical professor, are there any questions? And I go, yeah, what’s 35? Do we need to know that? Is it something important? He goes,” Oh that’s the spot price of gold per ounce. Right now, if I were you, I would take all your student loans and by every ounce of gold you can buy because I guarantee you it’s not gonna be 35 by the time you graduate.” Fast forward to the time I graduated. Gold was 900.  [Jaz]Wait, it went from 35 to 900? [Lane]900 bucks an ounce. So we were still as students then we had to wax and cast, you know, we had to do all our own lab work and the school and ways to try to save money in the wax pattern room. We would sit there, they would make us like, try to use a round burn and scrape out like the inside of the wax pattern to cast it to save gold.  [Jaz]So that we need to build a foundation, build a core to, to save one goal. It makes sense. And so that make, that makes total sense.  [Lane]But by the way, a number of older studies, they, they haven’t been replicated in a while, so I don’t really cite them very much. Showed that just in vivo studies, teeth prepared were foundation fillings replaced. They could be amalgam, they could be composite, they could be whatever, tended to leak less than castings fit to a preparation without foundation fillings. So again, I think it goes back to this whole milling internal accuracy. If you have too many undulations that your poor casting has to fit on, it’s either gonna hang up on a high spot, a tight spot, right? So it, it does make sense.  [Jaz]And then what about minimal thickness? We talk about ceramic all the time. Minimal dimension. What about good old gold? Right? We’re, we’re in a tight spot, we’re in a second molar it’s a tight spot. And we’re thinking, are we gonna have enough space? How much is enough? 0.5, 0.71 millimeter. Oh God. How much do we want in the load bearing areas?  [Lane]Right. So this is the beauty of Nickel Chrome. Half a millimeter’s more than enough, right. Obviously if you’re gonna use type two gold, half a millimeter is not enough. If you’re gonna use type three, depending on the parafunctional habits of the patient, you’re probably okay. But they will wear through it. And so you go to type four, which is, you know, the hardest. Yellow metal we, yellow gold we have. But yeah, with the materials you’re using and Jaz, half a millimeter’s fine, we can expect good.  [Jaz]So with the ones with the non precious metal, I’m using half a mil, which is great. But then when, when those who are using gold, you said, just remind us again for the younger colleagues, type one is the highest gold content, the softest not used very much type 1, type 2 is more for inlays. Type 3 for gold and frameworks. Sorry for Onlays and Frameworks, is that right?  [Lane]Yes.  [Jaz]Talent and frameworks.  [Lane]Yeah. That’s a good, that’s a good, kind application and type four is the hardest noble gold. And so, when you don’t have a lot of room, half a millimeter, it would be well indicated. [Jaz]Okay. That’s great. And then when we are temporizing, so if it’s half a mil occlusal and then buccal lingual is no 0.3, no 0.5, whatever it might be thin, where if you ever try doing as, I have a bis-acryl, it’s gonna be like onion skin thin and it’s not gonna work. So what techniques do we need to employ to provisionalize for gold? [Lane]When typically, and we’re going to the short tooth, limited occlusal distance, I cement it with Duralon and water. That’s just my go-to. I just accept the fact that I’d rather, let me back up. So the beauty of most foundation fillings, it usually involves some immediate dent and ceiling, which usually means that you have less sensitivity at delivery. So for most gold, if you have a retentive enough prep and you can use something like, reinforced ZOE, like B&T or IRM, you don’t even have to numb a patient to deliver the restoration. When we get to the shorter teeth where we need to use Duralon and water, it’ll retain the provisional quite well. Oh, and by the way, I also Arab braid quick, lightly a braid, the intaglio of my provisional when I’m worried about it coming off. But then you have to numb the patient to typically ultrasound off. Most patients would rather get numb again.  I’d rather numb them schedule an extra 15 minutes, even for mandibular block than get that phone call at 10 o’clock in the evening or on the week and say like, provisional came out, and by the way, we’ll bring it in with you. I bid on it, so. [Jaz]I’m confused there. So the provisional itself is like Duralon, like actually just molded on, or is it just like it — [Lane]Yeah. With Bis-Acryl.  [Jaz]Okay. But don’t you find that bis-acryl was like, too thin, too weak to see through with those thin dimensions for gold? I have not had a problem with that. [Lane]If you’re really, really that concerned. You know, ’cause I think there’s a, there’s a second question in here is that bisci, krills by nature are very brittle. And so that’s, we worry about breaking them, but they’re only brittle when they move. And so that’s why you need a pretty strong looting agent, temporary looting agent, because what happens, what they lift it just ever so slightly, then they bite down on it and it pops off, or the, it cracks. So the workaround, I, I don’t fond, I may, I can count the times I had to do this on one. Two, three, maybe four fingers is to use PEMA, you know, like SNAP or, or a PMMA, like Jet. But that’s so much extra work and typically not necessary. So  [Jaz]Great. No, that’s reassuring. because that’s physical is what we all have so we can use it and just to use Poly F, Duralon, something like that makes total sense. Couple of questions from the audience. I’m gonna then revert back to some of my questions I had is, any thoughts on gold vertiPreps? Gold Verti preps.  [Lane]Well, where do you think  Verti preps came from? The vertical prep is nothing more than the feather margin, which was the go-to standard for gold, again, for a number of reasons. Cost, right. And, again, we didn’t quite figure out how to work out all the issues of fit and finish. You understand that at the end of the day, you want what we feel clinically is a sealed margin. We wanna look at a radiograph and hope it looks pretty. So the beauty of a VertiPrep crown, be it gold or zirconia, which is radio opaque, is, it always looks like it fits beautifully. And so, that’s really where the whole VertiPrep is just a rebirth of the feather margin. And by the way, the bat burs are nothing more than gingival rotary curettage diamonds that were created. All we had for impression material was hydrocolloid, which has horrible tear strike. So we would trough the tissue, the gingival, away from the margins to create enough horizontal space for the hydrocolloid to capture the margin, not tear when we remove the impression material. So VertiPrep, the baters, it’s just one big complete circle. You know, what was–  [Jaz]Wow.  [Lane]Once is now new. [Jaz]Yeah, I love that. I didn’t know. I can visualize now how it creates a space, but some people may just put cord for longer or may use a laser. That’s how you are pretty much using it to create the space.  [Lane]Right, and again, we didn’t have lasers in the fact that we, all we had was ElectroSurge good old fashioned ElectroSurge. And man, let me tell you, patients aren’t happy when they smell a barbecue and they realize it’s coming out of their mouth.  [Jaz]I always warn my patients before I use my thermo cut on high speed, no water. And I say it’s gonna smell like a barbecue. And no patients have taken offense just yet. But Julieta asked, would you still use, I know you have good, good opinions on Nick from what I’ve read before, immediate dentine ceiling for gold restorations. Because I know you talk about delayed dentine ceiling, immediate dentine ceiling. So what do you advise for gold restorations? Does the material choice have a factor to play here? [Lane]I don’t think it matters quite honestly. Again, the nice thing about the immediate dead ceiling is no postop sensitivity, right? And probably the need many times you don’t need to anesthetize at delivery. But if you’re gonna hang your hat on biomimetic dentistry, and I’m gonna get in a whole bunch of trouble for this, they really do hang their hat on immediate dent and ceiling being superior to delayed dent and ceiling. Well, I can assure you now there are two good systematic reviews and one RCT. An RCT Randomized Clinical Trial, right? No difference. After a few months, the immediate dent and ceiling is no better than delayed dentine ceiling. So I don’t think there’s anything wrong with it. I would do it because for patient comfort and predictability. Yeah. So absolutely go for it.  [Jaz]Great. Thank you so much. Harmit. Hello Harmit. You say the biggest headache she’s had recently is physical temp bonding to my immediate dentine ceiling. What would you place to prevent this glycerin? So, yeah, that’s something, once you’ve set it all up to place a glycerin and cure through it, you lose the oil, the oxide inhibited layer and, and that’s all fine personally.  I don’t know about you Lane, but I don’t have this issue. I just allow the patient’s saliva to do that separating medium for me. I don’t tend to have that issue for many years now. But anything further you can advise on that.  [Lane]No, I’m the same. I just use saliva. May, may I ask though? You know, I think it’s also bis-acryl specific. I know I get sent things to evaluate constantly and I noticed a couple products. I can’t mention their names because I don’t remember their names. I had trouble with saliva. It would adhere to my immediate dent and ceiling, but I have no trouble using luxatemp so I don’t know what you’re using Jaz but yes,  [Jaz]We’re using pro temp. It’s been fine. I haven’t had that issue. I’ve had it, I’ve had it before, years and years ago. I just make sure I don’t dry the tooth. I let the saliva be there and I’m able to remove my provisional and that’s not been an issue. So maybe try that Hermit, if you, maybe if you’re drying before you placing your physical, that could be then encouraging that to happen. But of course you can glycerin cure like many of us do. April, I’m gonna come to your question again higher, but April ask when he talks about Duralon plus water and not Duralon plus the sticky mixing liquid, it comes with, is that what you meant?  [Lane]No, good question. So basically like one to one to one, like one scoop of powder, one drop of Duralon, the poly acrylic acid and one drop of water. So you’re just adding some water to the polyacrylic acid to dilute it, which also thins it. You’re not going, oh, yeah, it’s perfectly adjusted cement, you know, you push it down. What, how’s that feel? I can’t feel my teeth touching because it was too thick. And then you go through and adjust, and if you’re point half, if you’re half a millimeter thick, you’re gonna cut through it and piss yourself off. So, , it does help to add the, a drop of water to the polyacrylic acid so that it thins it. And so your rest, your provisional seats better. Yeah. Great. Great question. I’m sorry, I was not.  [Jaz]Good question. April. Well done. Excellent. Do you still use a silicon putty index for your temporary stents? [Lane]Well, yeah. I, I use the, I basically use the non hydrophilic modified PVS I use Silginat by Kattenbach. For provisionals, I just use the cheapest PVS fastest I can find, I use a plastic triple tray because I don’t care if it destroys a little bit. So, you know, keep your costs down on that part, you know? You could really keep out and just use alginate, but God forbid your patient breaks or loses a provisional, then all the money you saved, you lose in time having to freeform one. So , just the DVS.  [Jaz]The same. And I’m glad you mentioned about the plastic triple tray because that’s exactly what I do for temps. I know Richard Coates messaged me earlier today. He said he watched my crack tooth walkthrough video, and he was like, oh, that’s a good idea. So I probably learned it from you. So we talk about indications for gold. When you are stuck for space, that’s small clinical crown, there’s still a, a place for gold, fantastic self-healing material. More 0.5 millimeters. All you need really anymore is a bonus, but don’t give too much, build a foundation so that you’re not having too much of it. You explain what burnishing is and why it was historically needed, but nowadays, if we do a good job, good capture of the margin, but we may not need that skill anymore. But it’s a fantastic ability for gold that we had. You talked about cement choice. You know, we talked about bonding panavia, we didn’t talk about it, but I guess any GIC based cement. Any of these modern cements will do. Considering in your mouth there’s 45-year-old gold crowns that were, were cemented with not the best stuff. The oxy, as you said. Any anything lab consideration? You talked fantastically about milling actually, and how we need to be mindful of that and the parameters. Any other, the lab considerations nowadays for the labs who are, so they’ve invested so much in going into zirconias and, the whole, even the modelless future that we’re, we’re facing, if you like. Anything to bear in mind either picking the right technician or anything to advise the lab? I just check that they’re doing this.  [Lane]Yeah, I think it is just opening, having a conversation with them. You know, it’s what the parameters that we’re now looking at labs is internal milk, internal spacing. Don’t give me too much. I do need enough for looting. And, this dialogue goes across the board, not only short teeth, right? Shorter teeth. We don’t want as much. For what I would call film thickness for cement. because that’s an analog. But we don’t want as much spacing as we would for a longer prep, right. Where the cement has to be pushed out through. And again, when we talk about full coverage now on a normal tooth, this is where I love some of the things that are coming out from the VertiPrep crowd is where do they excessively dye space, they dye space on the axial walls closer to the margins, right? Because again, as the cement goes down, right, if it can’t escape, it’s just gonna put lateral pressure at this. Lateral pressure may set up what we call missed fractures in zirconia. So the work around that is just give, make sure you have more room there because it doesn’t affect the marginal fit at all. It just allows the looting agent to get out of the way. You know, the labs don’t understand our our parameters and honestly, we do a horrible job of collaborating with our labs. We just assume they know everything and they don’t, and they don’t see delivery of things. So this is where, we need to educate them about everything from the occlusion we want, that we desire. The internal spacing of our restorations and you know, how fine, areas that we want mill. And I would tell you that it’s hard to find labs at mill metal. And so, you may not want to use your regular lab for that. You may wanna go to a milling, specific laboratory because it is different. I would emphasize we could get away, with zirconia because it’s so soft with maybe a three axis milling machine. But when it comes to metal, man, you better have a five axis machine, go on. [Jaz]I’m pretty sure the labs I use, I mean I use for the recent cobalt chrome stuff, I’ve been using a Precision Dental studio for those in the UK in Reading, as I do for so many so much of my work. And I think they all outsource it to like a spec specialized milling facility in Germany or something. Most likely. So that’s how it usually works. Peter asked about the cost and we, we said earlier that, you know, the cost is a major factor. It’s so expensive. But a great point that Lane made earlier is that, look, if your patient is really bought in and then they’re happy to pay for your time, plus the goal, then why not? Right? Yeah, for my patients, I’m like convincing them that, look, can I please choose a material that’s not as pretty, but because this is the best, because of the space considerations and they don’t wanna pay so much, and therefore the cobalt chrome works brilliantly for them. But if someone specifically is like, oh, you know what? I’ve had great success with gold. I understand. I’ve been educated by my previous dentist, that gold is the best. Then just make sure you don’t price it so low that you are, you’re not actually making your hourly rate. You gotta make it hourly rate plus the material. And sometimes you gotta find out, okay, what is the price of gold at the moment? Speak to your technician and quote your patient. Would you agree?  [Lane]It’s like a vacationing at a five star resort, there’s gonna be plus, plus plus costs, right? It’s, and they’re built in, but they’re there. Or if you prefer it, it’s just all a card pricing. I actually show them the lab bill here, here’s the invoice, here’s the goal. And they know beforehand they’re gonna pay my fee plus the gold, so they know they’re shown exactly what the gold price is. Now, I do hide the total fee, by the way, because some, some, sometimes there’s this disconnect between, how much profit we should be making patients. I remember when I graduated from school, what was it, a multiple of five. You should be, making five to, like, whoa, today that, that gets a little more difficult. You know, they just, again, patients appreciate the option, they appreciate the honesty that you’re showing them, but don’t. Don’t take off all your clothes.  [Jaz]Don’t chip out. I just remember this question I had earlier that I blanked out on, but I, it’s such a relevant question for me. because I often wonder, Hmm, should I intervene or not? Is I’m sure guys, we all have patients who have that lower molar gold crown, which is just now got like a two to three millimeter perforation and we can see the, the core material, but everything looks so nicely sealed. Should we— [Lane]Open it? Continue to monitor it,  [Jaz]Open it, right? So open it. So perforation means, okay, we need to now intervene, right?  [Lane]Yeah. You know, patients that love exploratory surgery, look, you know, the integrity of the restoration has been compromised by design. It your teeth wear out by the gold wore out, you know, this restoration may be perfectly fine, but it could be like mold, you know, in, in the walls of your house. It could be growing underneath it.  [Jaz]I love analogy.  [Lane]Right. Every ’cause everyone hates you understand, if you’ve got mold in your house and remediation is a big deal, then we could do a little exploratory procedure. I can make a a little bit bigger hole in there and look around and if it looks fine, I’ll cut back to some thicker gold and we’ll put a nice filling in it. Yeah we can go ahead and continue monitoring it. If we find that the decay is working its way underneath this, then I’ll stop and we’ll talk about what to do next. And so– [Jaz]Okay, that’s perfect. So the intervention is basically an investigation. And if you go in and it looks clean, just rebuild it at composite back to the same level again. And if not, then now and then you can plan the new extra criminal restoration. [Lane]You know what, who doesn’t appreciate attempts, right? It’s just human nature. Like, I trust doctor because he just doesn’t say I need it redone. He’s gonna verify, right? It’s the old trust but verify routine. And these little things are huge practice builders because the next time, even if you repaired it right, and some of you will, in the same breath, tell people, you know what? You should probably get another three, maybe five years out of this before we have to replace it. It goes by like that three to five years comes around and they wear another hole. And now you can say, well, now it’s time. And they go, yep. Okay. Let’s do it.  [Jaz]It’s a great step. And also then you gain that extra data about what the situation is, is the mold situation or not. Again, I love that analogy. I hope everyone enjoyed that as much as I did. Okay. Some questions now as we are wrapping up. Final couple of minutes. Okay. Hello, Vassi-Anna Bent. She ask, my clinic uses temp on that. I always think it’s too thick. Do you think I can do the same technique of adding a drop of water prior to mixing previously lane? We’ve used Vaseline? Is that acceptable?  [Lane]Yeah. Temp-Bond, if you add water to Temp-Bond, that’s what causes it descent. So don’t do that. Vaseline, yes, it’ll thin it, but remember Vaseline is a plasticizer, so it keeps the temp on from getting hard. So if the prep isn’t very retentive, you don’t wanna thin it with Vaseline because it will come off. But if it’s fairly retentive, then straight temp bond is fine. You know, the trick is to get to, dry the tooth, get it on quickly, and press firmly, and then have them bite on it. And I tell people to bite. It’s like, so. So many things, right? Taking a double bite PVS impression, the workhorse of of indirect restorations. You know, I need you to find your bite on the not numb side, or I’ll do a savior behind bite. And you know, you’re gonna need to keep your teeth together for five minutes. And when I say together, on a scale of one to 10, if one is completely open and 10 is as hard as you can clench, I want about a five. I just want moderate pressure. So when they’re biting on their provisional, I tell them I want a 6 or 7 And they go, oh. And you can see them bite a little firmer. So– [Jaz]I like that visual scale, if you like. It’s very, very, very good. Yeah. One technique I use for sometimes if your biral is a bit thin. This was taught to me by Sophie Lane who was taught by Attiq Rahman, who I’m sure you use this technique as well, is when you have a thin bis-acryl and you are worried about a cracking on the pressure of the cement is to just poke a little hole in it, an escape hole. So I think that’s what I was thinking, like, if you’re having a feeling, like a stick put a little escape hole, maybe politely lingually and then that’ll give it a nice escape and hopefully less likely to fracture. Yeah. Anything you wanna add to that lane?  [Lane]No venting is perfect, right? And again a little, just a little drop of flowable composite, zip hit it with the light and you’re fine and dandy. You don’t even really even need to smooth it most of the time, in fact. you know, when it comes to really short, short teeth, if there, if it’s an onlay you know, I’ll not only tack, a little bit a drop of a flowable on the margin of the buckle and lingual, I’ll lock it in underneath in approximately two, . [Jaz]Okay, great. Last questions. I saw research from Henry Kaye. I saw research suggesting that gold lasts 40 to 46 years. Would that reflect the body of the research? Hence, it would be okay to suggest that gold may be better value for money than a ceramic. I like this.  [Lane]Well, okay, so here’s the problem. When you’re looking at articles, the literature, you’re talking about all cohort, articles, right? So, Terry Donovan, the classic one is Terry Donovan looked at Dick Tucker’s nations, thousands of gold restorations, 40, 45 years and of course. Well, Dick Tucker did them. So attention to detail. A crappy fitting, indirect restoration is gonna have crappy longevity, period. It doesn’t matter if it’s submitted with panavia or zinc, oxyphosphate. So the truth of the matter is a well executed. A partial veneer, gold crown or even a gold crown will have a much longer run clinically in the mouth than anything else that we have today, meaning all ceramics because we just don’t have the longevity studies behind them. Again, lithium disilicate in its current form is pretty damn nice, but it took decor Empress two. Aris, which lasted a year before we got to emax. Same material, same company. It took four evolutions before we got there. And so again, we’re still talking 15 years, right? We’re not talking multiple generations. So there are people that are gonna go for longevity versus pretty. And I don’t wanna call it a marketing pitch to utilize metal in people’s mouths. It’s just a reality. Well, Mrs. Smith, what is your desire? Longevity, or pretty, you know, you’re say 45 years old possibly. If we make it pretty, you’re gonna have to have it redone once or twice in your lifetime. That’s just the odds. You’re 45 years old. You know, if we use metal and we’re conservative, you know, this restoration can last you the rest of your life. Okay. And just patients then pull their values into it. Right. It’s the patient’s why it’s not our why, you know? We’re, we’re just the providers of the how we do it. You know? We know what we do. Mm-hmm. We fix teeth, you know, it’s, how we do it is based on. The patients why? And this is why as you talk about Jaz understanding patients gaining their trust, don’t be in a rush to do a bunch of c when you first meet them. This is where trust and value are established. And so your words and your dialogues are actually being listened to versus just going in one ear and out the other. And that’s critical for all of us, no matter where you are in your career, because you always want to have the patient who is part of the decision process. You’ve heard my dear friend and my brother from another mother, Michael Melkers. I mean, he loves to quote Albert Schweitzer. Every patient carries within them their own best doctor. It’s our job to help them find that doctor.  [Jaz]Lovely. And Henry, just to add you, you mentioned, you know, better value for money. It was a paper I saw on the BDJ. It was maybe, gosh 10 years ago now. I saw it come through in the post and it was like, it had exactly that parameter, like, you know, gold this many years, therefore divided by the actual cost, whatever. And then, yeah, it came out the best in that regard compared to the data that we have for ceramics. And that’s exactly what Lane echoed and Julieta says, thank you. She always loved gold and now she knows why. Amazing. I love that. I guess last two questions guys. And then we will say a good thank you to Lane A higher asked, in what clinical scenarios might a THREEQUARTER or Seven Eighth Gold Crown offer a superior solution to full coverage? And what are the technical risks of these designs? I like this question.  [Lane]Well, again, at the whole concept of partial veneer is to save as much tooth structure as possible while, while protecting the cusps that are undermined, that you need to restore. So, properly done. There’s no need to do full coverage, right? Why? Why do you wanna do full coverage? You wanna cover from, let’s go from the top down. Alright, let’s do, why would we pick an onlay over a, a direct composite restoration Well, the cusps are unsupported. They’re gonna fracture. Then if there’s more of the tooth broken down, say the palatal cusp of an upper molar. Well, you know, now you’re going to circumscribe that, and that can be done with a three quarter crown, seven eighths crown may be necessary because, okay, now the buccal cusp of the tooth is broken. So we come around that we still have to cover the cusp. It’s just how much coverage do we need to integrate everything? There is a philosophy, this is my philosophy, so again, quote me versus date me. I would rather not for the reasons that Biomimetic talks about drop margins, past the gingival third of the tooth, not because of the more fringes and and strength, it’s just I don’t like margins, in non cleansable areas you know, it’s always still, I mean, how many patients do we see that still get, you know, caries on the roots, the buccal roots of their molars? So, that’s just me. But there’s really, in terms of longevity, a well-designed three quarter, seven eighths partial veneer crown is going to last every bit as long as a full coverage. And the reason we’ve gone back to partial veneer coverage and why I do like bio medic is that the more tooth we preserve means, the more we have to work with down the line. You know, there’s a point where a tooth can’t have any more work and we never wanna get there.  [Jaz]Well, whilst we argue about the, the merging data and how some of the data may be in vitro, and we need more in vivo to be able to substantiate some of the biometric claims. One thing Pascal Magne said in a recent podcast coming out tomorrow actually, guys on Protrusive, is he said, the meaning the real crux of biometric dentistry is if something fails, the tooth is still there to work with. And that’s gotta be loved, right? So, so that’s great. Thanks for your wonderful questions. Absolutely brilliant. Last ones a crazy one. What about a gold crowns on implants? I know of a madman who wants gold on implants? Are the, are there any strong contraindications? None whatsoever.  [Lane] Again, we started this whole conversation as gold’s weakness is its strength, right? Implants don’t have PDLs. Right? Think, about this. Can you, some of my biggest zirconia failures were all on Xs opposing all on X zirconia. They just broke and we’re talking well designed connectors. I mean, these, these things were thick, but yet they still broke. We sent them in for fractographic analysis. And the failure mode was, was again, one, was a tool grinding mark that just never healed it. But the sheer fact is that we, you know, having a softer, forgiving, adaptable material on top of an ankylos tooth, which an implant is, I think is a great idea. It’s just getting patients to accept it. So do it.  [Jaz]If Eliana, if you’ve got a madman go with it. Use it as an experience to, to deliver something that’s gonna probably stand the test of time. And you know, as we know, implants are ankles, as Lane said, so it makes a lot of sense, so amazing. We actually managed to r through all the questions. Lane wise, I love I just wanna show some appreciation. I love your just no BS way of just educating. Honestly, I just feel when you ask someone who’s a podcaster, and I don’t know maybe I’ve shown this publicly or not, but of any guest I’ve ever had. The history of Protrusive or maybe I ever will, you have been my favorite in the sense of easy to podcast because I ask something and you give a wonderful, coherent answer and then you stop and it’s like, wow, okay. That was like, you just put it on a plate for us and like you are like, okay, next. And honestly, it’s just brilliance. Thank you for your education style. Thank you for your wisdom. Thank you for all your contributions to our little community over this one year so far as we’re a baby community growing and thanks for everything you do. Everyone’s just pouring in with thank yous and it is just so nice to see. So Peter agrees with my sentiments there. And Miles, thanks so much for joining us to make things practical. Understandable. Amazing. Thank you so much, lane. Anything to add? Are you coming to, I know you hate flying. I doubt you’re coming to Europe anytime soon.  [Lane]No, but there, there’s these two guys that are speaking in Chicago, Midwinter at the AES next year that I think I will fly to see So.  [Jaz]Oh my God, that’d be amazing.  [Lane]For those of you who don’t know, for those of you don’t know, the American Equilibration Society is one of the premier restorative academies in America. It is a huge honor to be asked to present in front of this group. Mahmoud is online to speak at our 2006 meeting. So, you know, my hat’s off to you, from mentee to mentor. This journey is wonderful. Thank you for everything you do. The torch, honestly, my friend as, as a mentor, is a and an educator is being passed to you and I cannot think of a better person. So, keep doing what you’re doing, man.  [Jaz]I love it. So thank you so much. I mean, me and Mahmoud we talk about this the next year, February, and we get this major imposter syndrome because it’s such a amazing crowd and all these educators. And thankfully they gave us the paracetamol slot on the second day, first thing in the morning. But, it’s great. We’re hung over grumpy then. Perfect. Honestly, it’s so, I mean, what a what a what a lineup, right? We’ve got Jeff Rouse, Dania Tamimi, Łukasz Lassmann. So guys, I would love for as many people as possible in this chat here to come and join us in Chicago next year. You know, hot dogs on Michael. Michael’s gonna buy us all hot dogs. It’d be great. Oh, hot’s coming to a lovely, amazing place, so already what I love here is Vassi says, I can’t wait to re-watch this amazing presentation. And of course, for those in the future listening to Spotify and stuff, I hope you enjoy it as well. Lane, thank you so much from all of us.  [Lane]Thank you. It’s been a pleasure and an honor as usual. And hey, feel free to reach out anytime. If you know, I’ll leave one of my father’s favorite quotes about me. You know, most of you got to hear the real, heart Puller commentary in London. But my dad was always fond of describing me as well. He may not be able to dazzle you with his brilliance, but he’ll baffle you with his  Jaz’s Outro:Well, I like that. I like that very much. And it just wraps things beautifully with the, none of what you say is ever my friend. I love it. It is amazing. Guys, thank you so much for this rare live podcast lane. Thanks again for making time for it, and I’ll see you in the group and see you next year in Chicago. That was good. Bravo. Thank you. Alright. Thank you so much. Well, there we have it guys. Thank you so much for listening all the way to the end. If you’re watching on the iOS Android app or the web app, scroll down 80% in the quiz, if you dare, and you’ll get your certificate sent over to you. We are a PACE approved education provider. If you’re not yet a member, head over to protrusive.co.uk/ultimate. We’ve recently added splint course on there as well. So if you’re looking to learn occlusal appliances, you can check that all there. So if you’re looking to learn occlusal appliances and management of bruto and protecting that delicate restorative dentistry that you do, that’s now part. Of the Ultimate Education Plan.  I also wanna take another moment to thank my team, especially some new members that we have got Dr. Xyra who joined us about three or four months ago, and she’s responsible for really improving our premium notes.  Also, some of our infographics that we make, she’s spearheading that and honestly, we’re able to add so much more value thanks to Xyra Also, a shout out to Angel, who’s the newest member. She’s really helping a lot with getting these initial edits of the podcast before they enter an even media sequence, as well as a lot of the video work behind the scenes, including editing the 21 day photography challenge coming next month. And lastly, our new manager, Alex. Alex, has been messaging some of you on cursive guidance. Alex, you’ve been an absolute breath of fresh air. We are so lucky at Protrusive to have you. Thank you for looking after the protrusive so well, and being part of the team. I’m just so excited about how we’re going to grow our mission. To make dentistry tangible, prorate, watch this space. Honestly, it’s a very exciting time here at Protrusive and I wanna thank you all for being part of it. Thanks for listening. Again, I’ll catch you same time. Same place next week. Bye for now.

Can you apply the Dahl technique to localised POSTERIOR wear? Spoiler alert: hell yeah! How can the Dahl Technique help when there is posterior wear and NO space to restore? How predictable is building up posterior teeth (rather than the usual worn anteriors)? In this episode, Jaz dives into the ‘Reverse Dahl Technique’, a twist on the classic method typically used for localized anterior wear. Dr. Hans Kristian Ognedal from Norway shares his insights, explaining how building up posterior teeth with composite can lead to occlusion magic!  If you’re curious about this technique and want to see a real-life case study, this episode breaks it all down, with a special visual breakdown for those watching on YouTube or Protrusive Guidance. https://youtu.be/V8MTFfXmdlw Watch PDP235 on Youtube Protrusive Dental Pearl: Jaz shares insights from Hold On to Your Kids by Dr. Gordon Neufeld & Dr. Gabor Maté, emphasizing how modern children lose parental attachment too soon, turning to peers for guidance. This shift can lead to anxiety and emotional disconnection.  Takeaway: Kids thrive when their primary attachment remains with parents, not peers. Strengthening this bond is crucial for healthy development.  Need to Read it? Check out the Full Episode Transcript below! Key Takeaways The traditional Dahl principle focuses on creating occlusal space for anterior crowns. The reverse Dahl technique is a direct method for treating worn POSTERIOR teeth. Diet plays a significant role in tooth wear and dental health. Taking photographs of patients’ teeth can help track wear over time. Understanding the etiology of tooth wear is crucial for effective treatment. Building up dental anatomy is essential for successful restorations. Occlusion should be viewed as a dynamic system rather than a static one.  Patients can adapt well to this treatment modality “Patients that wear their teeth, they don’t usually have TMJ problems.” Highlights of this episode: 02:22  Protrusive Dental Pearl 04:50 Guest Introduction: Dr. Hans Kristian Ognedal 07:06 Understanding the Original Dahl Concept 09:31 Exploring Reverse Dahl Technique 13:30 Etiology and Patterns of Tooth Wear 23:46 Facial Patterns and Occlusal Traits Linked to Wear 24:44 Clinical Approach to Posterior Wear 30:26 Patient Comfort and Staging Treatments 32:11 Cuspal Planes and Guidance 34:21 Review Schedule and Observations 38:44 Longevity of Treatments 44:04 Contraindications and Patient Selection  45:24 Case Studies and Practical Tips 49:30 Night Guard Use 53:06 Final Thoughts and Education Opportunities If you want to learn more about Dahl Technique, be sure to listen/watch: Why do some Dentists find Dahl Distasteful? – PDP016 Dahl Part 2 (The Spicy Bit) – PDP017 Dahl Technique and ‘Maryland Bridges’ – GF001 This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes B and C. AGD Subject Code: 180 OCCLUSION (Occlusal functional concepts) Aim: To explore and understand the Reverse Dahl Technique, focusing on its application for patients with localized posterior tooth wear. This technique provides a solution when posterior teeth are worn, and there is insufficient space for proper restoration. Dentists will be able to – 1. Understand the principles behind the Reverse Dahl Technique and how it differs from the traditional Dahl Technique. 2. Identify the clinical scenarios where the Reverse Dahl Technique can be applied. 3. Comprehend the role of composite build-up in restoring posterior wear and its impact on occlusal reestablishment. Click below for full episode transcript: Teaser: I think it's a tooth where it's probably a modern disease of our own course. I think I disagree on that one. I think the patients that wear their teeth, they're able to load their teeth quite hard, much harder than I'm able to do. I have an interior open bite and the Class III, I've never been able to touch my front teeth. Teaser:I don’t wear my back teeth. I think I am not able to generate a type of forces that wears my teeth. But I think most patients who wear their teeth, they’re usually in full occlusion. I think having posterior where it’s more a function of consequence of how they function, how they chew, how they eat, how they swallow, how they process food when they take food into the mouth. Jaz’s Introduction:So whether you use it or not, I’m sure we’ve all heard about the DAHL technique, right? This is when you have localized anterior tooth wear, and what you’re doing in this case is you are building up the anterior teeth even though you don’t have space. And so because you’re building these teeth up, when the patient bites together, now they’re prematurely hitting their front teeth, the back teeth all open. There are like bilateral posterior open bites, and what happens over time is intrusion of the anteriors and you know, over eruption or Dento alveolar compensation of the posterior and the occlusion. Like magic reestablishes. So if you wanna go deep dive into that, check out our previous episodes on the  DAHL technique. Like these are some of the ones we did five years ago with Tiff Qureshi, and they are literally like Protrusive Wall of Fame. So do check out those and I’ll link them at the bottom. But today’s episode, my friends is on something quite different. It is same, same but different as they say in Asia, right? It is the reverse  DAHL technique. Now instead of having localized anterior tooth wear, we have localized. Posterior tooth wear. Think of that patient who when they bite together, their posterior teeth are just shot, right? There is exposed dentine, there is lots of erosion, and so you’ve got plenty of localized posterior wear. And then the premolars, canines and anteriors are maybe a little bit worn, but not that worn. And the problem we have is that yes, the posteriors are worn, but when the patient bites together, the back teeth are all contacting, meaning you don’t have space. So with the reverse  DAHL technique or modified  DAHL technique, what you do then is you build up the posteriors in composite, you leave the anteriors out of the bite, and then like magic, the posteriors will intrude and everything else over ups, if you like, and the context will reestablish. Now, our guest today, Dr. Hans Kristian Ognedal from Norway, does a wonderful job of discussing this technique and his experiences, and at the end, he shares a case. So for those of you who are listening, while you’re jogging on a train, while you’re driving, don’t worry, I describe the caseand the exact scenario. For those of you who are watching on Protrusive Guidance or on YouTube, you’ll actually get to see the images as well if you listen all the way to the end. I was quite excited to record this episode because it’s a, a new one, right? It’s a, it’s a new thing for me. I haven’t seen much published on the interweb about this technique, so hopefully you’ll learn something new. Dental PearlTalking of learning something new, every PDP episode I give you a Protrusive Dental Pearl. Now, as you know, I’m a family man, and for those of you on our community Protrusive Guidance, I’m always talking about the books that I’m reading, or actually I’m listening to on Audible. The current one, I just feel compelled to talk about it. It’s called Hold on to your Kids. Like I’ve got two boys, a 6-year-old and almost 2-year-old, and I think a lot about being a dad and being hopefully a good dad. I actually always wanted to be a parent. I actually love my role as a dad it’s my favorite title in the whole wide world. Quite often I’ll pick like, you know, parenthood books or relationship books because just like I’m interested in dentistry and I read their dental literature. I’m interested in parenting and being the best parent I can be. So I kind of am attracted to these kind of titles. Now, the book, again is called Hold Onto Your Kid, it’s by Dr. Gordon Neufeld and Dr. Gabor Matè. And it essentially talks about how in modern society, children lose the attachment to their parents too soon. And so what it talks about is that what children of modern society do is when they lose that attachment to their parent, they then gain the attachment from their peers. And then it’s like, you know, the blind following the blind and there’s a major cause of anxiety and disconnection from family. I’m actually now just getting into the really good parts of the book where it’s actually telling me solutions, right. You know, the whole several first few hours are talking about the problem, right? The problem of losing attachment to a children and how you cannot serve two masters so they can’t be attached to their peers. And attached to you as their parent. At the same time, they have to pick one. And the way that we have the schooling system, the way that we have social media and phones, that they’re constantly now messaging each other and they’re gaining their attachment from their peers no longer from their parents. Now we need that parent attachment for them to have a healthy emotional development and emotional security. So I’m listening in now to all the strategies we can use as parents to literally hold onto your kids and hopefully watch them grow into kind and courteous, and emotionally healthy adults. So I just wanna talk about this book and I want to share it with you, right? That’s my pearl for today. I know it’s not very clinical, but I like to talk about what’s important to me. And right now what’s important to me is parenthood, and I know so many of you are in the same boat as me, so check it out, hold onto your kids. It is quite heavy. It’s like one of those books, like, you know that book, why We Sleep? Like you can just summarize that entire book in one sentence, which is like, sleep is really important, right? So the vibe here is that parent attachment is very important, way more important than peer attachment. And so hold onto your kids, but really it’s the strategies that it gives you. So I’m just getting to good bits. Now. And if you’re interested in this, do check it out. I’ll put the link in the show notes now, let’s now join Hans for the full episode. I’ll catch you in the outro. Main EpisodeDr. Hans Kristian Ognedal, welcome to the Protrusive Dental Podcast. It was so nice, , just a few, a few months ago now, I think, to spend some, , time together in Bergen. And I was really amazed by this presentation that you gave, talking about this technique that we’re gonna talk about today. You know, Hans, I didn’t tell you this right, but this podcast right now, it almost didn’t happen. If you asked me 20 minutes ago if this podcast happening, I would’ve said to you no. Okay. Because we were having a Lego incident. We couldn’t find a Lego. [Hans]You couldn’t find a Lego. Oh yeah. The kids were going to bed and, , the Lego was missing,  [Jaz]I needed new Batman robot lego that we built yesterday and the issue that we turned the house upside down and obviously I was getting the blame that the Mrs. was blaming me. And then, anyway, she had tidy it away somewhere and she won’t admit it, but she found it and I’m so glad that we get to talk about, and this episode gets to happen tonight because you’re such a busy guy, man, and so I’m glad. I’m really appreciative of the fact you made time for this today. Of course, please, of course. Can you tell us about yourself, Hans? [Hans]My name is Hans easy way. I really enjoyed dentistry. I’m not a specialist, but I’m specially interested in dentistry. It’s my hobby, it’s my work. I enjoy every part of dentistry, I enjoy talking with colleagues, I enjoy treating different cases of all kinds. I love composites. I love ceramics, I love surgeries, and , the lecture you heard was about treating worn teeth. And lately that’s what I’m talking quite a bit about. And, and it’s also a problem that’s rising and you see more and more of tooth wear and yeah. So it’s definitely a challenge that has come into modern dentistry. [Jaz]Tell the listeners where in the world you are speaking from today, just so I want them get a better context. [Hans]I’m speaking from Stravanger Norway. It’s in the southwestern part of Norway right now. We are in March and we. Don’t have snow at the moment, but it’s just turned cold again, so who knows what’s going to happen. It’s generally a lot of weather on this side of the Northern Sea, more mellow. [Jaz]You showed me some images, family images of the weekend going skiing and stuff and I mean, that was really cool to see. And you’re a family man, but you’re a really great dentist, very well-rounded, and you know the amount of where you’re treating. I think we have so much to learn and unpick with you today, Hans. Yeah. I think want to start with just, just a quick review. I know I have episodes on this already, but for our younger colleagues just recap the original  DAHL principle that we kind of used today when we’re doing the anterior teeth. ‘Cause we’re talking about the opposite today. Yes. But just recap the anteriors. [Hans]To recap, the original  DAHL’s concept was about creating occlusal space for anterior crowns. And so they made from cobalt steel plate tooth that they either cemented or just attached to the front teeth and then the patient walked around, chewing on those and over time would create occlusal space for making anterior crowns. But  DAHL has evolved over time. And now that we have direct composites, most  DAHL cases are made with anterior composites. You build them up politically, and then teeth intrude or erupt and into full occlusion over time. So that’s the original  DAHL’ concept with a modern take on it.  [Jaz]And in Scandinavia and in the UK we’ve really embraced it. I feel like we are the pioneers when you obviously Scandinavia, but then UK is very popular treatment, here, whereas my dear friends in the States, they’re almost very skeptical about this. And what is your take on this? Did you know international friction to adopt it? [Hans]I think there are quite a few myths concerning occlusion. They’re kind of scary, so when I was a young dentist, we didn’t learn very much about occlusion, which is perhaps why I do what I do, because I don’t know, didn’t know enough occlusion or didn’t. Believe enough in occlusion we left. That hinder me. I think it’s a problem with breaking myths. It takes a long time to adjust to new information and or new information trickling down and especially on the  DAHL concept, which was a thing in the 60’s and 70’s, there hasn’t been much research on it after that.  And it’s also a fairly cheap technique. There’s no one willing to invest in it and invest in doing the research on it, because if you do it right, it’s really, really cheap and you can’t make money of it as a company. So that’s, I think it’s somewhat forgotten and somewhat lost in strong opinions on occlusion that confined around the world, if that’s fair to say.  [Jaz]That’s a really, really good point about a lack of interest from companies and the trade in this technique. ’cause it’s the way it is, right? And therefore that could be a fuel and the fact that it’s not been pushed about as much as it could. Now, what we’re talking about today is a different way of doing  DAHL. Now, I like to call this the reverse  DAHL technique, but what’s the difference between the reverse  DAHL and the modified  DAHL. When you say that, do you mean the same thing or what do you mean? [Hans]Yeah, I think we mean the same thing. I was able to have a conversation with Reyes recently on the  DAHL technique and what he’s doing, and I told him what I was doing and yeah, I think it’s the same thing. It’s just, I chose to use the word modified because I don’t think it’s really reverse. I like the name. [Jaz]I think it’s cool, like Opposite  DAHL technique, Reverse  DAHL technique. But yeah, I see it okay so guys, when we say modified or reverse, we, we mean the same thing.  [Hans]Because a reverse start to me would mean that you grind teeth down to let them over the rough. That would be the opposite of doing good. Well, the opposite of want to what you want to achieve.  [Jaz]Exactly. Now we know there’s the direct composite splint technique, which I did have the authors of that paper on the show two years ago. We know when you have a cracked molar and you actually bond composite. To make it in supra occlusion and then the composite will stop the cusp from flexing at the same time because that’s the only tooth and occlusion that’s going to intrude. Then when you take off the composite, you now have occlusal space. Is this something that you did first or you entered into, or I guess share your journey about how you first got into this? Was it from anterior  DAHL to in posterior a modified way? How, tell us more about that.  [Hans]Well, I started like everyone else doing the Anterior  DAHL, and then I started to struggle with what you do when you wear your molars. And in the beginning I did what I was taught. I was taught to do gold on lace you can make them really thin so you don’t grind away too much tooth, or if the tooth was damaged in other ways, you could do a crown. So that’s without touching the vertical dimension. So that’s where I started. And then I thought, okay, this is going to be really expensive for the patient, or some patient couldn’t afford doing treatment that way.  [Jaz]So when in those scenarios we have, posterior only wear the way you would manage it traditionally at the beginning was gold posteriorly to rebuild the structure or or protect the integrity of those posterior teeth, right? Now, when you were doing that, you were still conforming or were you opening the vertical dimension on the gold?  [Hans]No, I was still conforming, trying not to open the video. If I was, I would combine that with doing something interiorly because I was really afraid of opening the vertical dimension and-  [Jaz] Despite doing the anterior DAHL stuff. ‘Cause for me, early on in my career when I started to do dial, that was a massive help in losing that fear, right? When you start doing  DAHL and you do a lot of it, you’re like, hang on a minute, my patients aren’t dying, their condyles aren’t popping out. Maybe we’re okay.  [Hans]Yeah. Like I said, this is really early, so this is maybe 17, 18, 20 years ago, so because I’m not a young man anymore, but then it kind of progressed. I started covering exposed dentine, I thought, well, at least I’m going to buy this patient maybe a year or two.  And it’s really easy to do just flowable composites and when a referred patient to orthodontists to have work done, not particularly wear patients, but they were putting on, oh, we need to elevate the bite we’ll put on like three millimeters on this tooth and the patients didn’t seem to complain about it, and I thought, well, maybe I should try putting on a little bit more. And then I knew that if you want composites to last, you need millimeter and half. I thought, well, well, let’s try that one. Let’s try putting on a millimeter and a half.  [Jaz]So kind of like you applied the bite turbos in the orthodontic world to this setting. It’s interesting though, Kushal Gadhia, a restorative consultant once taught me years and years ago, and I love it because sometimes patients tolerate big changes in occlusion better than the tiny changes. And that was like a really funny thing to learn actually. And I think it holds true.  [Hans] Yeah, I think there’s some truth to that. If you’re off by a 10th of a millimeter, that might be quite painful for the patient. But if you build it up two millimeters that doesn’t seem to pose a problem. Patients usually tell me about, it feels a bit weird the first, first week or so, and then it feels fine, they’re not bothered by it. There might not be an occlusion at that time, but they’re not bothered by it anymore.  And some people just forget that they’ve had it done at, or they just function normally. Through the day, and when you see them next time, they’re almost in full occlusion. So I have done that on single teeth. I have done that on just a few teeth, but usually when I do posterior buildups are that high. It’s part of a full case where you do multiple buildups.  [Jaz]Okay, well let’s move on to that then. Let’s imagine a case of localized posterior wear, right? So we’ve got anteriors that typically look pristine, right? And maybe they have their mamelons got the incisal halo. They usually have good looking anteriors, but the posteriors are worn into dentine. I think it’s important to discuss the etiology aware in these patients. What have you found was, was the cause to factor in these patients that pattern aware? [Hans]The pattern aware. I’m not sure if I have a part in my lecture where I talk about the pattern aware and usually I divide the cause of wear. It’s, well, I’ll have to go back to what’s erosion, what’s attrition, what’s abrasion, and I find that in most cases there are some assets involved there’s some erosive component involved in where, and if you want to see that, okay, there’s no most likely an erosive component. Where’s that acid coming from? Is it internally or is it externally? So having a chat with your patient, having the patient make a chart of their diet for a week, for instance. And then you can go through that with your patient and try to pick out stuff. And you can see, because you can’t really tell if the assets from the external or internal. From the pattern of wear, because I think the pattern of wear is probably due to the way the patient chews, how the tongue covers the teeth, how the cheek covers the teeth. So you can’t really say, is this internal, is this external? So if I can’t find anything in the diet that can cause that type of erosive wear, of course we’ll have to look at, do you have some type of reflux? Is it, you might not have symptoms on reflux, but you might still have reflux. I’m not sure if you think know the term silent reflux and I, I apologize for my English. [Jaz]It’s oh, dude. You should hear my Norwegian. It’s not very good. No, dude. Honestly, you’re doing great. But they’re silent reflux, quite classically. People say that you have like this, like, like this, like a little cough that’s called kind of is pathognomonic of this.  [Hans]Yeah. But you have to kind of tease it out in the conversation because they haven’t really thought about it and they say, well, I haven’t really thought about it. And then you see them in a couple of weeks or a month later and they come back and say, well, yeah, actually I feel some of the things that you’re talking about. [Jaz]So at that stage from you, is it before you do the treatment, is it referral to the GP or how do you make sure that before you start treatment you fix it? [Hans]Referral to the GP, sometimes referral to gastro. There are some new guidelines and gastro in Norway. So now they start treating on suspicion. Instead, if you’re un under 50 years old and they suspect that you have some gastric reflux problems, they start just treating with Antiacid right away. So because they think that swallowing a camera and doing pH measurements is, is way too invasive and takes too long and costs the society too much money, so much easier to get a packet of tablets and try it out.  [Jaz]It’s like, you may not be treating the root cause, you’re just kind of medicating the issue. But that’s a, a whole different topic as long as the acid is not destroying the teeth, I guess. But ideally in a utopian society, it’d be different.  [Hans]If you are discussing the root cause, I think the diet, not the modern diet, is an underlying cause of most of these ailments. So diet is underlying gastric reflux, obesity, and also tooth wear. Because we live in a world where all food is you can get hyper palatable food that is really scrumptious to eat, sometimes very high in calories, sometimes no calories, high in acids, and zero nutrition. And I think it’s a tooth where it’s probably a modern disease of our own course. Whereas in the past, like if you see there, I went to the London Museum and saw the old Egyptians in there and had took pictures of their teeth, and they were eating drains with sand in it, and of course they’d bought their teeth, but now we know better. But now we’ve caused our own problems by having the food industry working.  [Jaz]So to add to that, professor Bartlett, when I was his DCT trainee, probably the worst train he’d ever had, but he, he taught me one thing, which was when you have the purely Attritive patient, the patient who’s like, you know, a severe grinder and you can imagine the tooth contact time for that individual, you know, during the day and night could be high in an imagined scenario, but even that patient will not wear away their teeth that much because ultimately enamel and enamel is like two similar AKA identical materials rubbing on each other. The wear is not that extreme compared to, let’s say, rough porcelain against enamel. The enamel will take a hammer, right. So actually when you put a one drop of lemon in the equation, you see serious escalation. So I’m glad you started with that, that actually acid erosion’s a huge, huge player. And when we see these worn teeth, don’t ever just think, oh, this grinding is, you know, 99.99% time, there will be acid erosion and that’ll probably be the primary player.  [Hans]I completely agree. I have some bruxist in my practice, there’s some psychiatry involved in bruxism, at least with a patient I see. They have maybe a tick, like they’re tapping their teeth or grinding their teeth and those cases are of course, really, really problematic to solve. And of course it’s also psychiatry, which means there’s less income. There’s yeah, all sorts of problems regarding those patients. And of course my composite doesn’t last as long, but you can redo ’em. That’s the beauty of this technique that we’re going to talk about is that you could just redo it, you can sandblast it and you can put on some extra.  [Jaz] As Tiff Qureshi who, who does so much for  DAHL and making  DAHL accessible to dentists around the world, and what a absolute legend he is. I love his term, you know, recycling the  DAHL, you know. Five years, 10 years later, recycle my patient’s on, on her second recycling of the  DAHL right. And it’s just amazing what you can do exactly how you explained.  Just find up on the etiology so why do patients present with localized posterior wear acid erosion a huge player. I, and please, like, correct me if I’m wrong, because I feel as though you have a lot more experience in looking into these localized wear cases. I feel as though these patients may have started with an anterior open bite type of occlusion whereby, they already had a heavier posterior occlusion, and then when you put the acid to compound on that, it’s like the opposite to the deep bite patient. Think of the deep anterior deep bite patient where they, they destroy the anteriors more and the posterior are sped it’s like the reverse situation. Where you’ve got the class three or the A OB, the posteriors are just get more chewing time, more contact time. And then when you throw acid into that, by the time the posteriors have then worn down, the anteriors now are getting in contact. This is just my theory and this is what, what do you think about this? [Hans]I think I disagree on that one. I think the patients that wear their teeth, they’re able to load their teeth quite hard, much harder than I’m able to do. I have an anterior open bite and the class 3, I’ve never been able to touch my front teeth, I don’t wear my back teeth. I think I am not able to generate a type of forces that wears my teeth. I do have jaw pain though.  On the opposite side, you have the patients who never have jaw pain in in the muscles, and they. Are usually in full occlusion. They have a really heavy bite on and they load all their teeth because they need all their teeth to support that amount of force. I have this one patient who he managed to intrude his teeth. He had a full arch bridge on 11 teeth, and he managed to intrude that bridge into his gums. So that’s an outlier of course, but I think, most patients who wear their teeth, they’re usually in full occlusion. I think having posterior wear, is more a function of consequence of how they function, how they chew, how they eat, how they swallow, how they process food when they take food into the mouth. I think that’s probably more important because I don’t think none of these patient, I think it cry to having a anterior open bite that usually means patient with anterior open bite, usually have a large maxillo mandibular angle. They have usually like a long face like I do, usually more crowding. If you have a tongue thrust, you’re biting on your tongue which kind of stops you from biting too fast.  So the interior open bite cases, those are actually the cases where I don’t recommend doing a modified  DAHL reverse style. If they wear their teeth, they usually, they wear their cusp, the molar cusp, they wear them flack because they, that’s the way they function horizontally. But when they’re worn flack it stops. If you don’t put acid in there, or significant amounts of acid, even with exposed dentine, that where just stops when the cusp are ground down and the patient functions in laterotrusion, then it stops in those patients.  [Jaz]No, no. Definitely. Where when I observe that you find that, yeah, the molars are very flatten, but they stay like that. When you see them year after year, and you could do a time lapse and, see how, how they progress and they stay very stable.  [Hans]Yeah, I definitely do recommend taking photographs, following your patient with wear. It’s always beneficial to have a long-term relationship with your patients, so usually if you could at least observe them for a year or so, that would be nice. If they’re in pain, if you have to do something. Yeah. You don’t have to shy away from that rule and, and treat them of course, but if you can spend some time with them, have a checkup or, or two, take some photographs and sometimes information pops up. That’s really interesting to know.  [Jaz]It is important to have those conversations and plant those seeds. [Hans]Oh boy. But I place a lot of blame on, on diet, but of course, there’s some environmental courses as well. So if you work in industries like smelting, there’s sulfuric acid in the air. If you work in swimming hall, the chlorinated water. Chlorinated it with highly chlorinated water that also may cause erosive wear.  If you’re a farmer, you’re using methyl acid you use it to preserve grass in dairy. Okay. That will also be in the air while you’re working with it so I’ve seen a few farmers having worn their teeth, and I think it’s probably due to that because couldn’t find anything in the diet, couldn’t find anything on reflux, so possibly environmental for them. So it’s a good thing to know your patient and have a conversation that you’ll learn. Surprising stuff once in a while.  [Jaz]So that’s where the occupation history and the social history definitely comes into play in these erosive cases. That’s a hundred percent for sure. In these cases, Hans, have you noticed a pattern of types of occlusion? So do you find that you’re seeing more class 2 people, class 1, class 3 people? Like any traits that you see people with shorter faces, stronger muscles, traits that you see?  [Hans]Yes, definitely. So in the literature it is called Brachy facial Patients, the square faced patients. Those are definitely on the wear list of patient who wears their teeth. You can also see that kind of in the middle, the miso facial patients, and then you’ve got long face patients where you don’t see much wear, but usually you see more TMJ issues. So definitely it’s the Meso facial or the squareish face patient. I usually take pictures of my patient’s face from the front and from the side, and that’s quite informative sometimes.  [Jaz]I think that’s so important for anyone who perhaps doesn’t do that. Sometimes when I was younger, I was only taking photos of the teeth and I was missing that information. And I think the more you appreciate the face and the role of that and the muscles is definitely a great, great idea to start taking that facial photo as well. Let’s imagine that example case that we’ve imagined there are posterior localized wear, and we’ve said that “okay this patient has probably a brachy facial, strong muscles, silent reflux, and they’ve managed to see their GP, and let’s say they’ve controlled it, and now you’re looking to treat and plan this case because this patient’s young. The primary reason to treat here is not aesthetics, it’s far from it, is to preserve their teeth to make sure that they will keep their teeth for as long as possible, right?  [Hans]Preserve the teeth, but ultimately also to preserve aesthetics and functioning. Because if you lose your modus it will inevitably hurt your front teeth over time. [Jaz]Do your patients complain of sensitivity?  [Hans]Yeah. Then usually I do an impression just to have a model so I can have a look at the model and the way I do the reverse or modified  DAHL, it’s a direct technique so after I’ve assessed the models and I’ve checked the curve of speed and check if are there any interferences for the teeth to either erupt or intrude, and we’ll have to have a chat about eruption and intrusion after this one, then I build up to, usually when you worn down to the dentine, you’ve worn about two millimeters off the molar cusps because young molars and young healthy molars, they have about two millimeters of enamel on top of the cusps.  So, if you add back anatomy and use anatomy as your guide, you will add about approximately the right amount of composite to the top of that tooth for the composite to be fairly aware assistant to not break.  [Jaz]The first question I have there, Hans, is it makes sense to use anatomical norms ’cause that will give you not only the right form and function, but also actually gives you the right amount of thickness for your composite anyway, which, like what you said right in the beginning, but just to go back one step, we gotta talk about it, right? Joint position. Right. In these cases, are you using centric relation as your guide or not? How are you recording the joint position before you wax it up on the articulator.  [Hans]Like I said, my occlusal education was very poor, so I usually start from MIP from full maximum inter cuspation. And since after I build this up, the patient rarely hits more than maybe one point on each tooth, maybe on the seventh so I try to kind of divide the forces between 3/ 7 and 4/ 7, for instance, and you’re hitting just two points. It’s really, really, really easy just to make sure the patient hit those two points about the same time just for comfort. But otherwise the occlusion will evolve from there. So the occlusion will evolve from there to what I’m thinking is that, Joint position in these cases doesn’t really matter because you’re working in a system where everything changes. I think we as dentists now, and I think this is part of why occlusion has become such a difficulty, is that we’re thinking of our mouth and our teeth are static because they are firm there’s no cells that change the surface and not like the rest of the body.  But the truth is teeth are living, teeth are moving and they are in place because of all the functional forces that are on them. They’re tongue, lips, cheek, chewing forces, habitual forces are keeping teeth in their place. And so we’re working in a system that that changes all the time. I don’t think really think it matters. What I do think matters if that when you cover that sensitive dentine, the patient will be happy for it and we’ll be able to chew off of that and we’ll be able to have a glass of wine and some shrimps and a shrimp salad sandwich without being in pain, which is from day one after doing that treatment. [Jaz]Okay. Well, in this case, I love the idea of the second molars in equal intensity contacts, but in a typical case that you’ve treated, is it just the second molars that are getting the composite or are you having to do the second molars? The first molars and the second premolars, but actually because you’ve built them up to anatomical form, it’s actually only the second molars because the way the jaw closes that are taking the contact, that will then intrude and then, then the second, the first molars and the premolars will eventually come into contact. Just explain that.  [Hans]That is completely correct way to put it. Just because the function of the jaw, how the jaw functions, you will only be hitting your most poster posterior teeth when you’re doing those buildups. But of course, I take the. Opportunity to build up the rest of the teeth that are worn, but the patient will, of course, only hit on the most posterior teeth. [Jaz]And in this case, would you typically just do, like, obviously I’m sure you’re looking the anatomy of the teeth and you’re thinking, well, both the upper and the lower are destroyed. So let me add in wax on both, or like split the difference or do you tend to have a strategy to preferentially wax up one arch more than the other? Or what have you found? Or is one arch more affected than the other usually?  [Hans]I usually don’t do wax up. To me, this is a direct technique for different reasons, but I’ve been practicing my anatomy for a long time it feels really easy for me. [Jaz]So it’s a free hand technique? [Hans]It’s a free hand technique. [Jaz]That’s so cool.  [Hans]So you don’t need to use technicians or use wax-ups. Those techniques are for the really, really difficult cases where you don’t have. Much anatomy to guide you. So if the teeth are completely destroyed, maybe you lost a third of the occlusal height, completely exposed dentine, then it becomes a lot more difficult to do those buildups because you don’t have any reference points. I find that my technique, I was lucky to be able to see one of Didier Dietschi lectures on interceptive dentistry, and he does that directly in the mouth. And this technique resembles a lot his technique, but he’s of course much more fluent in occlusion than I am. So he takes that into concern but he says the problem is how to get enough space for the most posterior teeth, and this technique, the reverse  DAHL, the modified  DAHL. That’s the answer to that question. You let the teeth move so you build up. So yes, you build up all the teeth that needs to build up.  [Jaz]Yeah. So upper as well as lower, basically  [Hans]If there’s words on the upper. Yes, I treat those as well, perhaps not at the same time. Perhaps we’ll do the lower first and then we’ll wait a few months before we do the uppers, just to make the patient a bit, a little bit more comfortable. But I have treated patient who wanted to have it all done in one go, and of course, they ended up maybe with a 6 millimeter anterior opening afterwards. Yeah, it worked out. But usually I have patients that are close by so we can stage the treatment a little bit more and perhaps make it a little bit more comfortable. Although I haven’t had any patients really complain about discomfort.  [Jaz]Well, we’re gonna unpack about, when you monitor these patients, how long it takes and whatnot. We’re gonna get to that. But just one little thing, which I find amusing is that if I was doing this treatment, like if I’m building up the lowers, I would be looking at the upper and if I’m seeing like a really sharp cusp, I’d be smoothing it down. Do you adapt to that as well? To, to try and get nicer forces? [Hans]If you have a really sharp cup, I, I know about your contracept of Robinhood dentistry, but in this case, we can do more Oprah Winfrey dentistry so you can get a filling and so if you have a really plunging cusp in the upper and you have composites or amalgams, uppers and lowers and you need to, and they kind of born u-shaped. Yeah.  Then I would probably just build up old teeth during a short period and then you’ll be able to lower the Cuspal planes. So that you get the Cuspal plane won’t be as steep anymore. And you can build the cuspal planes so that they’re less steep than the canine planes, and that takes away a lot of those problems. So the patient get more freedom and attrition in and horizontal movements, and you transfer guidance to the anterior or the canines.  [Jaz]Okay. So let’s talk about that. You’ve just done, let’s say the, the lower second molars and the first molar and the second pre-molar. When you deliver this, the contacts equal intensity only on the second molars ’cause the way the jaw closes. Yeah. But at that moment in time, do they still have some canine guidance? [Hans]Well, it depends on how deep your bite is. So if patients with really deep bite, when you open them a millimeter and a half posteriorly, they still can touch with their front teeth. They can still bite off food with their front teeth. So some patients are like that. Some patients have less where you open them up. They don’t have any contact on the front teeth. Doesn’t seem to matter much. Both groups of patients, in my experience, doesn’t really experience much discomfort.  [Jaz]Are you having to adjust the excursions in any way to make sure they’re to a particular liking? [Hans]So that’s what you do on the follow-ups because after doing a full jaw buildups, at least I’m really tied. So I’ll just make sure that they’re hitting those two points. And you’ve made cusps a cost. We’ll have some planes to them. So you can have, sometimes you have to adjust for excursions on the cusp, and sometimes you can use cusps to kind of guide teeth into the right position if you have a pronounced curve of spee for instance, in an older patient, you get most of the tooth movement, I believe, is in the lower jaw you get intrusion in the lower jaw. And that can open contacts and then you can use the cuspal planes to kind of guide those teeth and close those contacts over time.  [Jaz]But the day they leave you, when you fit them, obviously with Tide and stuff, but when they grind left and right, it’s not only the dots on the second molars, but they’re also grinding on these second molars. Right. And, but that’s okay. That’s how you leave them. [Hans]Yeah, I’ll just leave them like that and, but sometimes, of course it’s composite you can adjust it. And like I said, you’re also in a working environment where everything changes. So what might be completely fine on the day you leave them. Might not be fine when they come back after usually I have, I see them after a month to do some adjustments. Hopefully we’ll get to talk about how we do that. I do that, but yes, you can be mindful of excursions. Not too mindful though. Because now you just built up those teeth and everything’s changed for the patient. Nothing works the way it used to. The neurology isn’t there. Reaction patterns aren’t there. So that just needs to settle. Patient just needs a bit of time.  [Jaz]Okay. And the patient then goes away. What’s your review schedule like for these patients? Like how often do you see them and then more importantly, what have you observed, Hans, when you’re seeing them they come back at week one. They’re like this, they come back at week five, and I, I’d love to know. What is an average of what you’ve what you’re seeing and when do they fully establish contact?  [Hans]Yes. I think we have to stop talking about the Curve of Spee in this case, because teeth have a constant width. They don’t change the width unless you, you grind on them or on them. So the curve, it works like a bridge, like the keystone in a bridge. So if you try to compress the curve, compress the teeth into the curve, for instance, for uppers, if you want to intrude uppers, that’s really difficult because. You’re trying to put teeth, trying to compress those teeth into a curve, that means you have, might have to release, do some IPR between those teeth to have them intrude and the same with the lowest, the curve of speed. Usually if you have intrusion, then intrusion is easy, but if, if you want them in a younger patient, if you want them to erupt. That means you might have to release little bit in between the teeth to give the teeth an opportunity to erupt into the curve.  Other than that, you might, sometimes you need the help of an orthodontist if you really don’t want to grind on teeth or there’s no opportunity to grind on fillings or things, and sometimes you can just leave it like that and just be aware of that. It just takes a lot longer when the teeth have to move a little bit horizontally to adjust for that curve of speed.  So when the patient comes back in after a month, they usually see them after one month. They’ve been well informed about this being a bit little bit awkward in the beginning and after a month, they’re well on the way. Usually they’ve closed more than half the way down after a month. [Jaz]Do you think there’s any condylar repositioning happening there? Do you think that very quick change? Like in the anterior  DAHL we say that if you see a lot of change happen very quickly, that’s not necessarily intrusion and dento alveolar compensation, that could be the condyles repositioning. Have you suspected the same in your cases?  [Hans]Why not? Why shouldn’t that happen? Everything else changes. I do think I think in terms of how fast the patient comes back in a rule of thumb is that a tooth can move about a millimeter per month. So to me it seems like that’s approximately the rule that I follow. So that’s why my take is that it’s probably mostly intrusion for those patients. I check with my foil, I check with my contact paper, and also I use a floss. So I check the contacts with the floss. If they’re really hard, that tells me something about how the teeth move. So if you have a really hard contact and it didn’t use to be really hard, that means that, okay, if it’s in the upper jaw, yes this tooth is probably intruding. If it’s in the lower jaw, then yes, this tooth is probably erupting and you have to decide if you want to give, make some space for that. So that’s what I do on normal checkups. But most of the time patient is completely fine. Yeah, it was a bit awkward in the beginning. Feels better and better. Then we do an evaluation. When should I see you again? Perhaps I see you in another month. Perhaps I see you in a couple of months and sometimes patient close the occlusion really fast then, is that, no, I can’t be bothered by coming back. We’ll see you at the next checkup. So, and then they do, and it’s, it’s fine.  [Jaz]Well, a bit like the question I have my mind now is a bit like orthodontics. Like I am imagining at that first review that there will be some increased physiological mobility of those second molars, which is part of the process, a bit like ortho patients, aligner patients, when you take off the aligners, there’s some mobility and for a younger dentist who’s never seen this before, that can be quite worrying, but just it confirmed. Have you observed that? And just to reassure everyone.  [Hans]That definitely happens. And in one case, I built the posterior cuffs, I built them too steep. I was into a pronounced anatomy at the time, and I, of course, had to adjust for excursions on those teeth and they firmed up. And for the next checkup, they were fixed again.  So, yes. Be aware of teeth moving. Sometimes it’s a good thing, so sometimes it’s a bad thing and I’m not sure if me adjusting the occlusion on those teeth helped or contributed to do the case or was irrelevant to the case. It might have just solved by itself without me intervening.  [Jaz]Good point. And in these cases, when you see them again and you follow them up, what percentage, fully established contact, and then how long on average does that take? Does that take like a, a year, two years, you know, quicker on younger patients? Longer and older patients kind of thing?  [Hans]No, I think it depends on how much force the patient is able to put on a teeth. Most people I treat for posterior wear are not young guys. They’re, they’re older people. They’re 35, 40, sometimes 50’s and deruptive potential of the teeth is not, is not really high. In  DAHL study, he said that his patient, his selection of patients, and that’s one of the myth myths of  DAHL, is that it’s about 60% eruption and 40% intrusion, but that’s the average of the selection of the cases that Dahl investigated. But he says in his article that it seems that eruption is more pronounced in younger patients. And intrusion is more pronounced in older patient and he related that to facial growth and facial changes as you age. So it kind of depends on the age of the patients. If you have an old patient, you, most of the changes will probably intrusion and if you have a very young patient , most of it will probably eruption. [Jaz] And at the end, once a teeth established contact. Are there any adjustments you need to do at that point, or do you find that this everything just falls into place nicely and you don’t need to do any adjustments?  [Hans] Yeah, usually I don’t need to do any adjustments. But I do think about occlusion when I do the buildups. Like I said earlier, I prefer to make the cuspal planes less steep than the canine plane, so the patient usually ends up in anterior or canine disclusion canine guidance. Do you need canine guidance to function for most patients, probably not, but it’s a way to possibly save my restorations a little bit longer just to make them it last a little bit longer, to not place them under tensile forces and try to make all the forces on the composite compressor. [Jaz]Very true. And that’s a huge tip right there, guys. You know, Hans said to try and keep your restorations under compression ’cause our materials can handle that much better. And so you mentioned the word longevity to make it all last longer. What do you tell your patients and you know, sometimes we, what we tell our patients is not what actually happens. You know, we actually hopefully undersell it and over deliver. So how long does it take until Hans is gonna recycle a posterior dial case?  [Hans]I’ve haven’t had to recycle many of them so far. I’ve recycled a couple of them and that was like 10 years and 12 years. So last quite a long time. Then I have a couple of patient who crushed their composites. So the composite looks like gravel on top of their tooth. And we had, and then I said, okay, this is, we need ceramics here.  So sometimes that happens, but then you’ve created a space for the ceramics so you can do the ceramics much more minimal and invasive. But I do think that ceramics does have a, apart from being quite expensive doing ceramics, I think they do have a place in the posterior  DAHL, modified  DAHL technique as well. And if you’re really brave and know, think you know what you’re doing, you might go directly to ceramics.  [Jaz]That was just what was I was gonna ask, basically, I mean, I’d only trust you to do that because you know, I think you need a bit of experience when you’re doing these kind of cases I guess. But have you done that then? How many cases you’ve done? Yeah. We’ve just gone to ceramics, especially nowadays with the, I’m recording soon with Pascal Manet on occlusal veneers, right. And you know, 0.4 millimeters zirconia, occlusal veneers, or maybe some thicker lithium di silicate ones, so minimal prep, ’cause you already have the thickness, ’cause you open the bite. There could be some benefit here.  [Hans]But I’m thinking also that you’ve negated the problem so you don’t have to make really thin occlusal veneers. Yes, I’ve read about it and read the some research on it. And it’s quite a favorable prognosis, but you don’t have to make 0.4 millimeter occlusal veneer. You can probably make them for a decent thickness that really make them last because teeth will move and perhaps you can do this, do a temporary in composite, just a quick and dirty one. And then wait for occlusion to settle, and then you can do it in, ceramics to give a very long lasting restoration.  So in a few cases you’ve had to do that because they’re trying to destroy the composites. But in a lot of these cases, you’re seeing ’em last and you’re probably saying, you’re probably just observing and monitoring. Yeah. I think it depends on how much of the damage is caused by the patient’s by attrition, how much of the damage is caused by erosion. So how much just physical and how much is chemical? So I do, I’ve seen patients that have followed up for a long time and which they have mostly erosive wear.  And then you see they undermine the restorations that I’ve done. So the restorations are still there. The enamel around it just kind of disappear and then you have to go back. But then it’s composite so you can go back in and you can put the rubber dam on and you can do some air abrasion and you can, I love my aqua care for that. Do some air abrasion and then you can just bond may highly filled flowable or maybe normal paste composite and just repair those damages and then you can go on for a long time.  [Jaz]Brilliant. And just ’cause we’re wrapping up now, I’d, I’d love to see Hans, if you are able to on the app or on YouTube, have you got maybe a, a before and after when the occlusion was established, just an example case to help the visuals? [Hans]Yeah. Let’s do that.  [Jaz]Okay, so while you are doing that, and, you’ll see the share button at the bottom. I’m gonna ask you, I’m gonna be very naughty and while you are focusing on get finding in case I’m still gonna ask you some questions. Okay. So you have to multitask big time. Okay. Yeah. Contraindications. Are there any contraindications to this technique that you can present to, a very keen young colleague who might say, oh. I’m gonna try this tomorrow. Can you put some shackles on them and suggest some contraindication?  [Hans]Anterior open bites, do not do this in anterior open bites. The diagnosis is the selection, worn posterior teeth. Those patients, when you give them that diagnosis that you have posterior tooth wear, that’s when you can do this type of treatment.  [Jaz]Kind of those tough cases where you’re scratching your head thinking, how do I fix this? Because there’s so much more wear posterior than there is anteriorly, and you’re kind of like scratching your head and then you think, ah, yes, this technique exists.  [Hans]Yeah. So you already selected your patient by having a patient having wear. So, it’s important that there is wear, and also if you can stop the wear by getting the patient to change their habits. Even exposed dentine will last a really, really, really long time without wear. So you might not need to do buildups. And that’s why I said you have to have a proper diagnosis. You have to know why the damage, why is the patient looking like the patient does right now, before you start doing any treatment. So that’s my take on it. And also patients with TMJ, then again, you normally don’t have occlusal wear. Avoid opening the bite on the posterior, it might be quite painful. So let’s see if I can share an image with you from a case of done. This is the posterior doll case, so I’m just gonna describe it for those audio listeners. [Jaz]Right. So those on Spotify and Apple, some beautiful rubber dam dentistry going on here with the beautiful Teflon ligature as well. And it’s a classic erosive case with the wear. You see the cupping, I see some attrition as well on the second molar. So yeah, the kind of like the scenario we described. [Hans]Yeah. So we abrade that, clean it up well, put in some separation between the teeth and then start building up. I usually start a little bit on the marginal ridge then cusp by cusp. Your comms are beautiful man. Yeah, thanks. Thanks, lovely, Nancy. These sessions are quite enjoyable for me. I love building that up. And this patient, you see, that’s him right after, he has quite a deep bite, so it’s a deep bite patient, but with those crowns on the centrals, but rest of the teeth unrestricted. Yeah. So probably a trauma case. Yeah, a trauma case when he was quite young. Those crowns are made by a dentist in London, not by me. He was working there at the time. Really nice crowns in, in my opinion. So that’s right. Straight up, right after I’ve built those teeth up, you can see there’s a little bit of marks on top of the cuffs there that’s not really context, just an abrasive mark from the occlusal paper. And these are pictures.  [Jaz]So lovely shot here. Clearly showing the posterior separation. Yeah. In the premolar region. Right? So obviously anterior we can’t appreciate it ’cause you have someone with like a complete a hundred percent deep bite and now they have like a. 90% deep bite. Whereas on the premolars, you can see how they’re outta the occlusion now because you’ve only treated here second molar, and first molar, and lower only.  [Hans]Yeah, lower only on this guy because well, we’re staging the treatment on, on him, and like you said, he has bit of a plunging cusp on the upper, so perhaps I should have done the upper at the same time, but. I know, well, he’s local here, so I know I’ll have to treat him several times during his lifetime, at least my professional career if he decide to stay with me. And this is about, let’s, I have to check my notes on this one. Sorry. [Jaz]Hey, this makes you so happy. This, this, this is the money shot right here. This makes us happy. So guys, we are seeing the photo right, of the established occlusion and it’s just a thing of beauty. Yeah. Right. Those premolar spaces have been filled in just in a marvelous way. And the intercuspation here on the left especially is really beautiful. Yeah. It’s he’s really back to where he was before we began and he’s got the a hundred percent deep bite again, or maybe the 99% deep bite again.  [Hans]Yeah. It’s back to having a deep bite. He will, think should you really do orthodontics to fix that deep bite perhaps? I don’t know. He seems to work well.  [Jaz]It’s another option, right? You fix the deep bite and you create some space posteriorly. But then that’s, that’s a very tricky case in terms of Anchorage stuff, right? Because you’re trying to intrude the anteriors and intrude the posteriors. And so that’s a very tricky overall case I think. [Hans]I’m really happy to refer orthodontics to an orthodontist, so I’m not doing much of that myself, but that’s two months after on this guy.  [Jaz]Two months. That’s very impressive.  [Hans]Yeah, so like I said, it depends on how much force the patient is putting on on their teeth and how fast they can move them. And I think the case that took the longest, took about three years. I built her up, then she got cancer, got really, really sick, hospitalized for a long time, and of course teeth didn’t move but when I saw her a year ago, she was back to being healthy and then in full occlusion. So something is happening. There are some muscles involved I think. But she was comfortable all the time, even though her bite had hadn’t closed all the way, it just closed partially. She was comfortable, I said, okay, now that you are ill should we just grind away some composite to make you more comfortable? And she goes, no, it doesn’t bother me at all. And when I saw a year ago, she was back in full occlusion. So changing the occlusion doesn’t really matter. And as you said on the lecture, I saw you on you shouldn’t really be touching your teeth. Too much anyway during the day, during the 24 hours of the daytime. [Jaz]Very true. And the only question I have now, ’cause I know someone’s gonna mention the comments, right, is they’re gonna say, I think I know what you’re gonna say as well, and they’re gonna ask you, do you give the patient a guard after they’ve established their occlusion?  [Hans]Yes. Sometimes I’ve tried that. Generally guards are not used for a long time, perhaps maybe a month or two in the beginning. If the patient is still thinking about it and then they forget the guard when they go to their cabin or to on holiday.  [Jaz]To my cabin- [Hans] To my cab. Yeah. Reminds me, yeah, that one was really good. [Jaz]Reminds the performance  [Hans]Maybe to know what the f— says. So I think compliance on night guards to stop where is poor and I’m not always sure that it’s the nighttime where that is the problem. Perhaps it’s the daytime wear and then I’m not wearing a guard anyway, so I usually, I don’t do guards right now. [Jaz]I just still want to see what you are practicing.  [Hans]I don’t do guards. I thought I should tell this will wear and next time we’ll add some composite again. And you’ll wear that away again. I think that is more comfortable for the patient. But of course you have some patients who are really, really conscientious and, and are able to wear a guard during nighttime every night and do that consistently over the years. [Jaz]Hans, you would’ve seen in Didier Dietschi cases that he shows, right? He shows he’s like ridiculously brilliant 30 year follow ups, of anterior resins. The thing he says, which is the same thing that Tony Rotondo said last year when I saw him speak and show his like 22-year-old re recall is. The only reason this patient’s composites look so good is not because I am a master, it’s because she wore her night guard every night, and that literally, that’s what he said in his words. So sometimes when you get that patient who really wants to keep things. Things pristine. Yeah. And if the nocturnal brox has been an ecological factor Yeah. Then that can help longevity. But I completely take your view that it takes a special kind of person to be able to comply as good as those patients. [Hans]Yeah. Like I said, it has to be nocturnal where, and it has to be a really conscientious patient. They do exist, but how many patients, how many night guards do you need to make? To treat that one patient who will actually use it.  [Jaz]Asymptomatic patients ha have got the poorest. If you’ve got symptoms, you’ve got TMD and you’re symptomatic, and then you are, you are willing to wear even the most wackiest of spin. Yeah. But when you give an asymptomatic individual an appliance, then you will definitely get have to accept reduced compliance race. We’ve across the hour you are approaching midnight, but yes, so I wanna make sure that you get to bed,  [Hans]I’m fine. I’m happy, talking with you. I just wanted to make one last point.  [Jaz]Yes, please.  [Hans]Patients that wear their teeth, they don’t have TMJ problems, so they’re asymptomatic in the first place. So that’s a point to you that giving asymptomatic patients splints doesn’t really work well and sometimes if they’re dentists, they might. If they’re dentists, I do treat some dentists as well.  [Jaz]That’s very true actually. And, what, what you mentioned there was just on last point, what you mentioned there was is very true that the patients who have wear on their teeth, they often don’t have stresses on their masticatory system. With those patients whose periodontium. Has taken all the stress. Yeah. They often don’t have the wear the opposite in a way. Right. So, sometimes patients have lots of wear but no jaw issues. Sometimes patients have mobility in their teeth, but no wear.  And so this is all part, like the weakest link theory that is really good paper attached to this episode and it’s like trying to put patients into boxes, just like a stupid little thing to do, but it kind of explains what we see in the real world. Hans, thank you so much for this. Please do tell us about any education you run. I know you’re on the lecture circuit. If you’ve got any education coming up that you’d like our audience to tune into. I’d love for you to talk about that, my friend.  [Hans]Usually I lecture in Norwegian mostly, at least for now. Perhaps this will change after this podcast. You have a, you have a very widespread audience around the world at the moment. I do not have anything coming up. I’m very involved with building a new clinic. So that’s mostly what’s on my mind and we’ll see what opportunities comes later on. Other than that, if you want to see me, I do run the continuing education with the four fellows of mine here in Stavanger in this part of the country. So you, you can come see some of our courses if you like. We have some quite interesting ones-  [Jaz]And your Instagram handle so they can see your lovely photography and–  [Hans]It’s tannlegognedal it’s in Norwegian, my last name, and Tan Legg, which is dentist in Norwegian. So that’s my Instagram handle and you’re free to share that of course, on your video if you like. [Jaz]Amazing. No, I always tag our guests in, in the description. So Hans, thank you so much.  [Hans]Yeah, thanks. If anyone has a question, I’m really happy to answer them. Send me a message on Instagram. I think that’s easiest. No worries.  [Jaz]And send Hans a message on Insta or comment below. And I’ll tell Hans now and again check it and to hopefully see lots and lots of thank yous and honestly, Hans, thank you for covering a topic that is not widely talked about and it’s a really good minimally invasive solution when we’re scratching our head running out of ideas ’cause yeah, classically, yes, gold on Lays or these ways of doing it, but to raise the vertical dimension on posteriors only can be a very scary thing to do.  When you are, you know, let alone doing anterior  DAHL for the first time to do this Reversal  DAHL. And I think you’ve just covered it really well in a really pragmatic way. I like that you’re not using wax up, you’re not using funky stuff, you’re just building them up to anatomical form and you’re letting nature do the rest.  [Hans]And of course scanning has worked wonders. You ask about injection molding at one point, why not? But then you all already has involved some very heavy technology so you can manage the occlusion in a whole another way. This technique, the reverse  DAHL really started as a, as a really hands-on, direct composite way to do it, just to minimize the expenses of having models, having wax ups, doing difficult occlusal stuff.  [Jaz]Hans, appreciate your time and thanks so much for everyone for listening to the end. Jaz’s Outro:Well, there we have it guys. Thanks so much for listening all the way to the end. Now you know about the reverse  DAHL technique. If you’re inspired by this and you wanna learn more about the normal  DAHL technique, then again, I’ve linked it all in the show notes. This episode is eligible for an hour of CPD or CE Credit Suite are a PACE approved provider. Now that you’ve done the hard work of listening to someone talk about teeth for a whole hour, just answer the questions, get 80%, and you get your CE certificate. Our CPD Queen Marie will look after you and just like this, you can gain so many hours. Throughout the year making this one of the most valuable subscriptions that you have. So if you’re interested in joining us and join the nicest and geekiest dentist of the world, check out Protrusive Guidance. It’s an app on iOS, Android, but the best way to sign up is on the laptop. First, go to Protrusive.app. Sign up to your level of subscription, if you go for the ultimate, you get all my master classes as well, including my premium clinical videos. I wanna thank you again for listening. I wanna thank the team of Erica, Gian, Krissel, Julia, Nav, Emma, who at this moment in time is doing her finals, so wishing her all the best. And with that, my friends, thank you so much. I’ll catch you same time, same place next week. Bye for now. Oh, and don’t forget to give this a thumbs up.

Do you feel confident managing patients with TMD or oro-facial pain? Are you clear on when to treat conservatively—and when to escalate? What’s the best SEQUENCE of care for TMD patients? Emma returns to Protrusive Students fresh from her finals, joining Jaz for an insightful episode on the basics of TMD management. Together, they explore the foundational steps of TMD care, from proper diagnosis to the logic behind a structured treatment hierarchy. They break down conservative versus aggressive approaches, share clinical tips for muscle and joint assessment, and highlight common mistakes to avoid—especially during palpation and history taking. Whether you’re a student, a dentist returning to practice, or just want a refresher on TMD, this episode will help solidify your approach and boost your clinical confidence. https://youtu.be/p5VJzwSka94 Watch PS016 on Youtube Need to Read it? Check out the Full Episode Transcript below! Key Takeaways TMD is a complex topic with various treatment approaches. Patient education is crucial in managing TMD effectively. Physiotherapy can significantly aid in TMD treatment. Different splints serve different purposes in TMD management. Bruxism can be a silent issue that affects many patients. Identifying the source of pain is essential for effective treatment. Stress can exacerbate TMD symptoms in patient cohorts Continuous learning and resources are vital for dental professionals. Highlights of this episode: 02:35 Emma’s Finals Experience and Advice 05:16 Deep Dive into TMD: Clinical Insights 09:59 Common TMD Disorders and Their Presentation 18:31 TMD Treatment Options 28:00 Medications and Appliance Therapy 34:25 Practical Tips for Managing TMD 37:19 Addressing Bruxism and Patient Communication 41:00 Protrusive Pathways and Future Plans 43:46 Protrusive Students S2 🔗 Protrusive Resources OPPERA Study Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group† TMD Therapy Hierarchy of Management Effects of occlusal splint therapy in addition to physical therapy on pain in patients affected by myogenous temporomandibular disorders: A pilot randomized controlled trial Splints Decision-Making Flowchart  📚 Protrusive Pathways Structured playlists grouped by topic (e.g., TMD, bridges, onlays): TMD Content Playlist 📝 Crush Your Exam Student NotesDownloadable summaries by Emma, covering TMJ anatomy and function, are available inside the Protrusive Guidance App (request student access via Mari) If you loved this episode, be sure to watch TMD New Guidelines! Evidence-Based Care – PDP213 #OcclusionTMDandSplints #BreadandButterDentistry #Communication This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes  C – Maintenance and development of knowledge and skill within your field of practice. AGD Subject Code: 200 – Orofacial Pain / TMD Aim: To provide a practical, evidence-informed framework for the conservative diagnosis and management of Temporomandibular Disorders (TMD). Dentists will be able to – 1. Describe the three major categories of TMD and their clinical features. 2. Differentiate muscular from joint-related symptoms using simple chairside tests. 3. Explain the rationale for a conservative, staged approach to TMD management. Click below for full episode transcript: Teaser: TMD is one of those things, which is like so debated, so hotly contested, so controversial. Right. Teaser:Taking these broader categories, like how do these typically present in practice to during an exam, or does it chop and change for every patient? I tell ’em, I’m not a guru. I don’t know what’s gonna work. But can we at least try things that are conservative and then we can always escalate to more aggressive things?  Jaz’s Introduction:Welcome back to another Protrusive Student episode. Emma is back after finishing her finals exam. So, in Glasgow where she studies you do the finals exams in your fourth year. And so she’ll be soon heading into her final year, which is fifth year. So it’s strange that they do their final like academic exams in their penultimate year, but I guess that’s how it works there. And I’m pleased to say she passed. She passed, and she’s back again for this series called Protrusive Students. Now it’s not just for students, it can be provision for someone returning back into dentistry or validation for many clinicians. Or maybe you are feeling that TMD is not your hot point, and so this is a great basics episode to lift up your foundational understanding. Now, it’s very tough to cover TMD in this short episode, but the main takeaway I can tell you now is the hierarchy of treatment or management is probably a better word than treatment. We do talk about a few clinical gems and a few pertinent points in someone’s history. Or the common mistakes we make when we’re palpating the joints and the muscles. But if there’s one thing that you’re to take away from this foundational episode on TMD management is the hierarchy of treatment and why it exists. What are the modalities included in conservative care and what are the modalities that are deemed more aggressive? And why we should have a bit more logic and sequence to how we treat our patient. You’d be able to download my hierarchy underneath the link if you’re on the app. And of course, for the students out there who have exams coming up or want some really good revision notes, Emma regularly updates the Crush Your Exam section. So in this section on the Protrusive Guidance app, you can access it on your phone or on your browser, anywhere you like, and you can download revision notes. For example, PS006 was indirect restorations, a really good overview for young practitioners and students. And for this episode, you can get everything about TMJ anatomy, which is so important. How can you understand what pathology is if you don’t understand what normal anatomy is? So to access that, just head over to protrusive app. Make your free account and join the ‘Are you a student?’ section. If you can verify you’re a student, you just need to DM Mari on the app. Her name is Mari Benitez. She’s like our CPD Queen, also student lead. She’ll just need some proof that you’re a student and she’ll let you access the Protrusive vault, which has got like all our infographics and papers. It’s our way of like supporting and nurturing you students. But like I said, this episode’s also useful for those who have a bit more experience, who are qualified, and you can even get CPD or CE credits for this episode. We are a PACE approved education provider. For that, you need one of our paid plans, and you scroll down, you answer the quiz. And Mari, our CPD Queen will arrange your certificate. Let’s now join Emma the Protrusive Student and welcome her back for this episode. Main Episode:Emma, welcome back, the Protrusive Student. Congratulations for passing your finals like in Glasgow. You do it in the fourth year. Tell us how was it?  [Emma]It was intense, but I made it through. I think anyone that’s done final exams before. You’ve just gotta keep your head down for a bit and get through it, really. But I survived. So here I am.  [Jaz]Never in doubt, Emma. Never in doubt. I remember we were chatting before you getting results and it’s sometimes difficult to gauge how you’ve done, like I was convinced, I failed. Like it was that one of the OSCEs went that bad. But actually I did end up doing very well and so it was a bit of a family joke now about how I catastrophize. That kinda stuff. But yeah, it was all good. And now that you’ve been through it, what’s the number one advice you can pass on someone who’s gonna be maybe doing finals next year, for example, or coming up imminently?  [Emma]I would say don’t underestimate anything ’cause they will just ask you anything question by-  [Jaz]You’re supposed to make it, like you’re supposed to make them calm and reassured that, that’s gonna overwhelm them like to the nth degree. But it is what it’s.  [Emma]I think you can either be one of two people. You’re either gonna be someone that knows a little bit about everything or a lot about certain subjects. So for me, I’m one of those people. I like to know a little bit about everything. There’s not one specific topic that is my absolute ride or die or something that I’m bagging on on coming up in the exam. I’m one of those people that like to try and cover everything-  [Jaz]And that’s strategy, right?  [Emma]I would say for me, definitely. Yeah. But I know some of my friends, they pick the topics that are quite common year after year, and they will know them inside and out, and they’ll compromise on the other topics that they just don’t have time for. Because you’re never going to know absolutely everything unless you’re you and you get a hundred percent in your finals.  [Jaz]That was one exam. But with you, what’s the pass percentage?  [Emma]I think like in Glasgow, I think it’s around about 60%.  [Jaz]In Sheffield, it was 50%. If you get 50%, you can be a dentist. Which coming into it like from a level, right? And like as a 19-year-old and going to dental school and then you get told that, hey, you just need 50% to become a dentist. And I was like, wow. Okay. But it’s tough, right? Yeah. That’s why honors is 65% and then you get your 50%, you’re like, whew, phew. That was hard kind of thing. Right? And it really puts you in your place. But I think the most important thing is they wanna see that you’re a safe beginner and that you are gonna go out ’cause epitomizes the fact that dentistry is something that you really learn once you qualify rather than in dental school. And so good. I’m glad you got through that. Today’s episode, we’re talking about something that I like to talk about. We’ve done episodes for dentists in the past, but today we’re gonna make it very student specific for you. TMD, TMJ. How much of the previous episodes on TMD have you listened to? How much, how much information about TMD have you consumed? I know you’ve got a really good tutor in Glasgow, Dr Ziad Al-Ani, who does wonderful work with occlusion, TMD. So I imagine you, your knowledge is better than the average student, I imagine.  [Emma]I think Dr.  Al-Ani is absolutely amazing. We have him a lot in first and second year, and then when we come back to do a lot of TMD and oral medicine and fourth year we go to Dr. Rob Riley. He’s an oral medicine specialists, so I think they teach us a lot. How much is examinable and relevant for new graduates? Unsure, but it’s all things that you need to be aware of. We go pretty in depth for TMJ, TMJD, big topic in Glasgow for exams and things.  [Jaz]I’m thinking that you probably know more than the average student about TMD. So like how much background knowledge, is there something that you are lacking confidence on or you are feeling confident on? Like where’s your head space around TMD?  [Emma]I would say for TMD, it’s one of those ones I quite enjoy, especially working for Protrusive. Like it’s something that you like to talk about, you talk about quite a lot. So working with you for the last few years and editing those episodes and doing all the notes in them, it is something that I think I have a bit of more of a background on, but it is a big topic, big, big topic.  [Jaz]But like it’s one of those things, right, where, yes, you learn about it and then you read them articles about it. You go to the books. But then when you have that patient and they give you this history, and then you are like, whoa, what’s the diagnosis? And then, you think, okay, how do I manage this? It’s actually, it’s one of those things that I think is one of the most difficult things to apply. And Jeff Okeson. The Jeff Okeson. I’m literally staring at his textbook in front of me. He says that TMD is a thinkers game. Right, very much is a, it’s a bit like ortho, right? Like it’s all the planning, the bracket’s fine, they go where they go. But it’s all about the planning and the sequencing and the diagnosis and that kind of stuff. So really, I want you to ask away any questions that you think will genuinely help you and students everywhere and we can, yeah, I think it’s nice to go back to basics, but here’s an interesting, I’ll just set the scene a little bit, right? TMD is one of those things, which is like, so debated. So hotly contested, so controversial, right? And I say this to my patients when they come to me and they expect me to be this like, or, you know, this guru that’s gonna cure them. I’m very quick to educate them that, hey, if you go to seven different practitioners, they’ll give you radically different. So it’s not even like slightly different. Like if you have a broken tooth, it’s either gonna be a crown or a filling. Very rarely. Or someone might say it’s restorable, not restorable, right? But like it’s gonna be a crown or filling. For TMD though, you have jaw pain. You can go to someone, they will say, you need ortho. You can go to someone and say, you need botox. You can go to someone and say, do you know what? Just go physio only. You’ll be fine. And so it’s a really tough space to be a patient in general anyway, it’s a very debilitating disease. It’s very, very debilitating. Has a huge impact on the quality of life on our patients, but it’s also more troublesome because as a patient that you are trying to read up on it and you are like, whoa, like I’m so confused. There’s so much out there, and then also gets carried through as a clinician. Because we then, there’s not just two polarizing camps. It’s about five different polarizing camps. If you listen to Daniele Manfredini, one of my friends, Morten, he went to his like a live thing in Italy, and he will get rid Italian hand gestures and he will bang the table and he says, occlusion has nothing to do with TMD. Right? And then he will put the splint in and just send the patient away saying, because why? Because occlusion doesn’t matter. Right. Whereas I’m training with Dr. Rob Kerstein, who’s coming to the UK in September. Hopefully we’re organizing that and he’s gonna give me hopefully, what we call DTR certification, which is basically Disclusion Time Reduction therapy, which is basically adjustments of teeth, of their own teeth to get them onto canine guidance as soon as possible. And you monitor it using these EMG things. And so what he’s saying is occlusion is everything to do with TMD and so I’m looking at these two camps and I’m like, whoa. And then the other three camps are lurking in between. And then there’s a bazillion, gazillion different types splints. So no wonder, Emma, it’s confusing. How can I help? Where do you wanna start?  [Emma]So, as students, as we get so much thrown at us, just information to remember and to recite and exams. But in dental practice, and I understand you probably see a lot more TMD patients than the average big time, but what are the most common temporomandibular joint disorders seen in dental practice? [Jaz]Okay, so if you can just categorize them broadly into three main categories, there are lots of subcategories. So TMD is an umbrella term, right? It’s a bit like I give the analogy of like, for example, if I say someone has perio disease, we automatically think of like pocketing and chronic perio disease, but actually, perio disease encompasses like a traumatic occlusion causing mobility. That’s the type of perio disease. It could be periodontal disease around an implant like perio-implantitis. It could be perio disease in the form of recession. They just have, they don’t have any like mobility. They don’t have any pockets, but they’ve got loads of recession. That’s the type of periodontal disease. Periodontal disease has lots of sub classifications and diagnoses. And so TMD has lots of sub diagnoses. So if you look at the actual, official, research diagnostic criteria of TMD, there’s like 13 or 15 different sub classifications. But broadly speaking, it’s muscular. Okay, so it’s extracapsular. So basically the capsule is that piece of anatomy that sort of encompasses the ball and the socket, i.e., the condyle and the fossa, so everything that happens in that space to do with the disc, and that’s intracapsular. Extracapsular, everything outside of that. So we’re thinking muscles, right? Yeah. And then there’s osteoarthritis. So this is like classically bone on bone. It’s like a wear and tear disease. So if you look at those three, then the most common is muscular, right? 70%. And then, it’s like a 25% intracapsular. So this is like clicking, locking, clunking popping, that kind of stuff. Very similar terms used on purpose. And then there’s osteoarthritis. There’s like degenerative, right? So there, over the years there’s been wear and tear. And classically you get crap as they open and close their mouth and you feel this like crunching and their jaw joint. But classically, they don’t have any pain. And so yes, there’s crossover, right? You have all three at once or you have muscular with intracapsular. But those are the broad ones, and muscular is the most common.  [Emma]The most common, yeah. So I suppose this is also a very broad question, but taking these broader categories, like how do these typically present in practice to you during an exam? Or does it chop and change for every patient?  [Jaz]Yeah, it can be. So TMJ right? It’s called the Miracle Joint, which is Dania Tamimi came on the podcast and said it so elegantly, but it’s also TMD is called The Great Imposter. Did you know that? So you can have like-  [Emma]I’m sure I’ve heard you say that before. [Jaz]Yeah. Yeah. So you can have like many other issues like tinnitus and headaches and vertigo and all that kind of stuff. But actually it’s a TM joint is a main culprit. So, it’s a great imposter for that reason. So how does it present? We’ll put it this way, because I get referrals for TMD and patients seek me out for TMD and actually as a clinician, I’m happy to say this, I know patients watch my podcast, which I wish they didn’t, but they do, and I’m happy to say that I’m happy to help. I’m empathetic. I’m a sympathetic, but I’m no guru. Right? I try and follow the best evidence available, which isn’t that great anyway. So I try and do things in a way whereby, okay, let’s do the most reversible and basic things. Safest things first, and escalate from there. And the peak of that would be surgery. So very few people need to escalate to that. Lower down is botox. Anything that’s irreversible, like orthodontics. We say that until we’ve exhausted, like, education, physiotherapy and appliance, that kind of stuff. Now, going back to your question, how do people present? And the reason I mentioned why I just mentioned now is when I used to be a purely a general dentist and I would just do a TMJ examination and I would diagnose, did you know you have a click? Or, oh, your muscles are quite sore, aren’t they? And so, that was not a symptom. It was a sign. A sign is something that the we find. But the patient hasn’t quite yet. It’s like subclinical and so success rate was through the roof because actually it’s not become a big problem yet for them. But now when patients seek you out for this care, then quite often they’ve had it for a long time. It’s very debilitating. It’s like trying to help someone when they’ve got small caries lesion and that it’s completely asymptomatic. Asymptomatic, so you know that the risk of root canal is so low. Versus they come in and they’re already in pain. And so, you know, pulpitis has started, there’s a higher risk of root canal treatment ensuing. And so it’s more difficult to treat, it’s more difficult to preserve pulp vitality. So I’m making that comparison because when I now see my patients, they have very clear like headaches, jaw clicking, jaw locking. Whereas when you have general patients, they often have have zero issues. A really good study to look up, Emma, for all our colleagues listening. So it was the opera study, I think it followed like 3000 or 4,000 healthy people who did not have TMD. Right? It followed them up then they saw who got TMD and who didn’t. Really fascinating, right? Prospective study. And then they kind of looked at these, they studied the people who did get TMD and they found like commonalities. Now they didn’t really go into the occlusion kind of things, but it was like genetic testing. They were often quite in a high state of stress. They had a few other things. Like they had like tummy issues like IBS, their gentle symptoms. They had other, like back pain, muscular aches around the body. So there was a common trends in these patients. So what that can teach us that it can affects a very specific kind of person. And in my practice, and also according to literature, it’s like eight to one females to males, eight to one. So we know it must have a genetic or hormonal component if that’s the case. So it’s that kind of a patient that can come to you. And I think one thing, one tip I can add is that if that patient comes to you and they’re complaining of a jaw issue, then Schiffman found a really cool way to figure out, okay, is this patient’s concern more muscular or more joint? So is it intracapsular or extracapsular? Is that you get the patient to say, can you point with one finger where the source of pain is, and if they point right by their ear, then it more than likely probably is intracapsular something to do with the capsule, the disc, the clicking clunking, that kind of stuff. Or if they’re pointing all over their face or lower down, then it’s probably muscular and that can help you to kind of figure out where to delve deeper into in their history.  [Emma]Okay. Yeah, that’s some good, like the clinical tips because just when you’re starting out as a student, you’re just feeling and you’re kind of blind at that point. You don’t really know what you’re looking for. So that’s some good-  [Jaz]What you mentioned there, what you’re looking for that, I mean, the top tick in this basic episode is classically when me and Krina are the physiotherapist I worked with and taught with in the past is when we’re calibrating dentists on palpating muscles and palpating the joints classically for the TMJs, we are too far anterior. We’re like feeling the zygomatic. We’re you’re kind of feeling your cheekbone, right? You go a little bit closer to the ear, right? And then when you get the patient to open a bit and wiggle side side, you should feel the balls of your condyles. Can you try that for me, Emma, right? Can you put your fingers, put your middle fingers that say just in front of your ear, and then open a bit and wiggle your jaw side to side. Did you feel the balls of your condyles, like against your fingertips, you’re in the right place now. Right? Okay. Whereas classically, if I don’t do that, wiggle bit classically, dentists are too far forward. The other thing I found is that when dentists are palpating the muscles, and we’ll talk about that if it leads that way, we’re being too gentle. We need to really be a bit more thorough when it comes to muscle palpation. And so it’s very difficult to talk about something that I wanna talk about so much about, but I’m also mindful about keeping this in tune with relevant for early career. People or students, or actually, this could be a good revisiting for someone getting back into practice or someone who actually feels though, you know what? They ought to just get the foundations of TMD. And so far what we’ve said is it’s an umbrella term. It can present in loads of different ways, but classically, muscular is the most common. But obviously there can be like clicking popping. We can talk about the mechanism of that as well. And just to like calibrate, like make sure you are palpating the right place and you’re able to at least locate the condyle and check the mouth opening. And I guess we can talk about the key things to record, but I want you to lead the show, Emma.  [Emma]Yeah, I mean the next question I was going to ask you was, we start basic patient education and you can go all the way up to surgery for treatment options and it obviously depends on the diagnosis. Should we dive into that sort of treatment options?  [Jaz]That sounds great. Let me share my screen. So if those of you are listening on Spotify, don’t worry, we’re gonna describe it. But there’s a really cool thing that I want to show, which is like a really nice pyramid, that we’ve been working with, which I also share my patients that I show them, okay, this is where we’re at and this is where we’re heading, and this is how we manage temporomandibular disorders. We don’t treat TMDs. We help to manage TMDs. And they kind of get it and they understand why. A really good thing that Jeff Okeson teaches is that, okay, there’s things that we know are like evidence-based, even though the evidence-based quality can be poor. And one of the reasons it can be poor is because there’s so much variability, Emma. Like your joint anatomy will be different to mine, just ethnically, genetically, you are a woman. I’m a man. Your tooth contact time, how many minutes a day your teeth come together is different to mine. Your incisive classification is probably different to mine. And so one of the reasons why the research is so different is ’cause it is difficult to compare. And get good research quality basically in that regard. But it is nice to be able to educate in terms of, okay, why we follow a certain hierarchy. Because as Jeff Okeson says, okay, let’s try and focus on the things that are reversible. But then, if you are treating someone and you’re doing what we call fringe treatments, treatments, which are, are not really evidence-based, they may be perceived that maybe be a little bit naughty, bit irreversible like orthodontics, but at least you’ve tried all the basic things first ’cause that could have helped. But then also at least, you know, okay, what I’m doing is on the fringe and to know you’re doing it. The worst thing you could do is do hocus pocus dentistry that isn’t evidence-based. But you’re not, you don’t really know that you’re on the fringe. You know, that’s the one of the worst places to be is what Jeff Okeson teaches, and I really respect that. Okay, so where we start is patient education, right? One of my mentors, Jamison Spencer, he taught me that TMD patients are nuts. Okay? They’re NUTS, okay? What I mean by that is, is not what you think. It’s NUTS means Not Understanding Their Symptoms. That’s what NUTS means. So we owe it to our patients to educate them, okay? About their anatomy, about what’s going on ’cause believe it or not, there’s a handful of patients every year. I see that just by education, I don’t like to use the word Cure, but I Manage them. They literally are really help. And even like sometimes telling the patient that our teeth shouldn’t be touching together during the day, and they’re like gobsmacked. They’re like, what? I thought our teeth should be touching together the whole time. And once you tell ’em that, and then they’re there in the chair, they’re clenching away. And when you tell them that, hey, this is pathological, this is not good. And then finally, after so many years of their life, they’re able to give their muscles rest. That’s it. They’re essentially managed, right? So we owe it to our patients to give them an explanation. Sometimes the patients are just, they’re not really, are not in pain. They’re just scared. Like, wait, what is this clicking? What’s happening? Am I gonna need surgery in the future? If you just explain to ’em what a click is and we can talk about that, then this is why this education is the foundation. Okay. So, any questions on that before we move to the next bit?  [Emma]Well, in terms of education, sorry. Not in particular, no.  [Jaz]Okay, so the next thing is, soft foods because we have to remember that the temporomandibular joint is indeed a joint, right? So if you have it as something dodgy, a dodgy knee, well you’re gonna go crutches or put less load on it, or not do strenuous activity. So when people are having a flare up of their TMJ, so for example, their joints themselves or the muscles, it just makes sense to eat as we had recently on an episode as well. Dr. Suzy Bergman said eat smaller, eat softer. Eat slower, right? Smaller, softer, slower, the three S’s. So it makes sense ’cause it gives the joint rest. So we educate our patients to do that. As part of education we also say, our teeth shouldn’t be touching together. And like I said, that can be very curative for a lot of patients. We tell them what a click is. So a click, Emma, do you know what a click is? Like what is that click sound? What does that mean? What’s happening to your disc?  [Emma]Is that in the disc displacing?  [Jaz]So when I open-  [Emma]Or reducing it?  [Jaz]Let’s, okay, so what does reducing mean?  [Emma]So reducing means it’s going back into its original position.  [Jaz]Lovely. And so, what Dania Tamimi came on the podcast maybe a few episodes ago, and she had this wonderful way of explaining it, is think not of disc displacement with reduction ’cause reduction is confusing term. Think of it as disc displacement with recapture. By using the word recapture, it really is like a light bulb moment, don’t you think?  [Emma]Mm-hmm. Yeah. Yeah.  [Jaz]So when you open and that click comes, that’s not what a lot of people think. Even Prosthodontists, I know of the thought this is, that they think that click is bad and that, oh, your disc is dislocating out of position. ‘Cause that click sound means it’s dislocating. No, that click means that the disc is already out of position and that click is the disc returning back onto the condyle is the sound energy of that motion. And so actually it’s a disc displacement with recapture. And so just going back on the education bit there, the next bit in the hierarchy is so TMD education, soft foods, and then ice and or heat. So, heat is really good for muscle, but sometimes they need to experiment and they do like hot and cold or just cold. Whatever makes ’em feel good is a simple, cheap, minimally invasive evidence-based way to help sore muscles and reduce inflammation. The next one is gentle stretching, because a lot of times your muscles can be in spasm and when muscles are in spasm to allow them to have stretching is really good. And to actually go forward towards jaw exercises like very specific exercises. Then in tandem with physiotherapy. Physiotherapy has got some decent evidence base when it comes to TMD. Chiropractors on the other hand, don’t have it. So like a patient the other day asked me, should you know I’ve found a good chiropractor? Should I go for them? I’m like, yeah, you can, because if it’s gonna help my patients and if my patient thinks it’s gonna help ’em, then that’s great. I’m happy for it. But if you have to spend good money, then why not do the more evidence-based thing first? Try the physio first. Knowing that the chiro is probably a little bit more in the fringe. And so it makes sense. And so physios can be incredibly helpful. Like my physio, I use Krina in central London. She does dry needling, she does red light therapy. She does very carefully targeted exercises. And that can actually improve their range of motion. So initially they might be opening 32, 35 millimeters without pain. And then after her physio, they’re able to get a 20% improvement in their range of motion. So, that’s there. Anything there before I escalate to the next two, which are more conservative?  [Emma]I was going to ask about like, all these stages and about soft diet. So are these things that you would do, the first two in tandem and then you would review after a certain period of time? Or would you just take it step by step by step?  [Jaz]Yeah, really good question. I think it depends on who’s in front of you. But most patients. Most patients, right? Because these are all basic things. Like you can do TMD education on everyone. If they’re actively in pain and the one that complaints is that it hurts to chew hard foods, then soft foods, it will be a mainstay ice and heat for those in pain. But sometimes the patient’s not in pain. They’re just like, they’re getting lock without any pain at all. There’s no pain. They’re just locking down. And again, so for that patient, you may not be necessarily saying, okay, put ice and heat ’cause they don’t have any pain. But it’s more about them giving them specific exercises to strengthen certain muscles to help their coordination, to help them unlock themselves at will. So, like you can’t go wrong by knowing these. But you might that pick and choose a few of these and emphasize more on certain facets of this, on certain patients than others. And that kind of depends on the micro diagnosis or the problems that your patient presents with. [Emma]Okay. That makes sense. Yeah. And about the physiotherapy as well. How, like just out of curiosity, how often are you sending patients to physio?  [Jaz]I would say 80% of my patients would benefit from physio.  [Emma]Okay.  [Jaz]Because it’s like a lot of times if I send a physio, then we may not even need to do an appliance. It just makes sense. And finding a good physio is really tough because there are physios who dabble in TMD and so they’re taking knowledge from other joints and applying it to physio, to the TMJ, which can help. But I encourage patients to try and seek out specifically TMJ specialist physiotherapists and ’cause in physio school, you don’t learn above the neck actually. So, you need to seek out physios who are specialized in TMJ. So it’s actually not just like seeing a physio, but specifically a specialist, really helps that. [Emma]Okay, that makes sense. Yeah.  [Jaz]Next one is medications. So, NSAIDs, ibuprofen, for example, if the patient could tolerate it, maxillofacial surgeons may recommend baclofen, which is like a muscle relaxant, something I don’t re-prescribe, but it can be used as well. So medications have their place. And the last part of conservative care is an appliance, in fact, a random, and there’s mixed evidence when it comes to appliance therapy. But the most recent randomized control trial, this was literally published, June, 2025. So this is like two weeks ago. So it’s in CRANIO, which is a highly respected journal, and its effects of occlusal splint therapy in addition to physical therapy on pain patients affected by muscular TMD. This was a randomized control. So diagnosis was extracapsular muscular TMD and the patients were allocated into the experimental group, which is basically education, physiotherapy, and splint. That’s the educational group, and the control group is education and physiotherapy. So you always have a control and then you have an intervention. So the intervention, the way we testing here is, does the addition of a splint actually help? And actually, this is not the first time this study has been done. I’ve seen previous studies done like this, and they found the splint made no difference. So again, evidence-based really varies, but this is a really recent one in a highly respected article, so let’s talk about it. The primary outcome was TMD pain intensity, and all outcomes were assessed at baseline, at the end of physio, and after six months at the end of physio as well. So there were 27 subjects, 7 males and 20 females. So 27 is not a huge amount, but in these randomized controlled trials in TMD, it’s difficult to recruit. And this is quite often in TMD lecture, you find that the N numbers are quite low. So let’s go to the conclusion. Findings from the present study demonstrated that pain NDI, which is Neck Disability Index and health related, quality of life improved in both groups. So that’s good. So we know that if you just do education physio, you’re gonna improve your muscular patient. But only in the experimental group, which was the splint group, these outcomes improved significantly further after six months. So like a few months, they’re both working, but at six months then actually there is a lot of merit in having an occlusal appliance. Thus, our results show that adding occlusal splint therapy to the physical therapy may produce higher positive effects in patients affected by myogenous TMD. So there we are. That’s hot off the press research. Happy that you asked me that because I’m able to talk about this, and hats off to authors. And then I’ll put that paper, link that paper in the show notes. So that’s why I think it has a place because if there’s bruxism happening, if there’s wear facets right, and they’re overloading their joints, then it sometimes makes sense to put something in between their teeth to prevent that load being transferred onto their joints. And they’re kind of like protecting the joints and protecting the muscles.  [Emma]For sure. And I know you mentioned there about splints and bite therapy. What do you offer, because I know there’s so many different types of splints and a lot of opinions on different types. So what do you use in practice?  [Jaz]I think in the interest of time, I think I’m gonna say if anyone’s really interested in this, it is a rabbit hole to go down, right? The evidence-based will say that there is no one splint that rules them all. I feel as though I’ve refined some protocols and I’ve got enough patient data now of my own that I do think certain splints are better suited to others, but this is not high quality evidence, obviously, but remember that when it comes to N equals one case studies. In the world of adhesive dentistry, you have all these like benchtop studies, in vitro studies. Something that one of my mentors, Lane Ochi taught me is that even if you just have one case report, N equals one, one case report. Okay? Involving a real patient that’s already better than any in vitro study ever done. Because that’s involves a real patient, right? So I think there’s a lot to be said about that. But if anyone’s interested, going down this rabbit hole, two resources I can link to this podcast. One is a flow chart I made, which pretty much summarizes my decision making in appliance therapy when it comes to permissive spints. These are splints that are not guiding the jaw anywhere and the jaw goes wherever it wants to go. Think of soft bite guards, think of Michigan splints, thinks of hard occlusal, flat splints, that kind of stuff. So I’ll link, I make sure, Emma, that we link that flow chart. And also we did, I did a couple of episodes, which is, Which is the Best Splint? There was actually a whole episode about that. So I think let’s direct our listeners to go down this rabbit hole. I think everyone needs to do their due diligence. But in a nutshell, if it’s a muscular patient, I find something like a B splint quite helpful, which essentially the back teeth are not able to touch. So if you try it on yourself, Emma, can you clench on your back teeth and put your fingers on your, like forehead region overhead? Just side ahead. Lovely. Bite together on your back teeth. And tell me what you feel on your hands.  [Emma]You could feel like your muscles portrayed in there.  [Jaz]Did you feel a bulge? Did you feel a bulge on both sides or just one side?  [Emma]Both sides.  [Jaz]So you have already a, more than likely a healthy masticatory system because a dysfunction patient is basically that bites so off that when they bite together one side bulges and the other one doesn’t. Or it bulges asynchronously. So one side bulges and then, then like a second later, the other one goes. Okay. So if they bulge at the same time, that’s good. And then feel your masseters. Can you go and feel by like the angle of your jaw a little bit lower down for me? A little bit lower down? Yeah, a little bit. Yeah. And now bite together and feel the bulge there. Do you feel that?  [Emma]Mm-hmm.  [Jaz]Okay, good. So a certain type of splint that when you are clenching together, you are not able to contract. It’s a bit like if you hold a pencil in between your front teeth and you try checking those muscle contractions again, you’ll feel a small fraction of that power. So I find splints like that are really good for the muscular groups, basically to just to give some sort of value to that. So after you’ve done all that conservative care, conservative non-invasive care, so conservative once again, TMD education, soft foods, ice and heat, gentle stretching, jaw exercises, physiotherapy, medications, and an appliance therapy specifically appliance that does not aim to change the bite. Then what you do is you evaluate. Okay. And then after the evaluation, and then you see, is the juice worth a squeeze? Are the risks of aggressive treatment worth it? And then the aggressive treatments, which we’re not gonna go to go into in this more basic episode, but is bite adjustment orthodontics, crown and bridge work and surgery. Okay. And then encompass within that as well is botox and stuff. Right? That’s a little bit more aggressive. It’s like the interface between conservative and aggressive. I would say botox somewhere in the middle which kind of paralyzes the muscles, but that’s kind of the mainstay of how we can, in the absence of high quality data manage TMD. Any questions on that?  [Emma]Yeah. So you show this to your patients, don’t you?  [Jaz]Yeah. I basically talk ’em through it. I talk ’em through it, because the problem with- I say the problem with TMD patients, I bless them, they’ve often been fobbed around and they are, like I said, they’re NUTS. They’re not understanding their symptoms and they’ve been down this dreary pathway or researching everything and they are really confused at what’s going on. And so they already have like preconceived ideas and unfortunately there’s so much marketing to these TMD patients and then messages like, Hey, you need ortho. Hey, you need this approach. Hey, you need a misalign to cure your TMD. And so bless ’em. They’re so confused. And so I say that, look, maybe that is the right way. I don’t know, but this is what I believe in because I tell ’em, I’m not a guru. I don’t know what’s gonna work. Can we at least try things that are conservative and then we can always escalate to more aggressive things. And that to me goes, that for me is a rational way to explain it. And my patients understand it. I think the way I explain that, they get it. They understand that I’m on their side. I don’t want to go straight to surgery unless it’s genuinely needed. I don’t want to go straight to botox unless we can do patient education and physio first before we escalate. And I think my patients have received that really well.  [Emma]And I think we learned similar in Glasgow. You know, start off with the basic things, the obvious things, and work your way up. But, even for me, I’m struggling with, or was more so when I was stressed during exam, struggling with grinding and a sore jaw and things like that. It’s calmed down a bit now, but even then it was just me as a dental student still just didn’t really know what to do about it. So there’s so, so many opinions in TMJ and TMJD, so it’s a hard one. But yeah, definitely that flow chart as well, that you were talking about, just lays it out nice and simple as well. [Jaz]Great. So we’ll make sure we reference all those. And I think one more nugget I can give to make it as valuable for everyone spending time listening to this, but like you mentioned, you are stressed, right? And so stress is something to do with it as well. You are probably clenching your teeth some more. So muscular overload. And then a really cool clinical tip I can give you is if the patient says their pain is worse in the mornings or the pain is worse in the evenings, that gives you a clue. So if the patient’s waking up in pain, then that could be the overwork, the dental gymnastics happening in the night. But if this pain, like they feel great in the morning, but by the end of the day their muscles are really burning, then that could be something that’s what we call awake bruxism. And the interesting thing about bruxism is that fascinatingly bruxism is not even linked to TMD. We haven’t even established those links, so let’s not even go down that rabbit hole just yet. But for some patients it can be a big deal. Because muscles get overloaded. But if someone is even thrusting their jaw forward, like holding their jaw forward without touching their teeth, yeah, that’s still bruxism. That’s still a pathological thing. So what we end up doing, especially as dentists, we’re like in this strange posture. And I speak to dentists all the time that jaw is in this funny position, and as dentists, we suffer a lot with TMD, muscular TMD ourselves. And so it’s about making sure that you are respecting your jaw posture, you’re keeping everything relaxed. You’re not keeping holding tension in your jaw because that could be a big part of your TMD story because even you transiently, you had TMD. Yeah, muscular TMD by the sounds of it. [Emma]Yeah. And it wasn’t until recently that I really noticed it. We were doing intraoral scanning at uni for like at the end of our exams. We go back for a few weeks. Dr. Maddison said to me, he was like, oh, hundred percent you grind your teeth in your sleep. And then, I have a partner now. We’ve only been together like a few months, and he was like, you grind your teeth and your sleep. I woke up one night and I was like, what the hell is she doing? And I was just like, chomping my teeth away. So that is not actually something that I was ever aware of either. But I notice it now, so I’m trying to stop.  [Jaz]Wow. Okay. So interesting. Let’s talk about that. Because when you tell patients, right, it’s like, well, we call it Grind Scene Investigation. Okay. GSI. Okay. Not crime scene, Grind Scene Investigation. Because when I was a newly qualified, I say to a patient, Hey, you grind your teeth, and you know what patients say? Like, no, I would know. I would know if I grind my teeth. Yeah. I would know. My partner would’ve told me. Kind of thing. But here’s the thing, right? I think it is like kind of like catching a solar eclipse. Seeing your partner grind, right? You have to wake up at that exact moment in time. It’s dark. Okay? You wake up that exact moment in time. You often don’t make any sounds when you’re grinding. And then how many minutes night are we actually grinding? It’s like 8 to 15 minutes for a severe bruxist. And so to catch that, the few seconds of burst of grinding activity. And that’s why the patient, like when you ask patients. If you grind your teeth self-reported, then the instance is low. But if you look at the wear sets, the instance is high. So actually go by the grind scene investigation. So you never say to a patient, you grind your teeth? You say this, you say patient, did you know that you had the signs of teeth grinding? So you as a dentist, we take control because either they don’t know that they had the signs of teeth grinding or they do know that they had the signs of teeth grinding. It’s not like a blame thing. It’s like, hey, you’ve got the signs of teeth grinding. Okay. This is the grinding scene investigation, therefore you have been right. So it may not be active, but I can see evidence of it kind of thing. So maybe we have to, to do an appliance for you, Emma, and we can talk about that. One thing we’re introducing to Protrusive is Pathways, right? Because I noticed we got so many hours of content on our podcast now, and I feel as though we want to invite everyone. Like if you wanna go down the TMD rabbit hole, we probably have like 12 to 15 hours you can consume just on TMD and have like a mini diploma in that, right? And be able to help your patients. So what we’re gonna do is, I’ll link below the playlist for all the splint and TMD type bruxism type episodes that you can go down the rabbit hole. But similarly, like everything around bridges, everything around onlays and crowns will have its own pathway. So we’ll release these Pathways. By the time this is published, this will be out there. And so I would encourage everyone to delve deeper and hopefully this is like a nice little, wet your feet and an introduction to TMD. We could go days and days talking about this, right? But it is one of those things that it’d be a nice to have this conversation, but I think it’d be a disservice if we try and just distill all of it, but now we can lead them to the Pathways which are available for free. Obviously if you wanna get CPD, then join one of our paid plans, help support Team Protrusive and what our mission, but. Any burning questions, Emma, based on our chat just now?  [Emma]None at the moment. I think that was good for me as well to maybe learn a bit more at the end there about my own possible problems with my TMJ and my pain that I’m having at the moment. But no, it was good. Good to be introduction, definitely.  [Jaz]Good, good, good. And maybe you can do a part two next year and build on this. What else, do we have any student notes? Like you, obviously you’ve been uploading your student notes in the Crush Your Exam Section of the app. [Emma]Yes. So I’ve made some student notes for TMJ, not so much TMJD, but more just about the TMJ cavity movement and-  [Jaz]Anatomy. Perfect. I was just gonna say that the top tip I’d give to everyone starting out is learn the anatomy. Like it’s so, so, so, so crucial. The muscle insertions and origins, what the disc looks like, because once you understand the anatomy, you can understand disease. [Emma]Yeah, for sure.  [Jaz]When mechanical disease is relevant to TMD and sometimes it is. So that’s a really key one. Also, in the future, if you’re doing bigger cases, reorganizing the bite. It’s important to have this knowledge to be able to assess a healthy joint, which will allow you to proceed to give that level of care.  [Emma]A hundred percent. Yeah. So a lot of anatomy and then just at the end, there’s a very small, like, basic understanding of TMJ dysfunction. Just a very small bit there.  [Jaz]Amazing. So if you guys wanna catch that, check out the Protrusive Guidance app, the website, protrusive.app. It’s free if you message Mari on the app, um, then she’ll be able to get you onto the secret student section, which gives you access to Protrusive Vault as well. But Emma, what have you got planned for the rest of the, I guess the version two, season two of Protrusive Students now that you’re a free woman.  [Emma]And so again, yeah, a free woman at the moment. Again, just going through, I actually have a list of potential topics. I know that we just did one on communication and we’ve got a lot of episodes on oral medicine, but maybe just some a student version, oral med, oral surgery, medical history. We’ve not done anything on endodontics yet, but just some basic understanding of those kinds of topics, so-  [Jaz]It sounds great. Okay., I’m excited. Let’s do it. So, whatever you decide, I mean, whatever serve the students the best, we will do it. And thanks for the wonderful notes that you make for us. And I’ll see you next time. Thank you so much.  [Emma]See you next time. Thank you.  Jaz’s Outro:Well, there we have it guys. Thanks so much for listening all the way to the end. Like I said, you can download the PDF of the TMD hierarchy on the Protrusive Guidance app. Just head over to protrusive.app on your browser, and then once you sign up, you can then actually download the Android or iOS app. But it’s really important to make your account first. For the students, you’ve got your own space, but for everyone, we’re a very inclusive community. As long as you’re a dental professional, we are here to support and grow together. We are the nicest and geekiest community of dentists in the world. That’s like our tagline. And if you listen all the way to the end, like you have done, and you are a real qualified dentist. I use the word real because recently in the news there was like this check dentist who was like fake and he was like YouTubing procedures, and he got away with it for a few years. That’s absolutely crazy. But anyway, if you are a real dentist and you wanna get CPD and CE credit, this episode is eligible. You can get over 350 hours of CE on the Protrusive Guidance app from clinical walkthrough videos to our bread and butter episodes. So do check it out and remember to share the love if you find that this podcast is helpful to you, your colleagues, your associate. Your mother-in-law, if she’s a dentist, might find it helpful as well. So please send it to everyone. And I thank you once again for sticking with us all the way to the end. I’ll catch you same time, same place next week. Bye for now.

Have you heard of Photobiomodulation (PBM)? Or are you thinking… ‘photo-what?!’ Is red light therapy just voodoo science—or is it already part of mainstream healthcare? Can PBM really help with wound healing, pain relief, and even reduce the risk of dementia? In this episode, Professor Praveen Arany joins Jaz Gulati to break down the science and clinical relevance of PBM in dentistry. They explore how this light-based therapy works, its applications in managing oral lesions, and why it’s already standard care for cancer patients undergoing chemotherapy. They also discuss real-world cases, practical protocols, and how PBM could shape the future of dental care. Whether you’re a skeptic or just curious, this episode will open your eyes to an emerging and evidence-based treatment modality. https://youtu.be/lQrawr3-YQA Watch PDP234 on YouTube Protrusive Dental Pearl: SHEEP Scoring as a practical tool to assess the prognosis and restorability of compromised teeth. 🐑 SHEEP stands for: S – Structure: Amount of remaining tooth structure H – History: Patient’s dental and medical history (e.g. caries risk, trauma) E – Endodontics: Endodontic prognosis (ease/difficulty of root canal treatment) E – Expertise: Your personal skill and experience with managing such cases P – Periodontal: Periodontal condition and bone support Each category is scored out of 10, and the total is doubled to give a percentage-based prognosis. This structured approach supports clinical decision-making, encourages honest reflection on the clinician’s own skills, and enhances patient communication during consent. The method is backed by literature, including a paper co-authored by Martin Kelleher. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Photobiomodulation can significantly improve patient comfort and healing. The treatment is standard for cancer patients undergoing chemotherapy. There are no known adverse effects of PBM when used correctly. PBM can be used effectively in various dental procedures. The future of PBM includes personalized treatment protocols. Research is ongoing to optimize PBM applications in dentistry. PBM is distinct from other laser treatments and has unique benefits. The technology is becoming more accessible to practitioners. Awareness of PBM’s benefits is growing in the wellness industry. 📚 ResourcesProf. Praveen Arany shares papers on: Light buckets and laser beams: mechanisms and applications of photobiomodulation (PBM) therapy Photobiomodulation therapy: Ushering in a new era in personalized supportive cancer care Photobiomodulation Therapy by Prof. Praveen R. Arany Photobiomodulation therapy in management of cancer therapy-induced side effects: WALT position paper 2022 For full PDFs, you can check out Protrusive Guidance. 📖 You can find more of Prof. Praveen Arany’s scientific papers on Google Scholar 📢 Two Upcoming PBM Courses! ADA PBM Course – A dental-focused program by the American Dental Association.📧 Contact: Sherie Tynes – tyness@ada.org PBM in Supportive Cancer Care – Held at Gustav Roussy Hospital, Paris.📧 Contact: Dr. Camelia Billard – camelia.billard@gustaveroussy.fr If you liked this episode, check out Medication Related Osteonecrosis for GDPs – What You Need to Know (MRONJ) – PDP215 #PDPMainEpisodes #OralSurgeryandOralMedicine #BreadandButterDentistry #CareerDevelopment This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes B & C. AGD Subject Code: 135 – Laser Therapy/Electrosurgery Aim To introduce dental professionals to the fundamental science, clinical applications, and emerging potential of Photobiomodulation (PBM) therapy in dentistry. Dentists will be able to – Define photobiomodulation (PBM) and explain how it differs from surgical laser applications. Describe three key mechanisms of PBM at the molecular level. Identify clinical situations where PBM can enhance patient outcomes (e.g., mucositis, ulcers, TMD). Click below for full episode transcript: Teaser: I did not think that you could use light in a therapeutic manner on people. We are not plants, we don't do photosynthesis. So how can you do light treatments on people? Teaser:People used to use a point and shoot approach. They just switch on the light pointed at the patient and hope that they get better. And hope is not a scientific strategy. So- In a 30-second soundbite, are you able to just describe the actual molecular mechanism or the physiology of how it actually gets the results it does? So our current understanding of photo biomodulation mechanisms is-  Jaz’s Introduction:Did you know there’s something called PBM, which stands for photo biomodulation and I know what most of you’re thinking. Photo what? Listen, I was as confused as you are and I thought, what is this mumbo-jumbo voodoo science? But then I found out that photo biomodulation or light therapy is already the standard of care when it comes to cancer patients undergoing chemotherapy. And then it reminded me of my physio who uses red light therapy for pain. And today’s guest, professor Praveen Arany, who does a wonderful job on educating us on this treatment modality explains about the mechanisms in wound healing. So, dear Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. I’m so excited to share this episode with you today for so many reasons. Number one, a lot of the guests I have on, we talk about restorative dentistry or occlusion, things that I really have an interest in and I know a fair amount about. But then this episode, I came in with nothing. I purposely didn’t do any research ’cause I wanted that magic and the aha moments to be alive. And I enjoyed this. I enjoyed learning about PBM very much, and I know you will too. Number two is our guest has no financial interest at all. He is a pure academic for the love of it, for the love of research. I even asked him to recommend specific PBM units ’cause trust me, by the end of this episode, you want to know. And he directed me to like guidelines. And scientific websites, which I absolutely love. So I think you really enjoy this, what I feel is really unbiased and it focused on an emerging technology, which I’m so excited to unpack today with you. So on Protrusive guidance, our community group. I asked a question a few weeks ago, do you know anything about or actively use photo biomodulation in practice? Okay. And 74% of us were like, what? What is that? We have no idea. 7%, just 7% use PBM. And only 18% have actually heard about PBM and its use in wound healing and in dentistry. And you know, interestingly, one of our members, Lindsay, she said there’s a lot of research being done on PBM at the moment, which you’ll see today. And then she wrote something fascinating, which is also something that was DMed to me on Instagram when I talked about this on the story, is how it can help you in pain. So for example, with Lindsay’s case, it cured her ruptured vertebral disc symptoms we’re using her laser, and she managed to avoid spinal surgery. And there’s also some great insight from our resident implant geek Doctor Pav Khaira, like research on PBM to reduce the risk of Alzheimer’s and Dementia. But why I can promise you in today’s episode is that we’re gonna make it very relevant for dentistry. You’ll learn about how PBM works and what indication should it be considered, and what are the protocols and what does the future hold. Dental Pearl:Now, before we unpack this topic, I’m gonna give you a Protrusive Dental Pearl. If you’re new to the podcast, welcome, it’s a good one to join. And every PDP episode I give you a tip, a pearl, a hack. Something you can use, you use straightaway. A lot of times’ clinical. Sometimes it’s mindset and nonclinical. Today’s is very clinical. So Dr. Jack, as he likes to be known on Instagram, DM me this pearl. He noticed that sometimes I mentioned on these episodes that, ah, I’m struggling to find a pearl for today. And so he rescued me. He said, listen, SHEEP, he said, SHEEP, remember the acronym SHEEP? When you want to find out the prognosis of a tooth, you can use SHEEP. And so let’s talk about this for a few minutes. From his DM, I was a little bit confused about its application. Then I saw Googled it and I found out that actually it’s a legit thing. And there’s an open access paper and the primary dental journal co-authored by the legend, that is Martin Kelleher, which reminds me I need to invite him to podcast, absolute hero, in UK Dentistry. He’s the guy who wrote the famous article like porcelain pornography and that kind of stuff. And he also famously wrote about the daughter test when we’re considering doing veneers, for example. Anyway, back on topic, SHEEP scoring, a practical tool. So I’ll make this paper available to everyone. But essentially a practical tool for evaluating the prognosis and restorability of compromised teeth. SHEEP stands for Structure, History, Endodontic, Expertise, and Periodontal. So the way it works is that you look at that tooth in question, let’s say, is a heavily restored lower molar, and we want to inform the prognosis of, let’s say, saving this tooth or keeping this tooth long term. You can now apply SHEEP. So S stands for Structure and for this particular scenario, because it’s heavily restored, let’s say we give the S a 3 out of 10. So for example, if it’s really low amount of structure, you give it a like a one. If it’s a really good amount of structure, like a virgin tooth, you give it a 10. So we give a heavily filled molar, for example, a three. The next one is H, which stands for History. So what the paper talks about is, is this the first time this problem has come, like a freak accident, or is it a recurring problem? So for example, if someone is a high caries risk, and like every six months they come with a high, they come with a new caries lesion, and now this tooth has been affected by caries, then you are gonna give it a low rating for history because this patient is a high caries risk patient and history is not on your side here. Also, the medical issues of this patient, like let’s say they have Xerostomia or something, would also count as history. If this is, let’s say a crack tooth and it’s a painful crack tooth, then that would score lower than an asymptomatic crack tooth. So that’s where you can score on the history. Then for E, you score the Endodontic prognosis. So is this tooth easy or difficult to treat endodontically? And actually what I like about this system is that it says how easy or difficult is it for you, the treating clinician? Because what I respect is that prognosis varies, right? Like the prognosis of an endo with me in my hands might be 80%, whereas with a specialist it might be 95%. So that’s interesting. I’m glad they touch on it on this paper. So let’s say, that same lower molar, it’s got really simple canals, nice big pulp chamber. You might give that an eight or a nine because the endodontic prognosis is pretty good. The next E is Expertise. And again, I really like this because it allows us to reflect honestly on your skill, like your individual skill. So when you are applying this E of Expertise, it’s like based on your skill, how much experience and expertise do you have to be able to do this? So for example, I’m going on a course soon to extrude, broken down premolars. I haven’t done many of these yet, so I would score my expertise on this very lowly. Maybe in a few years I’m gonna increase my score and therefore my expertise for this tricky implant case or tricky endo, or a tricky wear case will hopefully increase. And so your expertise directly informs the prognosis, right? So this is really, really cool. And the last one is P, which I’m sure you guessed it, is Periodontal. This is fairly easy because like the less bone support you have, the bigger the problem. If you’ve only lost a little bit of bone, let’s say you know, 10, 20%, then you might still give something a 7 out of 10 prognosis. But if you’ve got significant bone loss, then you might give that like a two or a three for the periodontal aspect of that prognosis. Okay, so what do you do with all those numbers? So let’s say there’s 1, 2, 3, 4, 5, 5 letters in sheep. Each one you score at 10, maximum score is 50. You double it. So if someone scores 10 in each letter, then 50 and you double it, it’s a hundred percent prognosis for this tooth. In our made up example, let’s say we get something like 31, you double that, you get 62%. It’s like a rule of thumb. It’s a nice way to give a number to it. Sometimes you go by our gut, but I like the idea that now we can go through this logical sequence and give it a percentage, which I think is useful in your consent procedure and also allows you to reflect on that case. So, Jack, thanks so much for bringing that to my attention, and I will make that paper available in the show notes. The best place to grab all these things is on the Protrusive Guidance app. Wherever you’re looking at this episode, scroll down. The PDF will be there, the link will be there. Team Protrusive, like to look after your geeky side, and we’ll make that available to you. Thanks again, Dr. Jack. Hey, enjoyed this episode on PBM. I’ll catch you in the outro. Main Episode:Professor Praveen Arany live in Barcelona. You are right now at the IADR. So, absolute privilege honor that you’re able to make time for this podcast whilst you’re on your travels, and spreading the good word about something that I tell you, I just don’t know anything about. And I refrained from doing a deep dive ’cause I wanted to just hear from you and be a very candid learner today. So Professor Praveen, tell us about yourself.  [Praveen]Thank you, Jaz. Thank you for having me. And I’ve heard a lot about this podcast and the popularity, so I hope we can get the word out on this really innovative treatment that has so much promise for healthcare, not just clinical dentistry. So I guess when I start talks like this or you know, introductions like this, I always point to the fact that I began in this field as a disbeliever. I did not think that you could use light in a therapeutic manner on people. We are not plants. We don’t do photosynthesis. So how can you do light treatments on people? Although you will notice, and I think all of us are aware that the ancient civilizations were aware of the therapeutic effects of light and specifically sunlight, but there was never a medical or a therapeutic manner in which they could do these treatments. So if you look at the absolute basic fact that the human body does not have a photo sensor, but we can see there is no camera in our eye, right? So the fact that the human body has evolved to have rhodopsin in your eye, that enables vision, it is not too much of a stretch to imagine that there are other non-visual ways that the body can use light. So if you start with that basic premise that there are certain biological molecules that can interpret light and use light. Then the extension to using light as a therapeutic agent doesn’t seem so farfetched. So I always like to start with this because I think it gives people some orientation and I remember when I was first introduced to it, I was very skeptical. I’m like, come on. How can people ever-  [Jaz]I have to say since we were introduced by email, I was also a little bit like, hey, wait a minute, is this legit? Is this like some woo woo stuff? But then, the source that connected us, he’s so credible. He’s so good. And I saw about your institutional role, professorship. So to tell us more about you as like your journey, your professor in New York?  [Praveen]In Buffalo, New York.  [Jaz]A little bit about you and how you fell into PBM, being a non-believer initially, and now presenting in Barcelona and talking about it so much. How’d that happen?  [Praveen]So, I think, like I said, the story began when I was looking at using light in a therapeutic manner in dentistry and in dentistry-  [Jaz]But is this something that was just like assigned to you as like a trainee and you were like, oh, have to do this, or was it like you chased it? Like how did you even fall into that?  [Praveen]Right. That itself is the fascinating story that I think began my journey in research. So you don’t hear of many dentists, especially, people who are focused on clinical to be thinking about research and molecules and molecular mechanisms. So it all began actually when I was doing my residency in oral pathology. I just finished dentistry. And all of us want to do something cool, right? We wanna distinguish ourselves. And so I was reading this book on pathology, and I think we all do in our dental training. But as a resident, I think you take even more interest right on what you’re reading about. And very interestingly, there was this book chapter on wound healing in pathology. So, most of us have trained on Shafer and Sook Bin-Woo, right? So when you look at the textbook of oral pathology, there is a whole chapter on wound healing. And intuitively you would think that wounds should be thought in physiology, not in pathology. So why is this chapter in wound healing? And I kept digging into that and I think, oh, that’s pretty cool that you have wound in our textbook of pathology. And interesting enough, if you put a piece of wound tissue under the microscope, it looks exactly like a tumor. It has the same number of disorganization, vascular inflammatory components that you see in a tumor that you would see in a wound. So I began my research career in a very naive manner. I was looking for a way to improve wound healing. Because people had made parallels between wounds and tumors, and the idea there was if you can control wound healing, then maybe someday we could control tumors at the molecular level. That’s how I started my journey, and I came across this fascinating paper by Endre Mester in the late sixties that had shown that using low par laser light, they could stimulate wound healing. And again, I told you about my disbelief and my skepticism about that. Interestingly enough, this work has been around for more than 60 years now. And when you think about what people have noticed in the clinic, you always talk about a clinical human phenotype, right? So people who have actually experienced something in the clinic is telling you something that is real. And that’s why I began my first clinical study looking at extraction wounds, tooth extraction wounds, and I was doing light treatments to see if I can replicate this phenotype, this phenomena that people had noticed. And surely enough, again, as a dentist, and as a beginner, I wanted to obviously be, look at the lucrative part of that, which is can we put implants faster? Can we do dentures faster? Can we rehabilitate faster? So that was, I’m gonna admit, was part of my motivation. But when I started looking at the molecular aspect of that, I was so fascinated that light could be used in such a therapeutic manner. [Jaz]You mentioned the sort of almost comparison, like we are not plants, right? We don’t photosynthesize, I’m just imagining like this study you’re doing and these patients, these poor patients are like staying open while there’s like a, some sort of a light beam on their socket and so how did it actually work and for how long did they have to have this light therapy to actually have clinical effect? [Praveen]So I think the best parallel is to think about how we do curing of composites, right? You remember how we, I mean I’m sure we do that actively even now. So you use a blue light, you shine it at the composite that you’re stuck into the prep and then you cure it. Think of it very similar to that. So it takes between three to seven, maybe less than 15 minutes to actually do that kind of treatment. And most of the treatments are less than five minutes. So in our study we did five minutes of infrared, 810 nanometer light that we were painting the socket with so that when you pull out the teeth, you have a complex, three-dimensional socket, right? So there’s a soft tissue, there’s heart tissue inside. So we were painting that for five minutes with light, with infrared light, and we were able to show that the healing was significantly improved in the socket that was treated. And we randomized it. So not always the lower jaw, not always the upper jaw. So we randomized that in our-  [Jaz]And you had a control group that had no light therapy or placebo light- [Praveen]That was the key part. So in that study, we used the patient as their own control. So these are full mouth rehabs that come from multiple extractions. So you assign one randomly to the control, which is non-treated, and the other one you treat. So one of the key parameters of wound healing, because all of us have different oral habits, nutritional demands, and parafunctional, oral functions. So, it is always appropriate to compare healing within the same person to get a true measure of whether a intervention is helpful. So we use-  [Jaz]So kind of like a split mouth?  [Praveen]Kind of like a split mouth. But this was upper lower jaws. Yes. So we found-  [Jaz]What I’m thinking of now is, what actually did you see that and also what benefit above normal wound healing did you get? So, for example, in the medicinal world, I read somewhere that if you take, if you have a cold and you take zinc supplements on average, you’ll like heal or get better one day sooner than if you didn’t. And so for them, some people are like, yeah, that’s great. It’s evidence-based. You’ll heal one day sooner. So is your socket less likely to get dry socket? Are you seeing that the wound maturation is like, two days ahead, three days ahead, any conclusions you’re able to draw in terms of what actually it tangibly does? [Praveen]That’s a great point, Jaz. So the most important part that we pay attention to is the patient comfort, right? Is there any way we can reduce the chances of infection? Can we reduce the number of swelling and pain that the patient has perceived? Now that’s a little subjective because everyone perceives pain very differently. What is a little more objective, unless you’re doing research, in the clinical scenario, what is very objective is how many pills are they popping, right? How many painkillers are they popping? And surely enough, if you take a drug history very carefully, you will find, and we found that there was less intake of analgesics. If you also look for swelling in the area as well as healing scores, you can look at healing in many different ways. And in the end, we ended up doing radiographs to look at the bone healing as well. We found that all these parameters were at least 30% to 60% improved. And again, that range is because all of us heal differently. But in every case that we did, we found that this improvement was consistently better when you did this light treatment compared to no light.  [Jaz]Amazing. And are there any, I mean, I know I’m jumping ahead now, but I’m actually getting very excited to hear about this. In terms of side effects and negative stuff, like for example, when we look at MRI versus CBCT, we think, okay, well MRI is great because there’s no radiation, but it’s like the fact that you are in a claustrophobic area, the cost of it is prohibitive. There are still downsides, but maybe not so many huge risks when it comes to MRI. What are we finding with this kind of therapy that purely, let’s start very small where we are now, I’m sure we’re gonna expand into different uses and indications, but purely to improve someone’s wound healing prior to implant therapy, for example. Are there any risks or has it been studied enough to see there’s any adverse effects?  [Praveen]So this is a great question to go to. The highlight of, I think this talk and this treatment, which is in cancer patients who are getting chemo and radiation, especially head and neck cancer, this treatment called photobiomodulation is standard of care. Which means every patient who’s getting chemo or radiation should be getting this treatment before they get chemoradiation and even transplant. So bone marrow transplants, right? So why should they get this? This is based on a systematic review and meta-analysis by three major scientific global organizations called the Multinational Association of Supportive Care in Cancer, the International Society of Oral Oncology and the World Association of PhotoBiomodulation. So these guys looked at 35 placebo controlled, multicenter, blinded clinical human clinical trials, and found that this treatment was very effective at reducing pain and incidents of oral mucositis, which is the condition that we all, unfortunately the patient get because of taking chemo and radiation-  [Jaz]Pain, ulceration, dryness, right? That kind of stuff.  [Praveen]So all of that incidences of the severity and the incidence period can be reduced by this treatment. In this study, what they also did was they looked at the tumor incidents that occurs. And remember, these are head and neck cancer patients. So if you do this treatment, do you at any, is there any possibility that you’re increasing recurrences or secondary tumors? In fact, they found that because you were doing this treatment, everyone was getting almost the complete dose of the prescribed onco treatment, radiation and chemo. That in itself enabled them to get better clinical outcomes, but none of them actually reported any increase in secondary tumors or recurrences. So in the human studies, we know that this is very clearly safe and effective. People have done more elegant animal studies where you put tumors into the animals and then give them different doses of light, and have also found that the tumor growth is actually reduced. Now, could this be attributed directly to the light or the effect of light on the host immune response remains to be fully investigated? But the bottom line is there are less tumor burdens in animals that were treated with light.  [Jaz]Like with radiation, there’s deterministic and stochastic effects. So for example, if you pump up the radiation, you know that you’re gonna get some local damage to cells, for example. Or there is like a stochastic, like random, they, it could cause mutations. Sounds like what you’re saying is that with this therapy, it didn’t seem to increase any cancer risk on these patients. But if you like pump up the time spent under this PBM or you pump up the sort of, I don’t know, the dose of light, I dunno what the correct term is. Do you get any like deterministic, local side effects, burns, that kind of stuff?  [Praveen]Right. So because this treatment can be done both with lasers and LEDs, this has become a key question whether we should only be promoting one versus the other. And unfortunately we don’t have an answer right now, whether we should be doing one or the other. We know that both are equally effective, but the lasers, as you can imagine, have a lower dose threshold. So they have a smaller therapeutic window before which they can get cause those thermal injuries that you were referring to. But the LEDs, it’s very subtle, so you don’t actually see burns, but you can neutralize your benefit if you increase the temperature too much. So, although both of them, if used in the right dose range, do not cause damage, the laser obviously has the potential to cause damage even when you’re using a defocused beam. So we have to be careful, but there is no evidence that there are off target or side effects of light. If you do end up dosing overdosing in your patients, especially if you’re thinking deep tissues like TMD or trigeminal neuralgia, these treatments have been shown to neutralize their benefits. So one of the biggest problems with this field of photo biomodulation has been the inconsistent clinical outcomes. And we believe and I think there is data to back this up now, that unfortunately the motivation of the clinician and the motivation of the patient is to get better sooner, right? So this is one case where too much dosing is actually detrimental and we have to be careful that we don’t overdose the patient.  [Jaz]Are you at a point now where you’ve figured out what that sweet spot is in terms of protocolization and so that it is information that can be disseminated to practitioners and primary care and they know which settings to use to get the best outcomes? Has it been studied enough or is this still like, we’re not sure exactly for how long or what intensity to use this technology?  [Praveen]So we do have a good handle on a specific application. So one of the problems with this treatment, I would say one of the benefits of this treatment, which is also a problem with this treatment, is there’s a very broad range of applications. So there are things like mucositis, TMD, trigeminal neuralgia, aphthous ulcers, lichen planus, pemphigus, and you would wonder, even in dentistry, and again, we are not talking about medicine because we have all these major chronic diseases like Alzheimer’s, Parkinson’s, multiple sclerosis, fibromyalgia, where this treatment has been shown to be effective. So even within dentistry, the fact that it has so many broad applications raises a very important clinical and biological question. How is this possible? How can one treatment be effective? It turns out the way-  [Jaz]And I guess the delivery also matters, right? The way you deliver the light in for TMD will differ to a different part of the anatomy. And then therefore, I guess working out what is the best for each disorder for that patient. And so that must be, ’cause it’s such a wide application, I’m already thinking, well how can you protocolize this and how can you then also tune it or make it bespoke for that individual? And I mean, I dunno, does the patient’s weight or their skin color vary and cause a change in how you would treat someone? [Praveen]So these are the intuitive factors that you would imagine as a photobiology with, with 101 basic knowledge of photobiology that we would want to optimize. So these are the concepts that are coming in now, unfortunately, I would say, like, three, four years ago, and previously, people used to use a point and shoot approach, they just switch on the light, point it at the patient and hope that they get better. And hope is not a scientific strategy, right? So that is one thing that I find as we show more and more of our molecular and non-linear physical phenomena work, you mentioned stochastic and deterministic reactions. So those kind of very precise dosimetry concepts are still, I think, in the research interface, but they’re coming rapidly to this treatment and that’s gonna significantly improve many of the clinical outcomes that are unfortunately still lacking.  [Jaz]Well, the questions I’m getting now, by the way, I’m really enjoying learning about this, but, lasers, right? So lasers are a topic that is actually we need to discuss on the podcast more. But what I get from speaking to people who are into laser. And also what I’m seeing from the people who sell lasers, right, is like, again, very similar to what you’re saying, very widespread application though you can use it for perio, you can use it in the root canal system. You can use it for these effects. And you can obviously use it in a different way to cut tissue or soft tissue. So it’s such a wide thing. So can you just like dumb it down for me in sense of, okay, you’ve mentioned PBM and you mentioned that laser is one way of delivering that. When we talk about lasers used in perio lasers used in root canal, how does that differ to what you are talking about in terms of PBM or is it the same thing? [Praveen]Excellent question. So I think, there are two major topics here. One is lasers in dentistry and lasers in clinical use, and the other one is photo biomodulation. So I think many of my, at least academic talks and my courses that I’d actually end up trying to bring this information to people have focused on differentiating them. So there is, if you think about light as a physical form of energy and you transfer that energy very quickly into biological tissue, it has nowhere to go, right? That light ends up evaporating or ablating tissue. This is how a surgical laser works. And this is exactly the property we use when we are trying to cut tissue, either heart tissue or soft tissue, and in some cases biofilms, right? So you can do disinfection with biofilms by simply abating them, evaporating them. Now, there are two other forms of light use, which is not well understood or well talked about. It is well understood, but it is not as much popularized in the media and I guess in our training. One is photodynamic therapy where you’re using a color dye and light to destroy its target, and that comes in two flavors. You can either destroy tumor cells or you can destroy microbial, polymicrobial films. So this is photodynamic therapy, which is disruptive in nature, you’re trying to destroy your target. In contrast to these two treatments, the surgical laser and photodynamic therapy, another form of light treatment is photo biomodulation. Now, how is photo biomodulation different? It is a non-surgical, non-thermal way of modulating the biological response. And this very nicely circles back to why is it working in so many diseases? When you use the right amount of light and the right, and you evoke the right molecular mechanism or the signaling pathway, you end up modulating pain and inflammation. You end up reducing pain and inflammation at the same time. With a different protocol and a different delivery system, you can stimulate wound healing, tissue regeneration, and a positive immune response. And that is why the term photobiomodulation is very appropriate. There are about 350 different terms, everything from low level light treatment to cold laser therapy to infrared or red light therapy, which is becoming a very popular term. [Jaz]So these are all the same things because I was gonna ask about red light therapy for TMD, and also low, is it low level laser? How do you say it?  [Praveen]Low level light therapy. Yeah.  [Jaz]So these are all the synonymous with the photo with PBM?  [Praveen]Photo biomodulation, PBM. So if you look up, you know how in academia how we organize stuff, is PubMed, right? So National Library of Medicine at the NIH indexes, the entire scientific literature. So photo biomodulation now is a catchall term that includes all the 350 odd terms that are present for this literature. So all of them, if you look at the science behind it and the mechanisms behind it, is photobiomodulation or PBM. [Jaz]Okay, that really helps actually in understanding. Is there like one machine which you can just twist the dials and then you go from it being a cutting laser to then you twist the dial and then it becomes in like low level light and PBM or is that yet to be invented?  [Praveen]That is actually one of the most popular questions we get Jaz. So when people, when I give these talks and lectures, they’re like, tell me one laser that I can buy and I can solve all my other problems. And I rightfully so, because these are expensive technologies. So you would like multi-functionality out of them. So when I get that question, I usually ask them a question. Name one bur or curette that you can do everything in your -. And the answer usually is, I cannot. Right? So you have to think about lasers like that. So every wavelength, every device has a very specific application. There are people who are trying to develop multiple units and there are people who are trying to adapt. Surgical lasers for PBM and they have had some success. But like everything else in life, you have a sharp pointy thing. You can do a lot of different things with it from, you can remove calculus, you can remove caries, you can reshape soft tissue or hard tissue. But would you be able to do everything effectively with one tool? And the answer is probably no. And similarly, I think laser technology has evolved like technology, I should say. And you may not need a laser in many of these things. It might be even more, I think one of the big questions in our field is, is it as effective to use an LED as it is to use a laser? And there are pros and cons to that, but I think that question is still very relevant as we are evolving with this technology. Right now, I can tell you both are very effective if you are in the right dose range.  [Jaz]Okay. That’s very helpful. Now my own personal experience is like once removed, the physio I work with for TMD patients, her name is Krina, she works in London, she’s brilliant. And she uses, I think she calls it The Velvet, I dunno if that’s a brand name, whatever. So it is low level light or it’s a red light therapy. And she says she’s getting good results with that. And so that was my first, like, me thinking about it. And then when I started emailing you and stuff, it was very interesting. It reminded me of that. And then someone in the US, Dr. Jamison Spencer, I did his course many years ago and then he was emailing me about it as well. So I was like, ah, I’ll remember this for when I speak to Prof Praveen. So what are the applications that you see dentists using it for? Yes, for myself, for example, if I was to get it, I would like to use it to help patients with their joints, but I also want my physios to have some role in that, for example. But should we be using it for wound healing prior to implants? Should we be using it after implant surgery to get better outcomes? Should we using it for, I don’t know, any other acute pain? So, it’s starting to sound like there are so many indications, but can you name, like, make it tangible, some real world indications that you think that general dentists should be considering, if at all? [Praveen]So if you’re talking about a laser, I think we have a list of applications. But if you’re talking about PBM specifically, photobiomodulation. I think your question is more directed towards that. Any clinical scenario where you are anticipating pain or inflammation or a lack of healing, that’s the definition of photobiomodulation. We find that we can use it very effect. Is it the only thing you’re gonna use? Absolutely not. So it would be an adjunct to your standard of care, but PBM has a very important role. Every time you anticipate pain or inflammation or a lack of healing. So the most common scenarios that we see, for example, are areas where you’re going to obviously anesthetize, right? So, which is pretty much every clinical procedure if you irradiate that site, I shouldn’t use the term irradiate, I should say treat that site with photo biomodulation.  [Jaz]Should you not say illuminate? Is that not the correct term?  [Praveen]Illuminate is a better word. I mean, we try to avoid irradiate because that normally brings in concept, thoughts of ionizing radiation and this is not ionizing. So that is the big misconception that we try not to promote. So we use the term illuminate or treat, which is a better term. Yeah, absolutely. So, I think if you can use your, if you use the PBM before you do anesthesia, that’s I think absolutely 101 in every clinical procedure, you’ll find that the patient is much more comfortable and will recover-  [Jaz]During anesthesia. So I’m thinking like a palatal injection, which is commonly, we think that that’s gonna be a painful one for our patients. Are you suggesting that by doing some PBM, the perception of pain from that palatal injection, which is just moments away is gonna be less? Has that been proven?  [Praveen]That is true.  [Jaz]Am I thinking correctly? [Praveen]That is absolutely true, and I think we have the strongest evidence with wisdom teeth, third molar extractions, where you do the light treatment for the biomodulation and then people find that you have to give them less anesthesia. They are more comfortable during the procedure. And then you come back after you finish the procedure, which is the extraction, and then you do the healing protocol. So one of the nuances I think, of what we understand now is that the pain control is a slightly different protocol than the healing protocol. So even though you might end up using the same device and maybe the same handpiece, you’re gonna do slightly different protocols for getting different biological responses. So in the first case, you wanna reduce pain. The second case, you wanna reduce inflammation and promote healing. So it’s gonna be slightly different. So that is pretty much, I think 80% of things we do, which is either anesthesia or some kind of a surgical procedure. And then of course there are these patients who come to you with aphthous ulcers, pemphigus lichen planus is very common, right? These are situations that unfortunately are very managed very empirically, right? And it’s effective. I mean, the reason we are still practicing dentistry is because our treatments are effective. But there is always that odd 5%, 10% cases that are not responsive. And if you go-  [Jaz]So anything surgical, it just makes a total sense. How about this scenario? I’ve just thought of like a patient who’s keeping their mouth open for, let’s say a root canal treatment or a crown, but they’re the kind who just is getting a lot of tension in their masseters, in their jaw joint. They’re feeling like they’re in a lot of pain, perhaps before the treatment, using that. And during, is that a protocol that you guys, that you’ve studied?  [Praveen]Absolutely. So there’s actually a whole term for that in physical therapy called DOMS. Right dos, which is basically the muscle fatigue that you get because of continued strain. And obviously you can imagine the masseter and the temporalis and all the other masticatory muscles are subjected to a given position. And when you do a procedure like, you know, keeping your mouth open for a filling, you are obviously putting them in a lot of stress and fatigue. So, if you do the treatment photo biomodulation before you start the procedure and even during the procedure, you will find that the patient is much more comfortable and you really feel the difference in the following day, 24 to 48 hours after the procedure, that’s when the real pain kicks in, right? So in the initial fatigue I think, they can manage because usually they’re anesthetized and they don’t, they’re paying more attention to the procedure, but the next day they start feeling the discomfort. And that’s what I think you will find if you start taking histories or even a lot of people now have apps where you can report things like this. A quick text saying, you know, are you comfortable? Do you need more treatments? If you wanna come in for another dose of PBM. And now there are so many of these PBM devices that are available to take home as well, the LED ones at least. So you can potentially, you know, have them take it home and take it home and treat themselves. So that’s also becoming a larger and larger possibility. [Jaz]Okay. And I’m just thinking of like the various, like if you do a really like deep crown and you had to remove some tissues and to use it then to help with their recovery. But let’s talk about ulcers, right, because I think that’s gonna help me help to make it tangible. If someone has an aphthous ulcer and it’s a very nasty one, and often they might come in and show you, or sometimes you notice it at that checkup, right? Do we have any data on how many days of difference it actually makes or any sort of perception of pain reduction or quality of life improvement surrounding the use of PBM on an absolute ulcer, which is not the worst thing in the world, right? It’s the first like, first world problem in a way, but it’s still unpleasant. It ruins your appetite. It can be very painful to eat certain foods and just annoys you, right? So how does it actually help?  [Praveen]Yeah, so that is one of the biggest practice builders, if you will, if you’re trying to bring this technology in, the ulcer is not going to disappear. You’re not actually zapping the ulcer out of existence. That’s not happening with PBM. Right? But when you do the treatment, your patient will tell you in the chair that they’re feeling better, right? So you can actually perceive the improvement within seconds. And this has been a major part of my lab’s interest in trying to understand how are you getting local anesthetic effects with light, which is non-ablative, non-surgical. These patients are comfortable in your chair, right? And there have been several studies looking at both perception of pain and what pain does, it heightens other perceptions. So hot, cold pressure, you know, hyperalgesia. So we can actually measure this very, very objectively with thin to thick filaments of metal, right? So we poke the patient just like we do, probing after anesthesia. You can actually probe this in a very scientific way and precisely measure how much pressure you’re doing to evoke a pain sensation. So people have done very, very careful measurement. What is still lacking, I think, is at the level of functional MRI kind of studies where we are looking at integration of central signals of pain perception. But the peripheral signals and peripheral perception of pain has been very well studied. And there are several ailments, including fibromyalgia, which just recently got the US FDA approval. So there is actually a device on the market now that is FDA approved for fibromyalgia, which is again, a generalized pain condition. You can imagine things like burning mouth syndrome, trigeminal neuralgia, and other fines of atypical pain, which are extremely painful. And unfortunately people resort to very severe surgical interventions. Could be at least avoided or prevented for, if you could get symptomatic relief. So I think it’s worth exploring. And unfortunately there is not like a precise device and a protocol that works. So you’ll have to look at the primary research literature to actually find that right device and the right protocol. But they do exist and there are some very, very good studies for each one of those applications.  [Jaz]With that ulcer patient. Again, just to make it really tangible, right? If that patient has an ulcer and they’re at the peak of it, during the laser delivery, sorry, during the illumination delivery in the practice, let’s say five minutes, wherever it might be for the protocol for that ulcer, they’re gonna be feeling better then and there. Do we know if that ulcer is gonna end up healing actually faster or the percentage improvement in quality of life? Or do we not have that data yet?  [Praveen]It does resolve faster. So if you have a painful ulcer and you do nothing to it, it usually takes 48 to 72 after ulcer. So 48 to 7-  [Jaz]But major ulcers are real and my mother-in-law gets em right and they’re really nasty. And they can be there for a while. I can really think of a good application for major would be something like this, right?  [Praveen]So not only is the immediate pain relief evident, but the resolution of that inflammatory response is also quite well documented. So you will see, the problem with these things is it keeps coming back. So you wonder if the treatment is actually not just laser treatment or photo biomodulation, but any treatment will it work. So I keep emphasizing when we talk about photo biomodulation that you cannot substitute standard of care. You do need a good diagnosis and the right prescription of the standard of care where PBM can either be used as the main treatment or as an adjunct. It is not magic. I think that why, I think a lot of people you will talk to try to palm it off. As you know, it’s magical light and it does cool things. It does cool things, but there is a rationale for that. So it’s not going to omit your good practices, and we give this great example. I’m sure you’ve heard this literature on lasers in perio, right. You know, that lasers have been used in perio for a long time. It’s rather controversial because people thought they could do everything with the laser. Everything from scaling root planing curettage, to disinfection, to healing. Yeah. [Jaz]I feel like those who are laser converts, they’re a bit like vegans. If they have a laser, you’ll know. Right? And so sometimes I feel like, and no offense to anyone who uses a laser, ’cause people swear by it and they love it. But I just feel as though, like, is it really that good? It might be, and maybe I’m missing out here, maybe I’ll eat my hat. But and soon to be discovered, but yeah, you tell me more about that.  [Praveen]So, lasers in dentistry is a rapidly evolving field, and the great news is, although it has existed from the LA you, the 1980s, it has been formally recognized by the ADA in 2023. So there is clearly a lot of good scientific literature supporting the use of a laser compared to all of our mechanical and rotary tools. So there is clearly a lot of more understanding and information about the superiority of a laser device for any procedure compared to a blade or a scalpel, which arguably is way, way more cheaper. So why would you buy a fancier tool to do the same job? But the laser does do a lot more. So this is a whole separate discussion on what are the advantages of the surgical laser. But there is nothing like PBM, so there is no tool, maybe the closest you would think of is trans electrical neural stimulation tends right where they use microcurrents to stimulate the analgesics response. Or there is a little bit, I think, overlaps with ultrasounds, when you’re trying to do photo acoustic signals. But there is a non-invasive way of doing something in the clinic that there is no other alternative to. And photo biomodulation is very, very uniquely placed in that. In fact, we think not very far away, given all the advances in optical diagnostics, that every dental chair will actually have a laser or a light device on your chair, right? It’ll be one of the things that you pull out and you can do either a light curing is an absolute easy thing to think of, right? But it can also do other things like diagnostics, maybe potentially PBM and maybe some of the PDT stuff.  [Jaz]I can just imagine like, those intra oral scanners that we use, they could probably just bolt one onto there. Maybe, it’s a good size head, isn’t it? Like maybe they should have a separate head or combine. It just makes sense that, that I think that kind of access could exist in the future.  [Praveen]The form factor Jaz that you’re pointing out is turning out to be the biggest barrier, right? For entry into a clinical market. We are all trained as clinicians. We are very comfortable with certain technologies. It’s very difficult to move a field if you bring in something which is very different, right? So, you will see that even most of the surgical lasers have handpieces, which look exactly like our surgical handpiece. You look at any of the major manufacturers, they look exactly like a manual. Okay, you don’t have the tactile feel. That’s definitely a limitation, if you will, from laser surgery, but like every other skill that we have learned, this is something that you get better at practice, right? One of the funniest thing I should mention here, Jaz, is that we hear this thought about, why bother with a laser? I can pull out a blade or a curate and you know, do this in 10 seconds. Why do I need to set up my laser and do all of this? Lasers are very slow, right? The laser procedure is very slow. Whether you’re doing a class two prep or anything, class one mini prep, class five preps, there is nothing faster than light in the entire universe. So how can you tell me that the light tool is actually slow? That doesn’t make any sense. So it’s basically your technique, and I think that’s one of the things we keep pointing out. Yes, there is some setup time, but there are so many advantages of this technology that you would not get with a mechanical plate. And I think this is coming to the forefront. I just came back from another meeting, you can imagine this is really catching on and there’s a lot of interest in different societies and professional organizations. And I just came back from the American Academy of Oral Medicine and the American Academy of Pain for very different workshops. One, obviously for the pain. We were just discussing how is this thing working? Is it, how is it doing? And I just effect how is it reducing Inflammation has become a big key because once we understand how it works, we can obviously develop protocols that are consistent and reproducible. So that is the motivation there. Well, the thing-  [Jaz]Well, just in terms of circling back to how it works though, like I just feel like you mentioned at the very beginning, the wound healing in a 30-second soundbite, are you able to just describe the actual molecular mechanism or the physiology of how it actually gets the results it does?  [Praveen]So our current understanding of photo biomodulation mechanisms is threefold. We have identified three separate molecular pathways that light can induce, just like you need to induce rhodopsin, right? You need to change the cyst to trance. If you remember our 101 physiology classes, it has to change its confirmation. Nightmares. I’m sure, but nonetheless, we made it through, right? So, there has to be a change in the biological system, whether it’s shape confirmation or it’s biochemical change, right? It has to be modified. So when you think about photobiomodulation, there are three well understood mechanisms. The first one, which is usually the most talked about, is the mitochondria, right? You have cytochrome C oxidase, which is present, which is an enzyme in the mitochondria that’s responsible for electron transport. And when light is absorbed by this molecule, it transiently increases the electron transport function, which makes the cell more resilient and more fit. It improves the fitness of the cell. You can imagine better mitochondria. Sounds great, right? You would want a better mitochondria no matter what. So you can, so this is one of the most talked about mechanism. It makes a lot of intuitive sense. You’re putting light energy, you’re improving energy in the cell, energy metabolism in the cell. And that for the longest time that used to be the most cited mechanism, it still is Tiina Karu and Harry Whelan actually showed this mechanism very elegantly in biochemical models. The second mechanism, as we were talking about earlier, is the pain relief. And that’s almost instant, right? So when you do light treatment, you instantly see the improvement in your patient. So this cannot be long term, transcription translation changes in the signaling. It has to be something as simple as what we get with local anesthesia. So there is something disrupting the neutral conduction instantly. And lo and behold, there are light sensitive receptors and transporters. So if you shine light at the right intensity of the right color and the right wavelength, right? So you can actually disrupt transiently and reversibly just like local anesthesia, neural conduction. And there has been a lot of very elegant work on different receptors and transporters. Some of the famous names are Opsin and TRPV1. These are molecular targets. So we have a fitness or resilient mechanism, which is the mitochondria. And then you have the pain mechanism, which is a transporter or a receptor. The third mechanism is the one that I described to you in the beginning, which is the wound healing mechanism. Turns out that there is a growth factor that is present outside the cell. And this growth factor is called TGF-β1. And that growth factor has very specific amino acids that are light sensitive. So when you shine light of the right wave angle and the right intensity, this amino acid actually senses light. And it changes its shape, just like rhodopsin and causes biological signaling. So activation of this growth factor, TGF-β1, has been shown to be a pro healing and it can actually recruit local endogenous stem cells to do tissue regeneration. So yeah, more than 30 seconds, but hopefully I give you a load up. [Jaz]No, no, it helps. And automatically I’m thinking of something really far fetched. Okay. Something really crazy. You know how people, some people, they will like sit in a chamber that is highly oxygenated, right? And so then in the chamber and so they’re getting more oxygen. They feel like, okay, I’m performing, gonna perform better. I’m having better oxygenation in my body. Do you think, I dunno if this applies. Is there like a red light chamber they can sit inside at very low level to just gain the health benefits to your total body for no reason, just for preventive medicine? Is that something that exists?  [Praveen]A preventive medicine and longitude. So I think the question now is no longer improving lifespan, which I think a lot of people are trying to do, but let’s improve health span. Where you are more functional at least at similar level, if not better. There is so much interest now and not just improving the length of life, but the quality of life really. Unfortunately, the reality is in the last decade of your life, you are not as functional as you are in the rest of your life. So can we use light along with exercise, nutrition? As well as the right structure. Human beings are social beings, right? So we can’t discount the others, but it is being very rapidly recognized that light in its many forms can be another supplement, if you will. It can be another part of this health and wellness protocol. And-  [Jaz]Dammit, I thought I invented something there.  [Praveen]The chambers is something that I think a lot of saunas have been modified to do. Very interestingly, there are beds that are available, like beds, just like the tanning beds and- [Jaz]That’s exactly what I had in mind actually. But there we are. It’s already been done.  [Praveen]Absolutely. So the beds are becoming extremely popular, both the athletes, right. A few microseconds of improvement of their performance is millions of dollars and lots of trophies and wins for them. And you pretty much name any peak athlete right now in any sport, whether it’s swimming, whether it’s cycling, whether it’s football, soccer, all of these guys are using it as a part of their regimen. So you will be shocked that, how many of them-  [Jaz]I had no idea. So this has been very educational for me. Not only just dentistry, but it’s in general. If you were to get your crystal ball out, Prof, you get your crystal ball out, right? Where do you see- I mean, it sounds like there’s enough evidence based now you are very enthusiastic about it. I’m liking what I’m hearing, but where do you see the entry point applications? Where do you see it overcoming the barriers that exist and at what stage you think is gonna take five years, 10 years? What’s your guess? Prediction.  [Praveen]I think where it’s going to immediately make an impact is wellness and longevity and better health spans. So the cosmetic and aesthetic and wellness applications are already on autopilot right now. So if you have not already, and we point to the fact that almost every smartphone that we have, smartphone or a digital device now has a blue light filter, right? It is a different part of the research and biology where we talk about circadian rhythm, but the awareness that light has a role in your physiology is very well understood. So we think PBM will become something very standard in regular wellness. Even when you fly, commercial airlines, you can see that they don’t switch on the light anymore. They actually cycle through red, blue, green, and then switch on the white light. Right? This is just coming from awareness that you don’t want your cranky customers in your home after a long flight, you want to actually cycle them and then the mood gets better. So, simple things like that, which we may not think of as PBM, have already established light as a critical role in our physiology. So I think the more awareness come everything from the desk, digital screens we are looking at to our digital displays, to the light that is eliminating in our rooms, they will all adapt this technology much, much they are, I think I should tell you, they’re already adapting these technologies. No lights are no longer just eliminating a space. You can actually have additional wavelengths that come on at a very particular amount of time for a particular duration, to improve your moods and elevate your performance both neurocognitive and skeletal muscular. So there are some, and Jaz, we can talk about this all day, but, there are these assisted living homes where they install these special PBM lights and they found less depression, less falls skill, falling over, which is the number one reason why these people pass away. Unfortunately, once you have a severe fall, unfortunately it’s downhill from there. So just switching the lights for 15 to 30 minutes of treatment every day has significant health benefits. So I think the wellness and of course you Google, I don’t know, Amazon, Alibaba, you’ll find a thousand different light marks that are available right now. And if you have children, like I have a teenage daughter, she loves a light mask, so she’ll do all her facial creams, but she loves the light mask as well. So, and there is a lot of cosmetic and aesthetic use that is already very prevalent. I think there’ll be increased awareness that will occur. In terms of the clinical adoption, which I think we are more thinking about. There are very well done studies, systematic review, meta-analysis, clinical practice guidelines, but they are restricted to specific applications. So, although we know that there’s a lot more that can be done, TMD, trigeminal neuralgia, BMS, all of these ailments, pemphigus, lichen planus, things that we have difficulty managing in our patients. Those studies are unfortunately not yet fully done, but mucositis is where we have the most evidence. And you need one thing, right, to get the field moving. So we think mucositis is going to be a big break.  [Jaz]But, like you said, the cancer world and mucositis sounds like there’s a big tick there, but I think what you’re saying is that the research is on the way to then have clear protocols and guidelines for ulcers management or wound healing after extractions or prior to wisdom tooth surgery, but that’s the next phase of research, you think? [Praveen]Yeah, I think those are primary areas for future research and optimization of these protocols. So when we started speaking, we talked about differences in skin color, time of the day, whether you’re a male or a female. All of us respond differently, so the fact that even in medicine now, we largely acknowledge that we can’t do, everyone is not a cookie cutter kind of treatment. We have to personalize and optimize. This particular treatment is very amenable to that, right? We don’t have to do too many things to change the intensity, change the treatment time. So I think this might actually to in many ways begin our precision, medicine, precision photo medicine, if you will, that would allow us to optimize and personalize for optimal outcomes. [Jaz]The Protruserati that listens to this podcast are all over the world. They’re a very geeky bunch, prof. Right? Would you be willing or happy to share some papers that they can just read in their own time? ‘Cause I think when something new like this comes along and naturally everyone’s skeptical, but then, you’ve presented it really well. But I think everyone always needs to do their due diligence to learn about things. I think it’s a wonderful thing to be able to read and assess literature. Are you happy to send some papers over that I can put on for a while?  [Praveen]More than happy. It would be a pleasure. So people, I think, don’t realize that in academia, the reason we publish papers is that people read them, right? So it is something that a lot of people don’t realize that, that that’s the whole point of doing research, right? You may not be able to convert it into a treatment. We all play to our strengths, right? We are dependent on the clinicians and the companies, the stakeholders, to actually convert that into a device or a product or a protocol. So I’m more than happy to share it. And I think the latest paper that forms the foundation for the ADA approval of photobiomodulation as a discreet kind of treatment. That paper probably is the most updated. And for those of you, like you said, are interested in the molecular mechanisms, I’m happy to send two or three papers across. [Jaz]That’d be great.  [Praveen]The more view of the field  [Jaz]Amazing. I can put that on the app for everyone to download. That’d be great. There people will be screaming and typing and say, okay, like, should I just wait and watch as I’m a general? Let’s say you’re a general dentist. You do everything from children to root canals to surgery. Is it the time to maybe dip your feet in, like everyone’s talking about 3D printing, should I buy a 3D printer now or should I wait a bit? Do you think dentists, are there any obvious products in dentistry that they should be looking at or they should be holding off? What’s your thought on that? [Praveen]No, I think, the fact that the FDA has cleared many devices, not approved, but cleared many devices should speak to the safety and value of adding a PBM device to your practice, right? So if you already have a surgical diode laser, you might just have to invest in a handpiece that makes that surgical device into a PBM device. But if you’re really interested and you’re new to the field and you’re seeing a lot of these patients, you will be amazed at how many devices are available right now that are more-  [Jaz]Do you have any financial interest in any of them?  [Praveen]None. I don’t endorse any of them. And I think that-  [Jaz]And that’s why I appreciate you very much. So, someone might listen to you today and think that, hey, this guy has got a big stake in, in PBM . But I love that. Yeah, you wish, right? But like, look, that’s why I appreciate you so much, as a professor who’s just, your enthusiasm and dedication to this topic, it just shines through. Are there any brands that you like that, that you think, that have been working well that perhaps a general dentist somewhere should consider as an introduction into PBM?  [Praveen]So I think, our yardstick for that has been who’s involved and supporting the field, right? There are many, many devices on the market. You go on Alibaba, Amazon, you’ll find like a hundred thousand devices. But the people who come to our scientific meetings and are contributing to promoting the field, those are devices and people that we know make good, good protocols and good devices. So my recommendation actually would be to go to the World Association of Photo Biomodulation website, or the North American, all the academy of Laser Dentistry or World Federation of Laser Dentistry, these scientific organizations are supported by several companies that it’s almost like a self-reinforcing prophecy, right? These are people who we trust to come to our meetings and bring good devices. So those are the units that I would say you should look into. And there are several manufacturers who are very well established and have a good following and are very responsive. If you’re new to the field, after you buy the device, the first thing you wanna do is get the training right. And that becomes unfortunately many people don’t pull that. They try it themselves and sometimes they don’t get good results and they give up on that. So that is something that we feel, if you’re active about seeking the training, you will benefit a lot more. And these organizations actually are, they don’t endorse any of the manufacturers, but the fact that they are supporting them and they’re being supported by these organizations is a fantastic place to start. And again, I can call out the names of different manufacturers, but that is not, I think the, I mean, I’m sure your readers can very quickly look at that.  [Jaz]Well, we’re gonna put the papers on, as you said, and then we’ll put the websites that you mentioned.  [Praveen]That would be awesome.  [Jaz]That clearly state those manufacturers. And I think it’s a very elegant way to convey that message. And so I’m very grateful for that. Prof, I’ve really enjoyed our time together. We’re coming to the end of the hour mark. Thank you so much for all the research you’re doing, for everything that you are sharing out there and this conversation that we had to really make things tangible for me. I’m glad I didn’t do any research beforehand ’cause it meant some of the questions I was asking was very much candid and fresh. And so thanks for playing so well with that and engaging so nicely there. Is there anything else that you, I mean, do you have any channels that you want people to support your research or reach out to you or anything like that? [Praveen]No. So, I think you will face the book papers, right? So the papers I think has major resource. I think that’s our best advertisement, if you will. And that’s the best kind of advertisement because it gives us a platform to show people where we are and what we are doing. The contact information is on that paper, so you can definitely get in touch it. We are easy to find on Google as well. The one thing I would say Jaz is, you mentioned this in the podcast today, that people need to differentiate between laser applications and photobiomodulation. And unfortunately because lasers have been around for the longest time, so has PBM. People get confused with, can I buy, the question we were talking about, can I buy one device that does everything? Unfortunately, I think the answer is no. And when you learn what else it can do. I think that that gives you a better platform. So, PDT unfortunately is not well understood, even though it’s been around for the longest time. It won the 1903 Nobel Prize in medicine and we don’t know much about this treatment, right? So, if there is interest from your audience and your forum, I would love to come back and talk about surgical laser applications and why it is different than the mechanical ablations. And PDT can be a whole, I may not be the best expert for that. I can recommend some of my colleagues. I think this is the kind of granular information, if you will, for someone who’s bit being bitten by the bug of curiosity in this space.  [Jaz]Oh, I think you’d be a most welcome guest again, but I do like engagement when it comes to this. So those who are watching on YouTube or Protrusive Guidance, I want you to comment below. If you’d like to see Prof Praveen again to talk about surgical laser applications, which I would personally love, but I want you to love it as well. Please comment below and then we can do that. I’ll, of course make the papers available. And yeah, thank you so much. Enjoy the rest of your trip time in Barcelona, presenting for the IADR, yeah, onwards and upwards, sir. Keep up the good work.  [Praveen]Thank you, Jaz. Thank you for having me. I really enjoy it.  Jaz’s Outro:Thank you so much. Well, there we have it guys. Thanks so much for listening all the way to the end. Look, you’ve done the hard work. Why not get some CPD or CE credits? Protrusive listeners who listen to a new episode every week, they easily get 40 CPD or CE credits every year just from listening to the podcast while they’re on the treadmill or on their commute. You can just satisfy all your targets. And now we’ve got like core topics like oral cancer, medical emergencies, that kind of stuff as well. Not only do you get the certificate, but you get to answer the quiz and validate your learning and reflect ’cause it’s important to be a reflective practitioner. Of course. If this sounds good to you, but you all have time for is the podcast, then you should join our podcast CE plan. If however you want access to the podcast, CE Plus all our masterclasses, then you want the ultimate education plan that’s got Sectioning School, VertiPrep for Plonkers, RBB Masterclass. And now recently Splint Course Online. And how could I forget? The Premium Clinical Videos, step-by-step walkthroughs, you name it. So the best place to check it out is protrusive app. Select your plan and hey, we have a free plan. All you need is to join your tribe, join your community. There’s so much value to be gained. We do have a manual application procedure, is important to us that only dental professionals join our network is how we keep it a safe space. So check out protrusive.app. I want to thank again, Professor Praveen Arany, who will definitely be inviting him back. But please comment below if you’d like that as well. And don’t forget to hit that subscribe button. It might sound like a small thing, but it actually really helps us a lot to get the right reach and help more dentists. I wanna thank Team Protrusive for the wonderful work they do in the production side. And thanks to you once again, Protruserati for choosing us for your dental education. I’ll catch you same time, same place next week. Bye for now.

Should you be re-treating that root canal—or referring it out? What are the red flags that scream “specialist only”? How do you confidently remove GP without compromising disinfection? Dr. Ayman Al-Sibassi joins Jaz in this endo-packed episode to help you navigate the tricky world of root canal re-treatments. From solvent selection and GP removal techniques to assessing case difficulty, they break down everything a GDP needs to know to make smart, confident decisions. You’ll learn how to spot the cases you should be tackling, which ones to send to your endodontist, and what tools and techniques will make the re-treatment process smoother and safer. Because not all re-treatments are created equal—and some are surprisingly simple once you know what to look for. https://www.youtube.com/watch?v=apMtcuNTLqI Watch PDP233 on YouTube Protrusive Dental Pearl: A crack in a bonded ceramic restoration isn’t necessarily a failure! Just like we accept cracks in natural enamel, we can also accept cracks in ceramics—as long as it’s been properly bonded. Shoutout to Dr. Pascal Magne for this powerful mindset shift! Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Specialist training in endodontics includes a variety of surgical skills. The complexity of root canal retreatments varies significantly. General dentists can perform some retreatments, but should assess complexity carefully. Patient consent is essential, especially regarding potential unrestorability. Communication about fees should be clear and upfront with patients. Red flags for retreatment include poor coronal seal and previous treatment quality. CBCT imaging is becoming increasingly important in endodontic practice. Collaboration between general dentists and specialists enhances patient outcomes. Many referrals stem from straightforward cases that are poorly managed. Using solvents can aid in GP removal but should be approached cautiously. Single visit treatments are often preferred for patient convenience. Adequate disinfection is crucial, sometimes necessitating a second visit. The survival rate of root canal-treated teeth is comparable to implants. Patient age and overall health should guide treatment decisions. Understanding the difference between success and survival in endodontics is essential. Highlights of this episode: 00:00 Introduction 05:02 — Protrusive Dental Pearl: Cracks in enamel vs. dentine  06:34 — Guest Introduction: Dr. Ayman Al-Sibassi and his journey into Endo  11:03 Assessing the complexity of re-treatments and when to refer 15:21 The role of CBCT in diagnosis and treatment planning 17:47 Ethical and financial dilemmas: charging for unrestorable teeth 22:05 Red flags in root canal re-treatments 34:55 Techniques for GP removal and file selection 47:07 Cost vs. predictability: re-treatment vs. implants and long-term outcomes Take a look at this Endodontic Complexity Assessment Tool to help you evaluate how challenging a root canal case really is. If you enjoyed this episode, you’ll definitely want to check out: Stop Being Slow at Root Canals! Efficient RCTs with Dr. Omar Ikram – PDP163 This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes B and C. AGD Subject Code: 070 ENDODONTICS (Non-surgical treatment)  #PDPMainEpisodes #EndoRestorative Aim: To provide clinicians with a structured approach to diagnosing, planning, and executing simple Re-Root Canal Treatments (Re-RCTs), while recognizing case limitations and improving treatment outcomes. Dentists will be able to: Identify clinical situations where Re-RCT is appropriate and distinguish them from cases requiring referral or alternative treatment. Describe the potential challenges such as canal blockages, separated instruments, or apical complications, and know when to refer. Communicate effectively with patients regarding prognosis, risks, and treatment expectations, including the need for possible referral. Click below for full episode transcript: Teaser: So if it's higher up on the attached gingiva, I'm thinking more about a root fracture. If it's lower down in the buccal sulcus, then it's more likely to be coming from the apex. And that is a, I'm not saying it's less, probably less likely to be a fracture, whereas if it's really high up, you're thinking maybe a furcation, sorry. Teaser: Fractures somewhere in the root essentially. If we come back to what I said about why most these more straightforward cases, why they fail a lot of the time. As I said, it’s because the gps already not that well condensed to begin with. So in terms of removing the gp, my first go-to in those kind of cases would always kind of be- so the reason I say that is ’cause they’re handfull, so they’re probably a lot safer than using sort of rotary files. You can control it a bit better as well.  Jaz’s Introduction:I used to think that root canal re-treatments were only for specialists and that GDPs should not touch them. Well. How wrong was I? When I entered my training post in Sheffield, it was a a dental core trainee post. Now the rest of the world is kind like a residency. It was like one year attachment with the restorative department, and this was in a dental hostel. I remember seeing a case, it was a central incisor and it already had a root filling, so it was up to me to do the root canal re-treatment. Now, I was scared. I was, oh my God, I’ve never done a re-treatment before. I’ve never had to remove gp. And also I was learning how to use the scope of the first time. So for me, I was nervous. I was thinking, this is very much specialist treatment. Will I be able to carry it out? Now, when the case actually came in front of me and I saw the radiograph, it literally was like a GP cone floating in this big wide canal. Just that one sultry master cone. Plenty of air and fluid if you like around it. No wonder it failed and I accessed the tooth. I literally, with my tweezers, could see so clearly that GP cone, I picked it out and I carried out the root canal treatment and that was the easiest root canal re-treatment ever. And it just made me realize that had this limiting belief that not all re-treatments are the same. So I guess the point of this episode and what we’ll learn with my guest Dr. Ayman Al-Sibassi, is how to know which re-treatments GDPs should totally get involved with and how to know where perhaps this is one to refer to our specialist colleagues. You’ll find out the best ways to remove the gutta percha. Is it gutta percha or is it gutta Perker? Honestly, endo is not my thing so much anymore, so I don’t even know how to say it anymore, but you know what I mean. The GP. Which is the best instrument, which is the best solvent? And interestingly, how much solvent should he actually be using? Like should you be flooding your canal with solvent or should you be just using tiny drops on your instrument? And related to what I just said earlier, I want you to understand more about risk and predictability of re-treatments. What are the red flags that you should not pass go? We cover all this and so much more in this episode. Now, if you’re new to the podcast, welcome. My name is Jaz Gulati, and therefore you are called affectionately the Protruserati. We are the community of the nicest and geekiest dentist in the world. So if you wanna join that community, head over to www.protrusive.app. The idea is that we don’t want anyone to feel isolated, that they can’t ask for advice. If anyone’s feeling nervous or unsure about certain treatments, well check the whole backlog of all the episodes we’ve done. But also having peers, like-minded Protruserati to support you is exactly what you’ve created on our app. Now those of you who are returning viewers and listeners, please do hit that subscribe button. Dental PearlAnd as you know, every PDP episode, I give you a Protrusive Dental Pearl. Now by the time episodes come out to publish, it’s actually probably been a few months sometimes what I’m kind of doing now is like early spring now, and I’m kind of getting ahead so that I can enjoy my summer with my family. But you guys all get an episode once a week. That is the dream. And one thing that you guys ask me all the time is Jaz, how do you do it? How do you stay motivated with your podcast? How do you get it done? How do you balance family, children, clinical dentistry, and of course watching cricket, which I love doing. How do I make it all happen? Well, I’ll tell you something guys. Something just from the heart. I have a big team now and they help me so much. It is a real team effort to get every episode out. Every episode that has CPD or CE especially, has probably been through about four different people and about three of those are dentists before it actually reaches publication. That’s so that we can actually quality control the CPD questions, the learning outcomes, and produce the best done for you notes ever. Like our premium notes are just such a brilliant summary. The key takeaways are summarized so nicely in our PDFs and to actually make that happen takes a lot of effort. Now because I have a team on board that rely on an income from Protrusive, it is so motivating to make sure I don’t let my team down. So I guess I’m trying to say. Thank you so much guys. Thank you so much for supporting the podcast. I’m feeling in a very grateful mood today ’cause yesterday I was at Dr. Pascal Magne lecture live in London, and I met so many of you that came up to me and said thank you. Like literally I was just amazed. Like I was, I was almost getting very emotional. You guys were coming and saying, hey Jaz, I just really wanna say this. I wanna get this outta my chest. And you said to me, Jaz, I just wanna say thank you.  Thank you for all you do and honestly, I’m passing this straight to my team. I really appreciate your kindness and all these years you’ve been listening and our channel’s been growing, thanks to you and for you recommending your colleagues. So if you still know people who haven’t heard a protrusive, please do send them episodes like this. The Protrusive Dental Pearl today is taken from Dr. Pascal Magne’s lecture yesterday, right? It’s very fresh in my head. Sometimes I get anxious about, oh, which pearl will I share today? Like the first few episodes, it was easy had loads of pearls I could pull out. You know, 300 episodes in now is difficult to actually think of a protrusive pearl to give you. So it was a really cool one yesterday from Pascal Magne. He says that when we see a crack in enamel, how do you feel? What do you think? Do you think that this tooth needs to be extracted? Hell no. Okay. Cracks in enamel are not a big deal compared to cracks in dentine. Cracks in dentine are serious stuff. Cracks in enamel are common. A crack is how the stress has dissipated. So the real pearl here actually is when you see a crack in your ceramic, don’t think that it’s failed. Don’t think that you are a failure. Don’t think that ceramic needs to be changed just because of a crack. And that was really eyeopening because sometimes when you place a ceramic and you see it a few years later and you start to see a crack inside, you think, oh goodness, this has failed. But actually, we shouldn’t think that if we accept it in enamel, why can’t we accept it in ceramic providing, providing that’s been bonded properly. A bonded ceramic is a completely different beast to a cemented ceramic. So in bonded ceramics, a crack is not the be all and end all. And please don’t interpret that as a failure is our tip for today. So turban tip to Dr. Pascal Magne for sharing that in his lecture yesterday. Anyway, let’s dive deep into root canal re-treatments for GDPs and I’d catch you in the outro.  Main Episode:Ayman Al-Sibassi. Welcome to the Protrusive Dental Podcast. Can’t wait to geek out endo stuff with you. But tell us the story, right? You just literally told me, that you have a baby. Congrats at 10 months old. But he or she, sorry?  [Ayman]It’s a he. It’s a boy.  [Jaz]Okay. Boy. Name?  [Ayman]His name’s Suleiman.  [Jaz]Okay, so Suleiman was born a day before your specialist exam, is that right? For Endo?  [Ayman]Yeah. Yeah, basically, yeah.  [Jaz]What was going through your mind and like how did you cope? Did it affect your exam in anyway? [Ayman]Yeah, well I think it was probably made it up to be more than it was. Only because, you know, the day before the exam you’re kind of like, you’re not getting any more information in, at that point anyway. You’re kind of just like bugging out at that point. You’re kind of stuffed with information. So in reality I couldn’t take any more information in. It was more just the panic of how am I gonna do this? Is my wife gonna be okay? I was thinking a little bit more about my wife, my son, not about like revising more, but just is, are they okay? That kind of thing. Basically it’s just, I had good support, to be honest. I had like a lot of good support. Like my parents, my mother-in-law and like my supervisors were, was super helpful as well. One of my supervisors even came and like dropped a bag of stuff at the hospital to help out and stuff.  [Jaz]Wow. Wow. That is a real special story. Where did you do your specialist training? [Ayman]University of Liverpool.  [Jaz]That is really cool man. I love that your supervisor was supportive like that. That is, you know, we need more of that in dentistry.  [Ayman]Dr. Marwad(?) Yeah.  [Jaz]Okay. Okay. Well I’m glad you name dropped. Buddy, look, I’d love to know a little bit more about you. Firstly, my listeners are gonna love like those listening on Spotify treadmill. You have this lovely years deepest voice, which is just the podcast listeners are gonna absolutely love this, by the way. So that’s a great plus. They’re gonna get through the end of this one, which is great. Tell me about yourself, mate. How did you get into Endo and, and the usual stuff.  [Ayman]So essentially, fourth year of uni when we kind of started do an undergrad, this is under undergrad, I mean undergrad sort of endo. We started like around third, fourth year, and I did a couple of endos and I just thought, yeah, that’s me. That’s what I’m gonna do. So I kind of knew since towards the last couple of years of undergrad that that’s what I wanted to do, and I always kept telling my colleagues. This is what I’m gonna do. So kind of when I left, I focused on that a little bit during my FD year. Did a little bit of it, well I didn’t really do any of it ’cause I went into DCT over a year after that. Did a year in Maxfax and then came out two years in general practice and then straight into specialist training. So I probably did in total a little about three years in general practice, one year of Maxfax. And then, yeah, went in specialist training three years full time, basically up in Liverpool. But yeah, I just liked it. I felt like it was a bit of a dark art. I liked all the gadgets. I like the instant results that you see as well, and I thought it was just quite niche. Not many people like it, and that kind of drew me into it as well. [Jaz]No, we need more endodontist on the register, there’s not many, I mean, the last I checked years ago, maybe nine years ago, if you know this number, it was something like 264, 9 years ago. I remember that number of, especially endodontist registered in the UK.  [Ayman]Funnily enough, part of my sort of doctoral thesis at Liverpool, which is part of the research we have to do there, attached to our specialist training. I had to actually look into how many there are. So there’s still around, I think around 300. But the thing is a lot of them will be like restorative consultants who don’t necessarily do endo mono specs. There’s probably a lot less than that.  [Jaz]Yeah. Okay. No, that’s a good point. And just about your training, I think it’ll be very useful for our colleagues who are in earlier stages of their career decision making. You knew you wanted to endo right? And you did. Almost like a distraction year when, if you think about it, it was a distraction year when you did MaxFax, ’cause it kind of, you, one might think it took you away from your goal, but maybe you needed it to actually reach the endo hand on heart. When you look back at it, do you think, ah man, I regret doing that year. I wish I did private practice, or I wish I did more endo. Or do you think back saying, you know what, you’re so glad ’cause it made you a more rounded clinician. What’s your take on that?  [Ayman]I don’t regret doing it. No, definitely not. Number one, because I felt like the year itself was quite full on, so I felt like it made me a little bit more resilient in terms of like doing things, working, just working hard basically. So that was one. And then the second thing is we did a fair bit of oral surgery on that rotation, so it kind of gave me some more surgical skills, which nowadays and endo are becoming a lot more important ’cause endodontists nowadays. Historically it might have been maybe more, a little bit more about the endo with like apisectomy and stuff like that being done by oral surgery. But it’s becoming a lot more within the remit of Endo to do things like, you know, apisectomies, auto transplantations, intentional replantations, root resections, and then even like resorption repairs, perforation repairs, stuff like that is all kind of coming within the remit endo now. So I think for that, it’s quite useful. [Jaz]Yeah, that’s good. It’s probably a stepping stone. I can see those surgical skills being useful later on. Thanks for talking about your journey, Ayman. I really wanna get into the topic of today, which is re-treatments, root canal re-treatments. I remember when I was working under my consultant as a DCT, when I used to type it, when I used to like write in the notes re RCT, he was like, no, you must write root canal re-treatment. ‘Cause what is a re-rct? Like, it was one of those pedantic things. But anyway, I remember I mentioned my DCT because I remember I had this limiting belief, Ayman. Yeah. I had this limiting belief ’cause I was a GDP. I was a DCT. If anything, right. And I was like, I can’t do a re RCT, I can’t do re-treatment ’cause I’m not a specialist, therefore I cannot do re-treatment was my limiting belief that I had. And so I remember doing this one case, it was a re-treatment, right? And it was like single central incisor and it was like, the thinnest, skinniest GP point, right? In this widest canal, like probably every time the patient walks, the GP point’s probably moving side to side in the tube. You can just imagine it, right? And so when I accessed that and I literally got my tweezers and I pulled out the GP. And I treated it and the sinus tract went away. I was like, holy moly, I just did a root canal retreatment. And then you realize, okay, hang on a minute. That was just a limiting belief that actually they’re not all the same. So my first question to you on that remit is what do you think about the scope of re-RCT for GDPs versus should it be referred to specialists?  [Ayman]Well, I definitely think they’re on a spectrum. So some of them, as you said, like will be a lot more straightforward, like the one you described versus some others, which can get complex depending on what you know, what they are. So you’d always have to kind of do a complexity assessment. So there’s different tools available.  The one I’ve used and the one I’m most familiar with is one called ECAT. It was developed by a couple of colleagues at Liverpool. It’s essentially an online tool that you can click through and it just basically gives you all the factors which will give you how complex it is. So things that I would look at just in terms of what would make it a very simple case, I’m usually thinking about patients medically fit and well. No sort of complex medical conditions.  Things like sort of bisphosphonates, not very anxious, mouth openings quite good. That would be the sort of patient factors I’d be looking for. And then tooth related factors to make it simple. Usually you’re looking at like an anterior tooth, usually a one to three. Premolars can get a little bit tricky sometimes. Not always, but the anatomy, I find that my clinical practice always get kind of fooled sometimes by how complex premolars can be. But yeah. So one to three is usually, as you said, GP points kind of floating around. Those would be kind of simple cases in my mind.  [Jaz]And then what about when you see one and you see that it’s been like there’s no voids and it looks like it was a decent job. And I look at it and I’m like, hmm, I know the radiograph. The problem is the radiograph doesn’t tell you if rubber dam was used. The radiograph doesn’t tell you if hypochlorite was used. So much information you miss when you look at radiograph, but sometimes you see. And it looks fairly good quality in a radiograph. At that point, I’m very happy to refer because I’m like, okay, well there’s something else going on here in addition, and I just think, our specialist friends need to eat as well, so this is the kind of stuff they should be eating. I’m just gonna do the cherry picking as a GDP should do. But of course, some GDPs, they love endo and they kind of like have a special interest. They do extra courses and then they, they know if it genuinely gives you excitement and a challenge, then do it. But for most GDPs it’s like, okay, that’s a point where I see a well. Filled canal. There’s no voids. It might be a little bit more challenging to remove the gp, which we’ll get into. Is that a, a fair way to think about it for a GDP?  [Ayman]Sorry, can you repeat that last question again? I did just cut up there for a sec.  [Jaz]Is that a fair way to assess a tooth as well? When you look at the, how well it’s filled on the radiograph.  [Ayman]Yeah. So that would be one of the things that I would say would make it more complex is out of one of many factors. So if it’s already like, like there’s certain quality standards that we look at for endo. So the main things would be, is it filled to within two millimeters of the radiographic apex and is there root filling walk condensed? And then also like coronally you’re looking to, so is there any obvious corona leakage there or anything like that? So if there’s nothing obvious you can identify on the x-ray, that could be the reason why it’s failed and you can’t see, for example, any cracks in clinically that you’re picking up as well. Then yeah, I mean those cases tend to be a little bit more complex. There might be like missed anatomy inside that you can’t see. Again, you don’t know what happened previously, and there could be a lot of leakage. So a lot of the times, if the root canals are old, there’s studies that show that a lot of the restorations, or almost all of them have some coronal leakage to a certain degree around them as well. And that can cause sometimes failure. I mean, in those kind of cases, I would always kind of be thinking about CBCT because there’s no obvious cause of what is causing it to fail that you can see. So that would usually some give you some more information. I mean, that’s what I’m thinking.  [Jaz]That’s fine. So, Ayman, how common is CBCT becoming in your practices as endodontist now either at the consultation appointment, or, are you really happy when a GDP sends a referral with a CBCT and gives you just more information? Is that becoming more common in practice now?  [Ayman]Yeah. Yeah, it’s definitely becoming a lot more common in practice, and especially as with CBCT, the machines are going in the direction of the doses becoming, or the radiation doses becoming reduced over time. So as that happens, I think it will become a lot more used. To be honest, the doses at the moment, they are not. I mean when you look at them in relation to like what you do in Maxfax, for example, remember we used to take full mouth, full face CBCTs of everything, for example, when the patient came in. So dose is actually like way, way lower than that. So yeah, and those doses are only gonna come down with time. So as that happens, it will become more common. In terms of when a GDP-  [Jaz]Can you gimme some examples of like, you saw the CBCT and it completely changed your treatment plan, it completely change your perception. How often does that happen?  [Ayman]Well, I can think of a case that happened actually a couple of weeks ago. So it was lower molar, it was re-RCT case. A patient came in and the root canal filling just looked like void. The big PA lesion, void the root filling. So anyway, I just, I started the root canal filling, re root canal treatment just based off of the PA. I didn’t really suspect anything, and I opened the tooth up. I was getting quite early apex locator readings much earlier than I expected. So then I took a CBCT of the tooth, and I found that actually the mesial roots, that sort of danger zone, that distal concave aspect of the mesial root was kind of completely resorbed away. So the gps were half sticking out into the fication area, which wasn’t obvious on the pa. So that means that the-  [Jaz]So this was a resorption and not like a strip perforation. How can you tell? [Ayman]Well, yes, it was difficult to know, and my suspicion is it probably was resorption because there was a massive lesion associated with it into that vocation area. So sometimes you can get something called external inflammatory resorption, which kind of eats away at that area of the tooth as well. But it may well have been a strip perforation. I’m not entirely sure just looking at that. Yeah, I mean that made in my mind the tooth on restorable. There wasn’t really much that I could do about it, so I had to tell the patient, you know. I can’t really do anything with it. Whereas previously I was about to go and reroute, can I treat it? [Jaz]I’m gonna get into removing GP and that kind of stuff. But now that you’ve mentioned this point of a very niche scenario, one of the questions we had from the community, I asked last night, I said to everyone, hey, I’m recording tomorrow about re-RCT. And so one question was, is it tricky question? Ayman, not in terms of like tricky endodontically, is tricky more in terms of ethical dilemma and charging of patients. Let’s talk about this before we go into the details of re RCT further. You have this scenario, just like you described, right, invested time in treatment. You’re now time committed. You do the CBCT, and now the tooth is unrestorable, okay? Does the patient then leave and they haven’t paid any money to you, right? Because now they’ve just been told that they can’t do it. Is there a fee that was agreed in terms of the consent and the consultation that you do? Is that okay if it can’t be saved? You’re gonna be charged this much and you’ll have that information because imagine as a GDP, you trying to, like the example Julia gave, Julia Tully, example she gave is that she opens up a molar and she can see the three main canals, upper molar, and then she just about sees the MB2, but she gets stuck at that stage. She can’t get into and navigate MB2 properly. And now she’s like an ethical dilemma. She feels though, well, okay, to get the best result. I need to refer you to the endodontist, but I’ve just spent an hour and 15 minutes accessing, removing caries, and then now, and that was all part of the endo, and now I have to refer, is it fair that I’m now charging my patient for my initial fee? So there’s no right or wrong answer, but I’d just love to know your take on that.  [Ayman]So two things. So from my perspective, I always would consent in a patient that the tooth is might be unrestorable. It’s almost like for almost every single case, unless it’s like, you know, no belly restoration is minimal or anything like that. But even then I’ll say, look, there might be a deep crack in there that we find or something like that. So I’ll always consent the patient for it being unrestorable and I’ll quote them a fee for an investigation fee if we don’t go on to completing the full root canal treatment. So, that’s, for example, that’s how I manage the case that I just mentioned. So I still charge them the investigation fee charged for the CBCT as well. Obviously, I didn’t charge for the full root canal treatment. In terms of if they can’t, for example, they can’t find their MB2, a lot of the times the patient for the GDPs, the patient, a lot of the time will come in in pain. So you’re still getting the patient out of pain, for example. And I would still, for example, charge maybe half a root canal fee because you still have done something with a patient. You’ve got them out pain, for example. You don’t necessarily always need to find MB two to get the patient outta pain. And I would assume that also it’s part of your consent process sometimes to say. Sometimes we can’t find canals, we might need to refer you. So if you need to do that, I would again, just consent the patient for potentially taking maybe half the fee or a third of the fee, because it’s still your time. At the end of the day, you’re still helping the patient out.  [Jaz]I agree with you so much, and I feel as though what we don’t wanna do is I feel bullied or curse that, oh, because I missed one canal or I can’t find it. Like you’re still doing the right thing. You’re thinking okay. I think someone else can navigate the deal, but you know, you would’ve got ’em out of pain. You would’ve done the hard work of caries removal, access removal. Sometimes you do a pre-endo buildup, you do all that. That stuff is valuable, but I think you just nailed it. You know, as long as you have this standard spiel in these situations, if we can do the root canal and everything goes well, this is defeat like you tell your patients your fees before you do the treatment. But sometimes things are really, really tricky. If they’re really, really tricky, I need to refer you. Don’t worry Mrs. Smith, you won’t have to pay the full amount. You have to pay a third of X or a half of X. And at least that way we’ve done some of the work and then the endodontist who may charge this much will do the rest. And now you’ve just been like super clear. And if you had that patient who doesn’t consent to that, then that’s the whole point of the consent conversation. Don’t think that if I tell the patient this, they won’t go ahead. Well, that’s actually the point of consent, right? And so you wanna have a patient who’s on board and who’s very reasonable and understanding of that, right?  [Ayman]Yeah, a hundred percent. Yeah. I would say like for example, you made a good point as well in terms of the caries. So a lot of the time root canal treated teeth, the majority of them are quite knackered to start with anyway. So you’ll almost always do like a restorable assessment as part of your root canal treatment. You’ll be stripping out amalgams, old amalgams, old composite caries, and that obviously, it’s still valuable.  Me as an endodontist, if you refer a patient to me and it’s already had the pre endo buildup, I’m like, thanking God at that point in time ’cause that actually saves a lot of time. So you’ve obviously done that service for the patient, it’s something that you’ve done, you’ve helped the patient out and you’ve saved me having to do it as well. So yeah, I would definitely still charge for that.  [Jaz]I think a really good way to do it ’cause this is obviously a real world issue. And then so there are some colleagues who would do the following. They would charge a fee for the restorability assessment and pre endo buildup. And that would come as a one fee. And then the second fee would be the root canal. And then at that point it was like, oh, you know what? I’m not charging you with the root canal ’cause I didn’t do it, but I did all this stuff. And it makes sometimes sense for the patient’s head. And so that might be a model that some practice may wish to use as not the main thing is that the conversation is had beforehand, so totally.  I’m glad we’re on the same page there. Just going back a bit before we talk about removing gp. Any like red flags that GDPs when they look at root filled teeth and they’re thinking, hmm, should I do a re RCT? Like, the one I mentioned was like, if you see that it looks like a reasonably good root filling, that is kind of like a little bit of a red flag that, hmm, should I be doing this? Another one would be like, if you see a separated file in there, then obviously. That’s one for you guys, not for us unless you are that way inclined. But I’m just giving like an easy guide to GDPs. If you see, I mean sinus tract for me is just a sign of infection. I know that can reduce the prognosis of your re-rct. Would that come as a red flag for you?  [Ayman]Just a sinus tract by itself?  [Jaz]Mm-hmm.  [Ayman]No. ‘Cause as you said, it’s just basically an external sign of the infection. Sinus tract by itself doesn’t mean too much. Although what I would say is depending on the position of the sinus track, that can sometimes indicate a fracture in the root. [Jaz]Tell us more. Where are you worried about?  [Ayman]So if it’s higher up on the attached gingiva, I’m thinking more about a root fracture. If it’s lower down in the buccal sulcus, then it’s more likely to be coming from the apex. And that is a, I’m not saying it’s less, probably less likely to be a fracture. Whereas if it’s really high up, you’re thinking maybe a furcation, sorry, fracture somewhere in the root essentially. Not always.  [Jaz]That makes sense.  [Ayman]It’s not like, it’s not fracture-  [Jaz]It’s the rule of thumb.  [Ayman]Yeah, I’m just a little bit more suspicious at that point, basically. And I think there is some research, I can’t remember the name of the paper, but there is actually some research on the position of the sinus tracts and how related they are to the presence of a crack. So yeah, which also confirms higher up on the buccal attached gingiva. More likely to be a fracture.  [Jaz]That’s a good one. And then obviously if there’s a post in the tooth, which actually one of the questions was, we’ll come to later, any tips on post removal, but I wanna save that for later. There’s a post, right? And unless you’re really into that kind of stuff as a restorative dentist and you get a kick outta that stuff, then I’d probably say that’s the one to refer. I’m sure you don’t get a kick out removing posts.  [Ayman]Is a question do I get a kick outta removing both?  [Jaz]Yeah, yeah. That’s the one where you’re cursing your referring dentist and not saying thank God.  [Ayman]Yeah, exactly. Yeah. I mean they can take a long, some of them come out in like two minutes and those ones are fine and you can kind of tell which ones those are gonna be ’cause they’ve got loads of space. But some of them they can take up to like an hour, like the long ones, well adapted really fat posts. But in those cases, a lot of the times you’d be thinking about a vasectomy and those teeth a lot of the time as well because yeah, I mean you might take the post out at the end of it and see that the tooth is actually unrestorable. Because it’s already been prepped to death to actually get the post in there in the first place.  [Jaz]And we’ll talk about some tips to remove posts, but any other last few red flags before we move on to GP removal?  [Ayman]There’s a few. So, kind of, yeah, if anyone is interested to see like this in a bit more detail, again, that ECAT tool goes through every single factor that you could kind of consider. So if you have application-  [Jaz]I’ll link it. I’ll link it.  [Ayman]Yeah, I think that that would be useful for anyone listening. So yeah, that it basically goes through every single possible factor. So just made a note of a few. And again, like I always kind of divide it into patient mouth, tooth related factors. So patient related factors, again, so for example, bisphosphonates, because there’s always a small risk that when you’re doing patency filling, for example. Potentially not always, but not a high risk, but that you could stimulate some kind of MRONJ reaction. Something like that. That’s one. Again, if they’re really, really anxious, you don’t wanna be sort of faffing about with taking a long time for root canal treatment as well. Limited mouth opening as one as well. That’s one we get quite commonly in referral practice too. So tooth related factors, I would look from the crown down. So number one, if there’s really, really deep restorative buildups required, so if you’re looking at like the margins on almost on bone, that’s one ’cause you wanna make sure you’ve got a good coronal seal. So that’s one that I’d be looking at. Any crowns or posts that you’re looking at there, especially if the crown or the post is in a different angulation to the tooth on the x-ray cracks is quite a big one, especially becoming more common nowadays as well. Cracks specifically as also associated with periodontal pockets. ‘Cause often with isolated periodontal pockets, ’cause often that means that the crack is extending down the root surface. Now those teeth, to restore them effectively, you often need a microscope because you’ll be bonding, composite down the canal orifice. And to do that without microscope is quite complex. So if you see an isolated periodontal pocket associated with a crack, a lot of the times, that would be quite a complex case to manage previous RCTs. As you mentioned, if the RCT looks good on the periapical radiograph, well condensed within two millimeters of the apex. That would be, you’re thinking why has this failed? So that might be something more complex. And also it’s well condensed. The GP is gonna be a lot more tricky to actually remove as well. It’s not gonna be straightforward. Fracture files you mentioned as well. And then more niche things I’d be thinking about are things like developmental anomalies. Sometimes you get like to taurodont, palato-gingival grooves as well. Which can sort of mask as endo problems. Well, C-shaped canals as well. Those are sort of things, fast breaks as well. That’s quite a, quite a common one that you see. So it’s kind of difficult to explain without an x-ray, but usually you see it, for example, on premolars, it comes back to our premolar while I was mentioning about premolars. So you see the canal, the canal, canal canals there, get to the apical third and then it just disappears. And then often that means that you’ve got some sort of deep apical split. So that would be quite a big red flag as well ’cause obviously you need a microscope to actually see all the way down there and actually help you to navigate around that apical complexity. Resorption, resorption cases as well. So depending on what the resorption, especially like cervical resorption, which is probably becoming more common nowadays. So resorption cases, ’cause a lot of the times they will need like surgical repair to actually access and fix history of trauma on anterior teeth. Sometimes they’ll have trauma to multiple teeth, which needs quite complex management. A lot of the times as well on the PA radiographs, you won’t see root fractures. They don’t necessarily turn up and that might need a CBCT to actually reveal that perio status as well. So perio endo lesions as well, which is actually, yeah, the topic of, that’s what I spent three years sort of researching at the University of Liverpool. Perio endo is quite a big one because a lot of the times the endo might be straightforward, for example, but to manage it appropriately, you’ll need a lot of the times regenerative surgery, which will become more complex in those cases as well.  So you might see, for example, an anterior tooth re-root canal in our treatment might be quite straightforward, but then to actually get the bone to regrow and the mobility to stop and the pockets to come down, you’re actually gonna need like bone grafting, membrane, stuff like that. So perio endo, especially like there’s a new classification. It’s by the, I think it’s the European Society or European Federation of Periodontology. [Jaz]Perio people, they love a classification. Like they’ll love bus one every six months, like they are the kings of classification.  [Ayman]So there’s a perio-endo lesion one. So they’ve divided it into grade one. There’s grade one, two, or three, basically. Grade one is if there’s an isolated pocket associated with the tooth. Grade two is one pocket on one surface, but not isolated. So it’s a wide base. And then grade three is wide or pocketing on more than one surface. So grade two and three, often those cases will require regenerative surgery, bone grafting, or enamel matrix derivatives to actually help them along. So those would be quite complex cases to manage too. I mean, I’ve been through quite a lot. Yeah. Sorry. [Jaz]You have, I mean, over, over the last two minutes you shared so many red flags there and so the general dentist listening to this like, wait, wait a minute. Like, are there gonna be enough cases left for me? So my question then for you is, how many re cts do you do and think, you know what, the GP could have done this. [Ayman]A lot. Yeah. So the good news is a lot of the cases that I do that are RCTs then these things have, are the red flags that I mentioned. They are there, but re-RCTs fail for common things. What’s that phrase? Common things happen for common reasons, so, the most common thing that I see with root canal treatments failing is poor coronal seal and poor apical seal.  So the GPS floating about, or this caries or some kind of leakage coronary, and those are the most common things that I see in terms of why that those kind of referrals come through. Probably, or maybe not common, probably about 50% of them are like that. Yeah. I mean there is a lot of cases like that. So while there are a lot of complex things, there’s also a lot of simple things that are easily managed. [Jaz]I think-  [Ayman]Easily. Probably sounds-  [Jaz]Easier.  [Ayman]So easier. Yeah, that’s the idea. Easier, yeah.  [Jaz]I think, Ayman, people might be thinking that, hey, why is the endodontist telling a dentist that, no, you could do a re-RCT, and I think it’s because you have enough, you guys are not gonna go hungry if the easier re-RCTs are done in general practice to give you the stuff that you’re actually trained to do. The things that actually are trickier. So let’s talk about when you are a general dentist and you are learning about doing retreatment is something that little bug bit me and I was about two years qualified and the first thing was actually DF1 actually had my first one. And I was like, how do I remove the gp? And so then you look into it and then you think about different oils and stuff. At the time I had bought, ’cause obviously chloroform in practice was difficult to get. So I used eucalyptus oil. I remember using it and then like a drop of it went to rubber dam and I forgot which dam it was. And a huge hole appears in rubber dam. I’m like, wait, no. No one told me this would happen. This wasn’t the playbook kind of thing. So it’s a lot of things that learning. So it takes us nicely to the question, okay, what are the tips that you can give to general dentists to remove GP effectively and safely and efficiently. [Ayman]Yeah. Yeah. So if we come back to what I said about why most these more straightforward cases, why they fail a lot of the time, as I said, it’s because the gps already not that well condensed to begin with. So in terms of removing the gp, my first go-to in those kind of cases would always kind of be headstrong files. So the reason I say that is ’cause they’re hand files, so they’re probably a lot safer than using sort of rotary files. You can control it a bit better as well.  Interjection:Hey guys, this is Jaz with an interjection. Just a really quick one, right? H files. K files, and C plus files. This just briefly, really quickly go through the differences, like going back to basics. So K files are the workhorse, right? These are the main files we reach for. They are triangular or square in cross-section. They use a rotational or a push pull watch, winding kind of way. Very versatile, and they cut to dentine both on insertion and removal, but not as aggressively as H files, which stands for Hedstrom Files. Now before we talk about Hedstrom Files, we just have to point out that whilst K files are like a workhorse and they’re so versatile, they’re not as aggressive as debris removal as H files are. And when you get a calcified or sclerosis canal, then you know what? K files are not as good as the C plus files, which I’ll explain in a moment. So H files, I was always taught in dental school that they look like a Christmas tree, and once they’re circular in cross-section, they do actually look like a Christmas tree to me. Now, they shouldn’t be used in the same way as you use a K file. Absolutely not. These are specifically push pull, and they don’t really do much when you push into a canal, but when you pull, they are very aggressive and very efficient. They’re good at removing debris. They’re good at cutting, and they’re even good. Very relevant to this episode at removing gutta percha, which is why they’re used for re-treatment cases. So whilst they’re efficient, you have to be careful because you could break them if you misuse them. So please do not rotate H files and use them like a K file if you misuse them, you can cause all sorts of errors within the canal like transportations and ledges and that kind of stuff. Now, mostly the C plus file. I don’t have much experience myself in using these files, but they have a very active, so they’re really good for sclerosed canals or calcified canals. That active tip allows you to get really good tactile feedback, and it’s just ideal for the negotiation of sclerosed canals. The main thing is to use the file for its intended purpose in its intended way. Don’t go using a H file in a curved canal in the wrong kind of manner. ‘Cause that’s asking for a file breakage. Now let’s go back to the episode.  [Ayman]So I would probably go for like a size 35 to 45. Nothing smaller than a 35 because when you screw it in, I find that they are more likely to fracture. So yeah, I would go for like a size 35 to 45, something in that range. And yeah, you kind of just ask, get your estimated working length off the radiograph and then you’ll kind of go into the top of, say the most coronal portion of the apical thirds. I’ll try and get the file down there. Screw it in just very gently. If it’s not go in, I wouldn’t force it ’cause you can end up lodging and stuff like that. But oftentimes you’ll literally feel the headstrong file. It’s passing down quite easily into space, or you’ll feel it screwing into like stickiness, and that will be the gp. So get it down there, make sure you got your length, and then you just kind of, it’s basically a pulling motion essentially. And a lot of the times in these cases you’ll find that the GP just comes out with one or two pull of that and it kind of just pops out with it. If it doesn’t, then you can use a second hedstrom file and like a braiding technique. So you can kind of put them both in together, wrap them around each other, but again, very gently, don’t wrap them around too many times ’cause you can fracture a file inside.  [Jaz]For this braiding technique. I’ve seen it been recommended for removing separated files and stuff, but in this instance, if you’re using two H files, are you now using thinner ones to allow both the files to go in at the same time? [Ayman]No, I would still probably be using like 35, something like that again, because often if the cases we’re talking about they’re gonna be one, two, or threes and the access in those cases, currently is quite big and it can accommodate two hedstrom files. I don’t find that it’s that uncommon for me to get two hedstrom files into these coronally. Obviously apically won’t be able to pass those files down, but coronally, coronal third, mid third, you should most of the time be able to get it in there. I’m not sure if that answers your question.  [Jaz]That does, it’s just reassuring. And so obviously you’re saying 1, 2, 3, for our American colleagues, we’re talking about upper centrals, laterals, and canines for our American colleagues. And then, so when the braiding technique, and correct me if I’m wrong, is you put in both the files and then the handles, you literally start like twisting them around and then braiding them. From the top and then on the inside the files are like wrapping, intertwining together. Which we are hoping will latch onto the GP, is that what we’re hoping? [Ayman]Correct. Yeah. So ideally you want to look and see if you can get one file on one side of the GP and the other file on the other side of the gp. And then you kind of just wrap them over each other a couple of times and then you kind of pull again, like if you’ve pulled a couple of times with a single hedstrom, it’s not coming out. You’ve tried a couple of times, the braiding technique, and it’s not coming out. You probably need something a little bit more. And I probably wouldn’t push too hard because obviously the more you put stress on the files, the more likely they are to fracture. So braiding, obviously you are bending the files to a certain degree as well, and if you are putting motions, bending it is putting a bit of stress on the files. So if you keep trying to do that again and again and it’s not working, I would probably move on to the next thing after that just to reduce the risk of the file fracturing essentially.  [Jaz]Okay, so GDP has tried those two things, and what’s the next call of action?  [Ayman]Yeah, so then I would be looking at essentially using a file, so a file system to basically remove the GP at that point. So the file system that I would use often, I’d go to something which we call rake angle. So if you look at the axial section of a file, you cut it down axial sections. Axial sections, like a bird’s eye view of the file. So when you’re looking at a bird’s eye view of the file, the way that the teeth of the file points, they kind of curve in a way which they end up biting into the GP rather than brushing it in a way, if that makes sense.  So it scores a positive rake angle. So often I’d go for a follow with a positive rec angle. The most common one that you see nowadays is Reciproc Blue. So that’s the most sort of common one that has a positive rec angle. And the use of that is that bites into the gp so when it reciprocates and bites into the gp, it kind of grabs hold of the GP a little bit and that can help to pull the GP out as well. So, that would be sort of my next step and my next go-to if the headstrong files aren’t really working. But again, you need to- [Jaz]And so when you are using the Reciproc Blue, ’cause I’ve never used this one before. Are you trying to take it to length and just allow it to sort of take you to length and then give up? [Ayman]Yeah. Yeah. Just so I’m on the same page. I’m not saying that Reciproc Blue is the only file that you can use for this. Of course, you can use things like -. Yeah, you can use WaveOne and stuff like that. In my hands, I just feel like it’s more efficient because of that positive rake angle. WaveOne will work fine as well, but it’s just a little bit less-  [Jaz]Glad you said that.  [Ayman]Essentially, because I think WaveOne usually in GDP practice, that is my understanding is that that’s the most commonly used file and it’s a really excellent file system as well. I actually use it quite a lot as well. For GP removal-  [Jaz]Well maintained the ties with Dentsply there. Good man.  [Ayman]Well, you know, I think Reciproc Blue is now owned by  Dentsply as well. They’ve been bought by, used to be, they’re both very good file systems for GP removal. Yeah, my go-to would be  Reciproc Blue . Sorry, I forgot what you were asking me now.  [Jaz]I was saying, so are you gonna take it to lent? Is it safe to take it to Lent at this stage?  [Ayman]Yeah, so, I wouldn’t go all the way with the rotary file. I would probably, again, look at the estimated working length and I would take it up to like sort of apical third top of the apical third, or alternatively to within a two, three millimeters where you think the GP ends. And the reason for that is if you keep trying to go past that, you can end up leveraging. And a lot of the times the GP stops at that point because there’s a ledge or there’s some kind of blockage in there. So if you try to keep pushing the file down there, you can make that worse or fracture a file or make it a problem that would be irretrievable at that point, basically as in a lot more difficult to negotiate, to patency to negotiate the canal. So I would stop at there where there’s still two to three millimeters of GP left. And then that last apical bit, I would probably be navigating using hand files. So 10, 8, 10 hand files with lots of irrigation. There’s a lot more control that way.  [Jaz]So I can imagine if you get lucky, you go towards the apical third with the Reciproc Blue in this example. And then you pull it out and then ideally the whole thing, the apical bit comes with it, but sometimes imagine it breaks up and so it’s left like an apical third plug of gp. At that point, you’re then using the files again?  [Ayman]Yeah, I would use, probably be using K-Flex hand files essentially at that point to try and get through. So like eight 10, those were, would be what I’d be using to negotiate the equal third. I mean, if the GP is really still, if you get to that point and the GP is feeling quite hard with the hand files. I remember when I started doing re RCT cases. You put the hand files in and you’re like, okay, it’s hitting a stop. Am I, is it blocked? What is it? So the main thing that you need to, you are feeling for at that point is to feel for that spongy feeling. And that’s how you know you are actually biting into gp. You will hit a stop, but it’ll be a spongy stop and that’s the gp. If you are hitting like a hard stop, like it feels like it’s like kind of pinging off the wall or something like that, then you know there’s maybe a ledge. Or there’s something else that’s more complicated. But if you are biting into something that’s a little bit spongy, you should be okay basically to keep, keep trying. And often I would be using like, sort of watch winding motion just to keep it, well keep the file well centered or like a 90 degrees, small, 90 degree pull motions to try and pick out the GP bit by bit. [Jaz]At what point are you thinking get that, grab that bottle of eucalyptus oil? Is that, Olbas, was it Olbas, was it, maybe it was Olbas oil actually. But I used it. Are you using those little oils, essential oils and stuff?  [Ayman]I use them very occasionally. Very occasionally, and the cases that I use ’em to are kind of limited to if I’m really struggling to get through the apical third of gp. But oftentimes I would find those are cases which are quite complex to start with. So the GP is already like super well compacted or it’s a really, really old re-treatment. So like for example, the GP has set rock card and I tend to find that when the root canal’s already been been in place for like 10, 15, 20 years, if it’s like relatively fresh, then the GP will normally still be quite soft and easy to pick up. So yeah, I would leave it in there for a few minutes and then pick out a bit more. And the reason I don’t go to it that commonly is because it smears, like with the rubber dam example, is it tends to smear the GP over the walls of the root canal. And when we think about the sort of biologically, what we’re trying to achieve with the root canal is adequate disinfection. So if you’ve got layer, layer of rubber smeared over the dentine or tubules, you’ve got a lot of bacteria a lot often hiding inside those dentinal tubules, which then becomes a lot more difficult to access with your irrigation. So although you might have got to the bottom of the canal, you’ve then just blocked access to a bunch of other bacteria, which could be in the apico ramifications and the Dentinal tubules. So yeah, you might be getting through one problem, but then causing yourself another one. It’s a little bit controversial. I mean, I think in America it’s a lot more common that they use it. In the UK, I see people, my experience is that my mentors and what I’ve seen people do is a lot less common in the UK because of that reason. [Jaz]It makes a lot of sense because if you think about how to remove once that GP has made, we know that a file system, you’re only really touching 40% of the canal space with the file. Most of it’s left untouched, right? And therefore, how are you gonna mechanically remove that without then actually over preparing the canal itself, right? Which is obviously the last thing you wanna do. So that makes a lot of sense. Now, for those getting a little bit stuck and they want to use some sort of solution. Can you just name what is it that you use? Is it Olbas or is it Eucalyptus? Is it something else that you have access to? And then what’s actually the best way to use it? Like do you dip your file in it and then put it in, or do you actually syringe it in like you would do hypochlorite and leave it there? What’s actually the accepted way to use it?  [Ayman]So there, in terms of what I use, there’s a few that you can use. Orange oil, eucalyptus oil. Orange oil is one, Eucalyptus oil and there’s Endosolv as well. I’m not sure if the Endosolv original is on the market now. I think they’ve changed it to Endosolv R I’m not sure. I’m not sure. I’ll have to double check that. But there’s a few. And these all basic kind of work on different arbitration materials. So for example, if you’re finding out to get down one, you might experiment with the other one and see if you get any further with that. But again, oftentimes if you’re having to resort to-  [Jaz]I didn’t know that it was interesting.  [Ayman]Yeah, I did know when I was sitting my exam exactly which solvents were good for which materials.  [Jaz]Baby brain. Newborn dad.  [Ayman]But yeah, so, you might go through a couple of them, but oftentimes if you’ll get into that stage, I’ll be thinking of the reroute treatment is obviously probably a bit more complex at that point anyway, so you might at that point be thinking about a referral if you’re really stuck in that apical third and none of the solvents are working. In terms of-  [Jaz]And how to deliver the solvent.  [Ayman]How to deliver it. So, in terms of delivering it, I would usually use it in a syringe. Basically. It’s the same way that I deliver the hypochlorite and I’ll just leave it to sit in there for a couple of minutes to do its work. Just kind of, have a little break, just let it sit. And then once it sat there for a couple of minutes and it’s done, its work, I would go back in with the hand files basically and just slowly start to pick away at it with the hand files.  [Jaz]Okay. I mean, I’m kicking myself now because I remember, years and years ago doing it and I was like literally dipping my file in it a little bit, dipping in the canal, dipping my file. Like it just makes so much sense. Just leave it to do work.  [Ayman]Yeah. It needs a little bit of a reservoir to kind of work. And if you imagine as well, it’s kinda like the hypochlorite, it reacts with the gp, so if you’ve got a reservoir of it, it’s of sort of continuously reacting. Whereas if you just put a little bit down there, then you are limiting that sort of reaction process in a way. [Jaz]Okay, great. And so in the interest of time, I’m gonna ask you my friend, when you’re doing these, firstly single versus a two visit, the endodontist that works in our practice that I work at, he is adamant, he swears by a two visit. The previous endodontist we had, younger grad, newer specialist. He liked one visit. Okay. And obviously sometimes they’d find a reason to change patient factors, tooth factors, whatever. Right? So what, firstly, I’d like to know what is your general preference? When you look at your diary, like a retrospective. When you look back at your diary, are you tending to do primary root canals in one visit or two? And then does that change because it’s a re-RCT and how you manage that in terms of timing?  [Ayman]So you’ve kind of touched on quite a controversial topic in Endo, to be honest. There’s actually quite a big divide in Endo among single visit and two visits. So depending on who you ask, they’ll probably give you different answers. [Jaz]That’s cool. But I’m literally generally interested in what you do. Okay. ‘Cause you can do it either way. And I just wanted to hear from you. What do you do?  [Ayman]Yeah, yeah. I mean, I would try where I can to do things in a single visit. ‘Cause I think that’s a lot of the times that’s a bit more patient centered in terms of what the patient wants. So the patient would obviously prefer for you to have things done in one visit rather than two visits. But having said that, if you think about the main sort of biological rationale or root canal treatment, you’re trying to disinfect the canal space. If I feel that I cannot adequately achieve that in one visit, then I think the patient would much prefer me to do a second visit rather than increase the risk of it failing. So things that would then push me to doing that second visit, if I think I can’t get that adequate disinfection process is number one, if I run out of time and I can’t find all the anatomy that I think is there. So that’s one. Then I’d be doing it in two visits. Number two would be if there’s a lot of discharge from the canal, so the canal is just weeping continuously. That would be another thing that would make me probably dress the canal as well. And then another thing would be perio endo lesions as well, that would be one that would dress the canal too. So there is some research to suggest that with peroneal lesions, if you dress the canal, although it this kind of controversy for endo, it might not have an impact necessarily on the perio apical healing of the tooth, which is the endodontic outcome. But in terms of the periodontal pocketing, dressing the canal with an interim dressing can improve the periodontal pocketing side of things as it sort of diffuses through the dentinal tubules into the periodontal ligament space. And then also in terms of teeth with cracks as well. That would be another thing. So if it’s got a crack with an isolated pocket, that isolated pocket a lot of the times is where the crack is leaking bacterial leakage, basically through the crack. And that’s manifesting of the periodontal pocket. So if you, for example. Do the first stage root canal. You clean everything out and then you dress it. Oftentimes, I’ll get the patient back in a few weeks later to see if the periodontal pocket has improved and reduced in depth. If it has, then I’m thinking that crack is probably a crack tooth worth trying to save if it’s not really improving or it’s basically getting worse and I’m thinking, is this really gonna work for the patient? So you can use it as a kind of diagnostic tool in that way as well.  [Jaz]A stepwise, careful approach, basically.  [Ayman]Yeah. So I’d be thinking exactly. Yeah, so the other thing is probably really, really significant swellings as well. So if the patient comes in with a massive swelling, that would be another thing that I would sort of be looking at as well. [Jaz]But you haven’t mentioned re-RCT. So what I’m trying to get to is, is the fact that it’s a re-RCT. Should that push our colleagues so GDPs now, right? So not the kind of specialist, what you do just because of re-RCT. Is there any reason why they should be thinking, oh, it’s gotta be two visits now, or is it still okay to do it in one visit? [Ayman]The fact, as I mentioned, I find that they occur just as much for re RCT cases as they do for primary cases, if not more for re-RCT cases actually. ‘Cause often the tooth has already been through that restorative life cycle for many, many years. At that point, the fact that it’s a re-RCT case in and of itself is not enough for me personally to do it over two visits. Maybe if it was a really good quality root canal treatment, that would be an indication. ’cause then I’m thinking as there sort of more virulent strains of bacteria. But that’s not really that evidence-based to be honest.  [Jaz]Well, I’m gonna just take a few questions from the community now, buddy. In the interest of time, right? Let me just head to the community here. There was some questions we had yesterday. Okay? So I posted yesterday saying, I’ll be talking about this topic. And James, oh man, James got some awesome contributions and he put up a radiograph of these post crowns and have a look at this, look at this central, which like complete destruction, caries, post, root filling, that kind of stuff. And he makes such a real world point here. He says, I’d love to hear us, your thoughts on value for money in re-treatments, right? So if you have a molar with an old crown, poor margins failing, inadequate root treatment, right? The total cost of doing a root canal, re-treatment, new core, new crown, okay? Possibly pre endo restorability assessment, okay? Can be so high that I sometimes question whether XLA and implant. Will be more predictable option for the patient. For example, the radiograph he posted was his father-in-law’s, and then if he’s doing the re-treatment, et cetera, and he’d be, even if he’s only paying the lab bills, that’s still coming up to a significant amount. So what do you think about this, cost versus predictability dilemma, especially in this world of titanium.  [Ayman]Yeah, I think that’s, it’s actually quite a common scenario.  [Jaz]Great scenario, isn’t it?  [Ayman]Yeah, really good question. It’s a conversation I have a lot with my patients actually. So the first thing to sort of note is that the survival for root canal treated teeth on average at around the sort of eight to 10 year mark is still in the like 80, 90% range. So it’s still quite high, which is at probably comparable to implants as well. So that sort of 80, 90% range is, yeah, not too far off what an implant’s survival rate might be at that, that stage probably a little bit higher for implants. But the other thing to consider as well is probably their patient’s age. So ultimately we’re trying to get the patient through their whole life with a functioning set of teeth. So if, for example, you get that 10 years out of the tooth, even though the patient’s paid a lot of money for it, granted you get that 10 years of life out of the tooth, you then pushed the need for an implant back potentially by 10 years. Whereas if you start off with the implant, obviously you haven’t got that lifecycle out of the tooth. And to replace a sort of failed implant, if it was to fail at 15 to 20 years, which is a reality of implants, then that becomes a lot more tricky than replacing a tooth. So I’m thinking of it not just isolated, how long will this tooth survive? It’s also how are we gonna get this patient through their life for the functioning set of teeth. And yes, a lot of the teeth that we treat are re root canal treat are very compromised, but it doesn’t mean that they won’t work into the future. The other thing to sort of consider is how you are assessing the outcome as well. So a little bit into the sort of nuances of endodontics, but in terms of you wanna look at success or survival, which are two completely different outcomes. So success is when you’re looking at the x-ray is the perio apical lesion actually. You know, reducing in size, is it getting smaller? That is a lot more of a stricter criteria than cervical, which is, is this tooth still in place in the patient’s mouth? So you might have a lesion, is the tooth still in place and functioning okay in the patient’s mouth? So how many patients do we see that have massive perio apical or big perio apical lesions, or not big, but as in like, you know, periapical lesions, but the tooth is asymptomatic and functioning fine in the patient’s mouth. [Jaz]So as a GDP, I had this conversation a lot. And the patient’s like, well, you know what? And we had that informed consent and that, look, I really, I’m doing just fine. I appreciate his infection. And we had that conversation and the patient has opted for that. I can live with this. I’m okay with it. And I just say one thing, which is what, what Dave Winkler taught me. He says, look, that’s fine. As long as you understand it’s like a dormant volcano. It can blow up any point. And I say, just don’t call me at Christmas. I just say that point and they get it. Like I said, don’t call me at Christmas. Okay. And then they get it. I was like, okay, fine. Yeah.  [Ayman]So if you are going by success, yeah, correct. You might find that more of these cases are more likely to fail compared to an implant. But if you’re looking at cervical, then you know, it might be that, and I mentioned survival rate at the beginning was 80 to 90%, not success rate. That is because a lot of these patients have these PA lesions, which are just sitting there completely asymptomatic, and those cases can last many, many, many years into the future. What’s interesting as well is the implant literature. A lot of it, if you compare their outcomes for like with what a tooth outcome would be, it’s actually closer to survival. So the implant could have like threads exposed, that kind of thing. But actually what they’re looking at in the implant literature is the implant still in the mouth. That’s commonly what’s looked at.  [Jaz]There could be a lot of, yeah, bone loss. There could be several prosthetic failures, which are very common.  [Ayman]And when you look at that, that 90% success survival rate that’s coated for implants is actually quite similar to the tooth survival rate. So yeah, you can have a compromised implant and a compromised tooth, which is surviving many, many years into the future. And that rate of survival is pretty similar for these compromised teeth into the future. So yeah.  [Jaz]I like that ethos of delaying implant as much as possible So I’m definitely with you in that. My friend, in the interest of time, we’re gonna wrap up. My wife has to go to a some sort of a pediatric dentistry conference, and I’m gonna get killed if I don’t be there in two minutes to help out. But, Ayman. As we wrap up now, firstly, thank you. Thank you so much for spending some time with me today and sharing and helping GDPs just overcome this obstacle. And hopefully, a lot of those people who had a limiting mindset like I did, you’ve helped out but also helped to identify which are the easier cases which we should be doing. And actually lots and lots of good reasons to make sure our endodontist colleagues. Don’t go hungry. Now, Ayman, can you tell us about any, either education involved in or how to follow you or how to reach out, how to thank you. All this kind of good stuff.  [Ayman]So, the main place I’m on is on Instagram, so it’s ayman_endo. That would be it. I’ve just recently started posting. I’m not like a big account at them or anything like that. That’s one. And then, yeah, just any of the practices that I kind of work at. If you have any questions you can kind of ask for me there or message me on Instagram basically. So the practice I work at, there’s a few one in Norwich. So they’re all listed on my Instagram anyway. If there’s any questions, just ask ’em on Instagram. That’s fine.  [Jaz]Well just, you know, Ayman. And I were touching base on Instagram, so thanks for all your applies and stuff. So, having helpful, friendly specialists to liaise with on a social platform that we’re so used to is just amazing. Ayman, if you’re interested in community, come and join us on the app Protrusive Guidance and be a resident endo geek on there. But, wishing you all the best hope Ramadan, Kareem and all that stuff as you were recording in the middle of Ramadan at the moment. Thank you. So wishing you all the best for that, Ayman. Thanks so much for making this time and making re-RCTs a lot more tangible for us.  [Ayman]Great. No problem. It’s my pleasure. Thank you.  Jaz’s Outro:There we have it guys re-treatments for GDPs. Thank you, Ayman. Once again, our fantastic guest with a lovely deep voice, a nice little feature for those who are listening. Now, listen, wherever you are, please do hit that subscribe button. It astounds me how many of you listen and yet have not subscribed? It does matter to us. 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Are you confident when increasing the vertical dimension? How do you plan, stage, and sequence a full-mouth case safely? What’s the right deprogramming method—leaf gauge, Kois appliance, or something else? Dr. David Bloom joins Jaz in this powerhouse episode to demystify the real-world process of increasing vertical dimension. With decades of experience in comprehensive dentistry, David shares how he approaches diagnosis, bite records, temporization, and final restorations—with predictability and confidence. https://youtu.be/gAaP0VYP84s Watch PDP232 on YouTube Protrusive Dental Pearl: Pick one occlusal philosophy and stick with it until you understand it well through real cases. Once you’re confident, stay open to other approaches—hearing different views will make you smarter, more flexible, and a better dentist. If you are looking to get started with the foundations of Occlusion, check out our comprehensive Online Occlusion Course. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 00:00 Trailer 00:55 Introduction 04:43 Guest Introduction: Dr. David Bloom 10:25 Equilibration Techniques Explained 11:18  Interjection #1 15:50  Opening Vertical Dimension vs. Orthodontics 18:06 Interjection #2 23:05 Whitening and Restorative Solutions 25:27 Guidelines for Raising Vertical Dimension 25:52 Interjection #3 29:28 Midroll 32:49 Guidelines for Raising Vertical Dimension 36:06 Visual Try-In and Adapting Vertical Dimension 40:16 Case Planning and Execution 41:16 Interjection #4 43:42 Case Planning and Execution 50:23 Material Preference for Provisionals 52:00 Bite Registration and Final Adjustments 55:06 Do’s and Don’ts for Clinicians 57:15 Conclusion and Resources 58:59 Outro Key Takeaways Vertical Dimension and Adaptation: Opening the vertical dimension in dentistry can be challenging, especially for edentulous patients who lack proprioception. However, with proper planning and understanding of occlusion, the human body can adapt remarkably well. Occlusal Philosophy: It’s important to learn one occlusal philosophy well, whether it’s Kois, Dawson, or another. Understanding different approaches can make you a more rounded clinician, as different patients may benefit from different methods. Equilibration and Deprogramming: Equilibration is crucial for idealizing occlusion by eliminating interferences. Deprogramming helps in achieving centric relation, a stable and repeatable position for the condyles, which is essential for successful equilibration. Orthodontics vs. Vertical Dimension: Deciding between orthodontics and opening the vertical dimension depends on the specific case. For example, pre-aligning patients with orthodontics might be necessary to address a restricted envelope of function. Testing and Adaptation: Testing the vertical dimension with transitional materials like composite can help patients adapt before moving to definitive restorations. Experienced clinicians may sometimes proceed directly to final restorations based on their judgment and diagnostic steps. Get CE/CPD for this episode only on the Protrusive Guidance App. 🖥️ A new website is launching soon by Dr. David Bloom — ppcontinuum.com Also, Dr. David Bloom’s hands-on courses on veneers and minimally invasive dentistry If you found this episode valuable, you’ll definitely want to watch PDP197: Vertical Dimension – Don’t Be Scared!, part of Occlusion Month. #PDPMainEpisodes #OcclusionTMDandSplints #BreadandButterDentistry This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes B and C. AGD Subject Code: 180 OCCLUSION (Occlusal therapy) Aim: To provide clinicians with a comprehensive understanding of how to safely and predictably increase the vertical dimension of occlusion (VDO) for restorative cases, using a diagnostic-driven, conservative, and patient-centred approach. Dentists will be able to:  Describe the indications and contraindications for increasing VDO. Differentiate between conformative and reorganized approaches to occlusal rehabilitation. Identify the steps involved in diagnostic planning, including CR bite records, wax-ups, and visual try-ins. Click below for full episode transcript: Teaser: You mentioned something earlier about dentures and vertical dimension. Ironically, I'm probably a little bit more concerned about opening the vertical in an edentulous patient than I am in a denate patient because it's much more harder for them to adapt because they don't have the proprioception. So composite will obviously be non-invasive. Teaser: We’re probably not gonna be prepping the teeth at all, but patients need to be aware that whilst there’s gonna be less cost, I’d consider it as a long-term provisional. Because- Transitional, almost. Transitional. Yeah, absolutely. I mean, ideally, if I’m doing restorative, I’d rather not whiten first, because if we have our super thin restorations and our whitening result, over time will fade. It’s much harder to top that up. If you have a restoration. The first step in a collaboration is to be able to manipulate someone into centric relation. And 90% of the population have a slide from CR Central relation to CO centric occlusion habit by whatever your terminology and the first step in a equilibration is- Jaz’s Introduction:So we’ve talked about this big topic before, vertical dimension and restorative dentistry. Me and Mahmoud did an episode basically reassuring you that you can safely raise the vertical dimension and that we shouldn’t be so scared of it. What I do in this episode with Dr. David Bloom is really lean on his decades of experience. Comprehensive dentistry to delve deeper into the intricacies of opening the vertical dimension, the staging, the phasing, the planning, and a full walkthrough of how Dr. David Bloom does it. And you know what? There’s many different ways to go about it. In fact, for those of you who can see me who are watching this, I’m a bit more formally dressed. I’m not wearing my hoodie. I was actually at an occlusion symposium today, and you had these great speakers and inclusion like Paul Tipton and Koray Feran, Tif Qureshi. And these guys were talking about the importance of canine guidance. And then you had Ken Harris, also a legend in occlusion. And one, the mentors on Kois. He did not care for canine guidance. It was irrelevant, it was not important. And if you go back into the Archives of Protrusive podcast, you remember two episodes we did with Dr. Andy Toy. About the posterior guided occlusion where actually we don’t want canine guidance. So it goes to show my friends that in the world of occlusion, there’s many ways to do it. Learn one way, learn it well, it will serve you well. And then the benefit of learning the other ways is that sometimes you’ll find a patient that really fits into that box a little bit better. For example, for many years I didn’t use a Kois appliance. I had my ways of deprogramming that I was very happy with, and just a couple of years ago, I did my first Kois, and I’ve done a few more since then. And there are certain patients and characteristics that just are very amenable to that way of doing it. But then for most of my patients, I use a leaf gauge. There’s two types of patients. There’s loosey goose and tighty whitey. The tighty whitey patient, we all know this patient, right? It’s the one where you’re trying to do some manipulation, you’re trying to seat the joints and their mandible is just so stiff. Whereas you have, they’re much nicer loosey goosey patients where you don’t have to work very hard to deprogram them or get everything nice and relaxed and hinging. And these two patients will need a different type of deprogramming. So I say learn one school, one occlusal religion well, and then start looking at the others. And I think there’s so much to learn from all the occlusion camps. Just like I said, two polarizing views I was listening to today on canine rises and whether canine guidance is even important at all. And you know what? I subscribe to them both. And you are thinking Jaz. That’s not possible. How can you serve two masters? Well, you can because our patients are so variable. They’re so unique. That’s what actually makes our dentistry fun. If every patient was the same, it would be boring. But our patients come with these unique challenges, these unique presentations, and we have to sometimes be very creative in how we treat someone, how we arrive at treatment decisions. And lemme tell you, learning about the different occlusal religions has made me a better, more rounded clinician. But for many of you listening early in your career. Honestly, just pick one religion, whether that’s the Kois religion, who don’t believe in canine guidance and certainly don’t believe in anterior guidance. In fact, the anterior teeth should hardly touch. Or you might go more Dawson, whereby anterior guidance is very important. And you know what the secret is that both these camps work? So pick one, lean in, learn it well, and eventually critique the others. Learn about everything and that my friends is the Protrusive Dental Pearl for today, if you don’t really have an occlusal philosophy, learn one. If it’s from me and Mahmoud and the OBAB philosophy as a foundation of occlusion, great. If it’s from Kois, amazing. If it’s from Dawson, super. Pankey, whoever, learn a school of thought. But then the second degree of this pearl is that once you’ve learned a school of thought and you’ve got some cases under your belt, then be willing and respectful for the other sides. Listen and appreciate other views. They will make you a better clinician. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast once again, David Bloom is back on the podcast today. We covered minimal preparation of veneers last time, and today we talk all things vertical dimension. I hope you enjoy this deep dive and I’ll catch you again in the outro. Main Episode:Dr. David Bloom. Welcome back again to the Protrusive Dental Podcast. Last time we spoke about veneers, something that you’re so experienced in. This time, we’re talking about something similar. ‘Cause quite often you’re doing veneers, but you are also doing, as part of a full mouth rehab, you are opening the vertical dimension and there’s so much we can talk about. But in this taster today, we’re gonna ask some really key restorative questions from someone who’s got so much experience in yourself. For those people who didn’t listen to that episode, can you just tell us about yourself, your passions, David?  [David]Yeah, well I’ve been qualified 36 years now. I’m A GDP. I was in the same practice for 24 years, which teaches you about failure, what works long term, what doesn’t work long term. And having done that passionate about cosmetic dentistry, but also about doing it as responsibly as possible, which means as minimally as possible. And so we talked about an additive wax up and how that can allow a visual, trying to confirm the aesthetics and then allow us to prep only where we need to. [Jaz]So guys, if you haven’t checked out the episode we did on minimal preparation of veneers, David, as I joked on the Protrusive guidance app, David has Graham for Graham, done more veneers and I’ve consumed peanut butter and I’ve consumed a lot of peanut butter. That was my silly joke at the time. But, you’re very humble. David’s also ex BACD president and big time educator as well. So I’m gonna, at the end do encourage you guys to do checkout this stuff, which is amazing. Let’s get the little details of restorative, right. It’s such a big topic in a way, David. It’s actually quite a challenging one to record. But I’m just looking forward to just geeking out with you on such a awesome topic when it comes to restorative of my own personal journey, David, and you may remember this as well, when you’re starting out the level of training that you accumulate from dental school and stuff like everything is conformative. And then when you have an opportunity to open the vertical dimension, like your first you’re learning just to deal with caries, then you’re learning to deal with, you know, the very foundations. It seems like a big step at the time to open the vertical dimension. And I remember the first few times I did it, is the patient going to survive? Is their head going to pop off? Are they gonna be able to chew? And that kinda stuff. And once you do it a few times, you almost become a little bit blase about it. But you kind of need to do it a few times to realize that actually the human body is amazing at adapting, providing we conform to a few rules. So we were gonna come onto that, but just at the macro level, David, how do you explain to young dentists, okay, how do you arrive to the decision to open the vertical dimension?  [David]Well, I think first of all, you have to have a thorough understanding of occlusion, as I’m sure you’d agree. And if you think about it, when we do occlusal appliances, flat plane appliances, we are opening their vertical. And as you say, the body is remarkably good at adapting as long as we stick to our occlusal principles. And I think once you also know how to do an equilibration, which I think is essential. It gives you the confidence to be able to move on, and it’s a reorganized approach as opposed to a conformative approach, as you say. But once you have the confidence in occlusion and you know, you can open verticals, it becomes less of a step. And what it does allow is us to be a lot more conservative because we’re giving ourselves space. So when do we do it? Well, it’s always an option when we’re treating the lower arch to consider. And one of the classic times to do it is if we have a deep bite and a deep bite. And I think we alluded to this in the last episode, especially what I see as I practice more and more class two div twos, we see a lot of wear going on because they have effectively a restricted envelope of function, an increased overbite, maybe a restricted overjet. And opening the vertical simply gives us space to add here and to add occlusally. So certainly a deep bite. I think wear cases, historically, we’d have done a lot of maybe crown lengthening, conventional plastic crown lengthening. But that’s obviously quite invasive. And with wear cases, obviously crown lengthening is still in our armamentarium and with additive composites, we may be looking at DAHL, which is maybe an interim, it’s maybe a different conversation again, but we can be additive and again, open the vertical. But with DAHL, I wouldn’t want to go straight to porcelain. I think it’s probably too abrasive in that situation. So I’d be looking at composite. And composite is gonna have less longevity. So composite will obviously be non-invasive. We’re probably not gonna be prepping the teeth at all, but patients need to be aware that whilst there’s gonna be less cost, I’d consider it as a long term provisional. Because- [Jaz]Transitional, almost.  [David]Transitional. Yeah, absolutely. Because longevity may be five years, maybe longer. But it’s not gonna have the same longevity of porcelain where we’re talking maybe 10 to 15 years. So again, first few times I was doing it, I might have been happier to do it in composite stage, but if we know we’re going straight ahead, a wear case is often a case where you may open a vertical as well. And obviously small teeth is a time we may do it out and I’m not concerned too much about the size of the teeth in that sense, but it gives us the possibility. But even a classic Class one case, it’s always something we have in our armamentarium, and I suppose it’s considerate, but I’m not advocating it for every case. But it can be very useful to have in our toolbox.  [Jaz]I think if it was just so many different things that we could talk about in terms of arriving in that decision and a flow chart and stuff. But I guess if there was one overarching theme or one word to use, I would say, it’s space as the primary thing, right? You need space to solve a problem. You need space because when the patient bites together, there’s no space to restore their missing lateral. You need to open ’em up to give ’em that tooth. You have completely worn teeth. You need to open it up to actually get aesthetically looking teeth as well as potentially looking at the gingival stuff. But I think that is a primary driver and a lot of the principles we can learn like with aesthetics, as you know, David, complete dentures. We learn so much about that and we actually forget that actually we’re change, we’re moving very fluidly, dynamically the vertical dimension in complete dentures and sometimes we forget that. Now you mentioned a few really interesting things. I just wanna just talk about that ’cause I think it’s really important. You mentioned a word equilibration. And I’ll tell you something David, you mentioned a word equilibration to anyone who’s maybe less than 10 years qualified and like they are trained in an era where that’s a dirty word. So can you just clarify what you mean when you say, as part of opening vertical dimension, you should have a skillset of equilibration? Just ’cause I think it is a lot more simpler than what can be interpreted. Just explain that part.  [David]Sure. First of all, I mean, if the dentist can’t say equilibration, they probably can’t do it. That’s something I’ve learned over the years. But an equilibration is a way of idealizing someone’s occlusion to eliminate the interferences. And the first step in equilibration is to be able to manipulate someone into centric relation. And 90% of the population have a slide from CR Centric Relation to CO Centric Occlusion habit by whatever your terminology. And the first step in a collaboration is removing that CR CO slide.  Interjection:Okay, guys. Interjection number one. What is deprogramming and how do you get someone, how do you manipulate their jaw into this centric relation? What is centric relation, right. Let me just break it down. Centric relation is essentially a stable position of your condyles. Nothing to do with your teeth. If we imagine very crudely that your condyles are like balls, right? You’ve got the left condylar bone and you’ve got the right condylar bone that roughly look like two potatoes, right? And we’re essentially seating them into the cups. Which cups are the fossae? So balls into the cups. It’s like your shoulder being seated into the shoulder socket. I say that ’cause I’ve got history of shoulder dislocations, but I remember one time they were relocating my shoulder and like boop, it just slip right in. The ball of the joint just goes right into the fossa. So crudely speaking, we wanna get that into position because it’s a repeatable position, it’s a comfortable position, and it’s somewhere we can keep going back to If we lose our way, if we’re confused, hmm, where are the teeth supposed to be? Then if you keep taking the balls back in the cups, then you have a point of reference. But to be able to do that, the muscles are always fighting you because the muscles have learned this existing bite, which is not in centric relation, your condyles are, the balls are not in the cup. So to manipulate someone, you first need to release their muscles, you need to relax their muscles to allow the condyle to seat, to allow the ball to go into a cup. And that’s all to do with the joints, not the teeth. But then certain teeth will hit when you go into centric relation. So there’s lots of different ways and what we teach our occlusion course is there’s hands-off approaches and there’s hands-on approaches. Like hands-on is like, imagine like bimanual manipulation, right? So you get your hands and its awkward way around the mandible, and you try and manipulate the condyles into the fossae. That can be quite tough, especially for a beginner. That’s not an easy thing to learn. And also when you get the patient to curl their tongue all the way to the back, that’s kind of like a forced position. Whereas I like hands off approaches. This is using things like a leaf gauge, something called a lucia jig, which will have another interject for coming up, or an occlusal appliance. Essentially, it’s allowing the back teeth to separate and allowing the muscles to guide the jaw into this repeatable position centric relation. So hands-off approaches and hands-on approaches. Let’s listen to the episode and let’s build from there in the other interjections.  [David]Once someone’s in CR, they’re obviously much easier to manipulate. They tend to have relaxation, neuromuscular release of their muscles, and then we are looking at eliminating any interferences in our lateral movements. And so it’s a process of learning how to do that. I know I shouldn’t use my hands ’cause those people who are listening.  [Jaz]Just describe what you’re doing.  [David]But when you are going back, you tend to find the contacts are on the mesial slopes of the uppers. The distal slopes of the lowers. And by adjusting those contacts, you’ll get to a point where CR and CO are coincidence. Then the next stage is to ensure we have anterior guidance, so anterior disclusion in lateral excursions. So we’re then removing our-  [Jaz]Do you mean posterior disclusion in lateral excursion?  [David]Sorry. Yes. I mean exactly that. Posterior disclusion in lateral excursions and removing those interferences. And if we’re going laterally that if we’re going to the right. That’s then gonna be on the palatal facing slopes of the uppers and the buccal facing slopes of the lowers. And I use this terminology to help patients understand as well. And so we’re getting to a point where CO and CR coincident and we have immediate anterior disclusion and excursions. [Jaz]Excellent. And I just wanna just add to that as well, in terms of the equilibration, like sometimes to young dentists, like what you described is a classic approach to equilibration, but much more fundamentally on a day-to-day basis, how can we make it more relatable day-to-day? Imagine that class two div two patient that you described, and you are going to do all the steps to open the bite a bit to fill in the space posteriorly. When you fit the restorations, there will be some adjustment to do right? The left side might be heavier than the right side. Even just to get that degree of balance between the left and the right, something just so foundational. We just do it. You do your composite and the composite’s proud. When you are adjusting that composite, you are in a way equilibrating if you like. You’re trying to achieve harmony and balance, and so it blends in with the rest in dentition. And when you think of it like that and then you think, okay, what are my objectives and goals I’m trying to reach. So when we’re doing a class one composite. If that composite that you just placed take the rubber dam off bite together, that’s the only tooth in the bite. Well, your goal is to go back to how you were at the beginning and have every tooth biting. If that was a case of your patient and you know your goal and the equilibration is the means to get there. And it’s important to remember that, that is it. And then when you’re doing these bigger cases, then we have our goals that we want to be in centric relation in many schools of thought, it’s a utility position, it’s a repeatable position, as you said. And so a equilibration allows us to get there. And on that topic again of the class two, div two patient, David, when you have that deep bite, right, when you have the wear and the incisors. Here’s a good question, right? Opening the vertical dimension versus orthodontics, how do you arrive at the decision that, okay, I’m gonna open the vertical dimension, versus actually, let’s just intrude those incisors, level out the curve of spee orthodontically, and give this patient a result by ortho. [David]Will you bang on? And I’ve made just a couple of notes and I will answer that. But going back to equilibration, what you were describing is an occlusive adjustment when we fit a restoration. Absolutely. We are adjusting the occlusion, but in a conformative approach. So we’re working in centric occlusion. I suppose the biggest difference for an equilibration is that we’re going to a repeatable position CR, because that’s our go-to point, but we’re working it as a reorganized approach rather than a conformative approach. And you mentioned something earlier about dentures and vertical dimension. Ironically, I’m probably a little bit more concerned about opening the vertical in an edentulous patient than I am in a Denate patient because it’s much more harder for them to adapt because they don’t have the proprioception. So just a couple of points to cover there. Going back to the class two, div two, I think we do have to be very aware that whilst we may be giving ourselves space in a situation like that, we are not actually addressing maybe the fundamental issue, which is the restricted envelope of function. And if we don’t correct the reduced overjet because we can correct the increased overbite by opening our vertical. If we’re not correcting the retrocline nature of the upper anteriors, we are potentially inviting more wear, especially if we’re treating the lowers in porcelain, because porcelain can be more abrasive. So absolutely there is a case to be made for pre aligning patients, especially with a class two div two, because we may be solving one problem, but swapping it for another. When it comes to the leveling the curve of spay, that’s less of an issue for me, restoratively, because actually we can add to the occlusals of the lowers without doing any preparation. And so that’s what I wouldn’t be so concerned about, not doing pre-restorative orthodontics. But for the restricted envelope of function, I think it is important you may be choosing to go full coverage on the uppers, in which case that wear is potentially gonna be less of an issue. But if you’re leaving the palatal of the uppers, then we may be not causing wear on the lowers, which is what we tend to see in an aged patient and a class two div two, but we’re gonna then have palatal wear on the uppers potentially moving down the line. And again, I think in any of this-  Interjection:Okay, interjection number two, restricted or restricted envelope of function to what it simply. It’s like there’s a lack of chewing space. Like if you go back to basics, there’s a certain like movements that the jaw can make. That’s the envelope of motion, i.e. Your lower incisors can go all the way forward. Protrusion all the way back, protrusion all the way left, right, opening. So there’s only so many different places your jaw can go. But chewing only happens in like a small, classically teardrop shape, right? It’s a teardrop shape. And that’s where magic happens. That’s where chewing happens. That’s where speech happens. But if this envelope is constricted or restricted, it’s like you don’t have any space at all. So like there’s a lack of overjet and your lower teeth are like right behind your upper teeth. There’s a real lack of overjet. And as you’re chewing, these teeth are like rubbing together. So it’s high frequency and low intensity. So it’s not very forceful, but it’s happening several times a day. Every time you close your teeth together, your teeth are potentially rubbing. So classically you get wear of the palatal of the upper surfaces and the incisor facial of the lower surfaces. And you see patients all the time like this where they just don’t have any chewing space. And so that’s the consequence of trying to work with a restricted or a constricted envelope of function. And these cases often need orthodontics primarily, or at least raising the vertical dimension, but primarily orthodontics ’cause it is a tooth position problem, a jaw position problem. And so really important aspect to grasp a night guard is not gonna fix this. It needs space. So there we are. That’s that interjection. Done. Thank you.  [David]When we’re opening the vertical, what we’ve got to be aware of is the length of the lower incisors, because that is gonna dictate whether the uppers can just be facial as in veneers, or if they then have to be full coverage. And then when they’re full coverage, we can’t call them veneers because they’re not veneers, they’re crowns, and therefore not gonna be maybe as conservative. Ironically, if we’re going full coverage. But all of this is worked out pre-preparation with, again, our visual triad. So we’ve got an additive wax up, one has to think three dimensionally. Are we gonna have to cover the palatal of the uppers? That depends on the length of the lower incisors. And we spoke last time about our smiling teeth on the uppers and our talking teeth on the lowers. We don’t want to have especially long what? Extra long, lower incisors because that’s gonna be too visible. But with our visual tryin, we are working this all out preoperatively. And we shouldn’t be afraid to be equilibrating our visual, try-in, making adjustments, you should be able to contour because it all needs to be worked out. But when we are adjusting our visual try-in, I may even equilibrate that and at that point I’ll take new putties because I don’t want to have to go through that process again. But we know that we are one step closer. We’ve checked the aesthetics. We’ve checked the occlusion and so again, it’s not a quick fix, but it’s in a logical pathway, a very useful item to have in our toolbox, but done in the same predictable diagnostic manner. So working out the length and lower incisors, that’s gonna determine what we have to do with the plate of the upper incisors. And going back to your question, we need to be aware that we may get space, but we don’t want to be causing a separate problem, which would be where, so absolutely a class two, div two, I would think of some pre restorative orthodontics to correct the retroclination  [Jaz]I think sometimes, in those cases it’s a bit like if orthodontics would completely solve their aesthetic and functional demands, then that probably might be the best way to go. However, if they have crowding. That’s gonna mean that you’re gonna have to be more invasive, all right? Or I sometimes find it helpful to tally up which teeth actually genuinely need restorations, and if that number is getting higher and higher and higher, I’m thinking, well, if I have to do orthodontics and then restore these teeth anyway, can I bypass the orthodontics and just restore these teeth and achieve the shapes and aesthetics that I want? You made a great point about the retroclination of the upper incisors. Sometimes, you know that is gonna be the main killer of your case. Sometimes it can be good ’cause it gives you so much space to come labeling and be minimally invasive. But if that torque is wrong, that loading after your restorative is gonna be problematic. And so sometimes that’s the reason. And then even things like if they’ve had ortho before and now they’ve got root resorption, then you wanna try and, and they’ve relapse and you wanna maybe avoid ortho and therefore restorative is more favorable. So you gotta really look at globally. But I’m glad you mentioned those points. Have you got something to add there? Sorry.  [David]Uh, yes, I have. I mean, I think we have short term orthodontics. It doesn’t necessarily have to be comprehensive ortho to give an ideal class one result, and we spoke before about anterior tooth alignment. I think the days of instant orthodontics with veneers is gone. It’s something we maybe did because we thought everything took 18 months or more of comprehensive ortho. But to correct those retrocline upper incisors really doesn’t have take a long time. I said a lot of the times, class two div two leveling. The curve of spare, as we said, is also not an issue and also is a great option. But ortho is not gonna correct size and shape and also isn’t gonna deal with heavily restored teeth. And so as you say, it’s planning it. And if we’ve got virgin teeth, then we’re probably gonna look up more orthodontics than if we’ve got heavily restored teeth, but orthodontics can’t correct size and shape and whitening is a great tool, but if patients, as we touched on before, live in Essex or or Liverpool, they may want to be going significantly lighter than B one. And again, that’s a time where a restorative solution may be necessary because B1 is quite a bright shape, but not for everyone. And sometimes we can whiten beyond B1, but I’m not gonna guarantee it. I’m fairly confident most of the time to get to B1, but not beyond. So there are times where orthodontics alone is not enough for very many reasons. [Jaz]Great point. And just on that whitening, I mean, I’ve noticed over the years that patients, despite me trying to manage their expectations and stuff, patients are less and less made up and overjoyed from the results of just whitening. I think the more I’m realizing is I actually, if I listen carefully, then perhaps I should have said, the whitening is a stepping stone to the shade that you want. Or perhaps we should go for the restorative. And then when they have the veneer done, they’re like, yes, this is what I wanted, kind of thing. And so I’ve noticed that the expectations and trends and desires are definitely increased for patients.  [David]Yeah, I mean, absolutely. I mean, whitening is predictable, but we are gonna have darker cervicals, however we look at it, because that’s what actual teeth have, and if people want a different look from that. But I think we should also, whitening is very safe. It’s non-invasive, as you say, potentially an entry level, but from a cost perspective is much lower ticket item. I mean, ideally, if I’m doing restorative, I’d rather not whiten first. Because if we have our super thin restorations and our whitening result over time will fade, it’s much harder to top that up if you have a restoration. So if I’m doing, and if I think it’s important, we know if the patients have whitened, so the lab can maybe factor that in than using maybe a more opaque ingot if we’re using Emax for example, because as a result fades, it’s harder to top it up. Whereas I’d rather get the color shift knowing that the foundation shade was darker. We are gonna get that color change into porcelain rather than whiten first. But as you say, whitening isn’t enough of a change for some patients and we can’t always whiten the cervical as much as they want to, whereas porcelain gives us a few other options.  [Jaz]I think nowadays I’m a little bit wiser from my experiences and I will show patients realistic photos. Like, look, this is what to expect, among patients who are I treat a very aging population in a village type practice. And so you, I’ll show them photos of cases where, yeah, there’s been a moderate improvement. Like this is what I can get you, but if you want to go for this, then maybe it’s looking at a different approach. And then just like you said, the cervical is not the same as the enamel. That’s more in the body and they’re not gonna whiten the same way. Going back to vertical dimension. When I was starting, and you know, DAHL was like, is like a gateway drug into occlusion. DAHL is like a gateway drug into opening the vertical dimension. And you do with DAHL for the first few times and the patient survives, it’s like, oh wow, okay, maybe I could just restore the posteriors now. And then you can suddenly realize you’ve done a full mouth rehab, right? And so the next thing I was afraid of was, okay, how much can I go here? I think once you overcome the fear of raising the vertical dimension, the next thing is have I done too much? And so what guidelines do you use David to kind of figure out the anatomical limits of raising the vertical dimension?  Interjection:Okay. Interjection, DAHL technique. One of my favorite things, it’s like a gateway drug into full mouth rehab. And I know a lot of our colleagues in America are against it or they don’t believe in it, or they call it unpredictable orthodontics, as I call it as well, but it works and it can really serve as an interceptive treatment for localized tooth wear. So essentially localized anterior tooth wear classically, and you build up the teeth and now you’ve raised the vertical dimension. The back teeth are separated, but like magic. After about, three months, sometimes a year, the teeth reestablish. They, the dental alveolar compensation takes place and then the front teeth intrude. Or maybe they flare out a little bit, maybe, I don’t know the exact mechanism, like we think it’s intrusion, but it’s pure intrusion always happening. Who knows, but essentially you’ve now created space before you did not have space, and then you managed to create space. So it’s a wonderful way to treat localized anterior tooth wear. But it’s important to also know when you should not do this treatment and it’s better to do a full mouth treatment. So the reason I say DAHL treatment is like a gateway drug to format rehab is in DAHL, you do the anterior six to eight teeth and you let the back teeth sort themselves out. Sometimes do the front to six to eight teeth, but then soon after just sort the back teeth out as well. It just makes sense. You’ve just, there we are. You’ve done a full mouth rehab. It’s not as tricky as what they say and the kind of case not to do DAHL on is when you’ve got like dentine exposure posteriorly. If you’ve got dentine exposure, posteriorly, do you really want to leave those teeth to DAHL into contact? No. You want to cover those teeth. So a full mouth rehab is more appropriate. ‘Cause actually you are being additive and you’re being more minimal in that scenario. Other times you want to avoid DAHL is if someone has an anterior open bite, then they’re usually not gonna have anterior wear. Usually it’s the people with AOBs that have their mamelons still, or their incisal halos. So usually they’re not gonna have wear anteriorly, but let’s imagine they did, and you want to now add in restorative material and open the vertical dimension. So they go from having no contact at the front and actually having a space between their teeth to now having extra contact on the front. The reason why that might not be a good idea is because these people, they might not have that much eruptive potential. Think about it, if they had eruptive potential, wouldn’t the front teeth have kind of erupted and adapted back into the occlusion? They would’ve, right? So that’s why we say, okay, let’s avoid it in anterior open bite patients. Let’s avoid it when you know what? This patient just needs orthodontics. If they’ve got crowding, why are we darling? Just align the teeth and sort the space requirements out during your pre-restorative orthodontics and intracapsular issues. If they got major joint issues, they got like history of locking, jarring of their jaw joints, significant pain from the TMJs. That’s not the kind of patient we wanna be doing any sort of reorganized dentistry. And last few is, if you have someone who’s got a reduced periodontium, i.e., they don’t have periodontal disease anymore, but they used to, but now they have recession and they have some mobility, which you’d expect. But now do you really want to overload because DAHL treatment is like a controlled overloading of the front teeth to allow them to intrude and the back teeth to erupt. I like that term, right? Controlled overloading. But do you really want to overload, even if it’s in a controlled way, teeth that have less bone support to begin with. So really, try and avoid when you’ve got someone with the history of periodontal disease. And lastly, imagine you wanna do a DAHL treatment, but your anterior teeth have all got like root canal treatments and posts inside. Do you really want to do a controlled overloading on structurally compromised teeth? So there we have it guys. A quick overview of when not to DAHL.  [David]Well, I think again, we need to think of it in terms of a rule of thirds, and by that I mean that if we are opening the vertical, a millimeter posteriorly, we’re probably looking more like three millimeters anteriorly because of the nature of the V, if you like that it’s less space. How much am I opening? Prosthetic convenience, so really the space that I need, and therefore we’re never gonna be opening more than really, maybe two to three millimeters maximum. It’s possible you could open more, but being realistic, we’re probably not having to go beyond that, and therefore that’s always okay in my experience so far. So there is a natural limit that occurs because we don’t need to open beyond that. And I’m not opening vertical to change someone’s face shape. That’s more of an orthognatic approach. So for me it’s prosthetic convenience that gives us a space. And again, we are working that out with the technician and I’m sure we’re gonna come on to how we do that. But I’m quite comfortable that I can open as much as I need to for prosthetic convenience without causing an issue. And that isn’t gonna be any more than probably three millimeters max.  [Jaz]There’s a really good paper by, Abduo, which I’ll link again. I think we spoke about on the podcast for about vertical dimension. I link that paper. It’s just a fantastic review. I’ll post it again in the show notes here, but that paper had a good guideline of up to five millimeters is fairly okay. And so keeping in line what you said there, measured anteriorly and then interesting when you measure that anteriorly. Let’s say your lateral is worn down to a two three millimeter stump, right upper lateral worn two three millimeter stump, and then you want to lengthen that by four or five millimeters, you open the bite, four or five millimeters there, and then in different people it’s can actually give you a different amount of space posteriorly. You mentioned a rule of thirds, very universal, but sometimes in a class three patient you’re getting a lot less in a class two skeletal patient, you’re getting a lot more, and sometimes in the past that’s given me some challenges whereby, yes, I’ve got the right space anteriorly. But I’ve got these great big spaces posteriorly, and now you are almost like doing a vertical cantilever. You’ve got like an onlay that’s like more height than actual existing tooth there as well. And so I kind of worry about that, David. Should I worry about that? Should I not worry about that? What have you, in your experiences long term, seeing these patients come back?  [David]I think to a large extent, aesthetically driven because if we’re bonding to enamel posteriorly, given that that I’ll be using a dual cure cement and not a like your cement. Again, I’m not concerned. I would like to have vertical loading. Sorry, actual loading wherever possible. But another tip, and again, you’re working it out and you’re right, it can be different in class three and class two patients, but we’re working it out in advance. I’m not concerned about the thickness. I’m concerned about the length of the lower incisors. And then a tip is sometimes I will leave the sevens out if they are fully dentate, because that’s the area where they may have issues. And those sevens may erupt, but it’s unlikely. If that’s an issue, you could then always add them in at a later date once the patient’s adapted or even put some composite on the occlusal surfaces to just give some light contact. So there are other options, but the extent of the opening, as you say, you are not really gonna ever need more than five minutes. I find actually this very, very rare that you need up to five millimeters. So in that sense, I’m not concerned. But you have to have the experience. You have to have the comfort of being able to equilibrate. But because we’ve gone through the whole process of the diagnostic try-in, I’m comfortable that I’m not opening excessively and that I’m marrying that functional side with the aesthetics anterior. [Jaz]Great. And I think this leads onto the next bit where you’ve mentioned about doing the visual try-in and then potentially considering testing this, right. Nowadays, we also touched on the fact that composites can be transitional, can be provisional, can be transitional, and we’re seeing a boom in injection molding. I think it’s a fantastic treatment modality to increase vertical dimension and give a transitional, let them adapt. And then potentially in the future, at some stage, the patient knows that, okay, we convert this in ceramics. I’m a big fan of that, but there’s is a couple of schools of thoughts here. A really good post by Lukasz Lassman will also be coming on the podcast soon. He’s a bit of a superstar, and this guy has posted some, the Markus Blatz of occlusion on Instagram kind of things from wonderful posts. And one interesting post was when you are testing the patient, takes about 90 days for neural circuits to adapt. And so he was suggesting that perhaps for the experienced clinician like yourself, David, that because in your hands, you know what’s worked, what’s what hasn’t worked, that perhaps, in your case, your judgment and the fact that patients do adapt quite well, you can almost go too definitive without that testing stage. Because when you’re testing in composite and then when you’re delivering in ceramic, for example. The two different materials, the brain has to adapt twice and sometimes it may better for the brain just to have to adapt once. So interested to know, in your years of experience, how often you might feel that it’s safe and best for you still to do the testing and that’s working well for you. Or do you sometimes go over the vertical dimension, go for the definitive, if you like, and let the patient adapt on the definitives. What’s your stance and philosophy at the moment.  [David]So historically when I was less experienced, and to be fair, it was less common that we might open a vertical, we would maybe test drive it with a flat plane appliance, so a Tanner or a Michigan. And I found that there was no one that didn’t adapt and I was doing a lot of flat plane appliances back then, and therefore, more experience than people that might be having a rehabilitation. They may have been having an occlusal splint for TMD reasons. But we have a few other staging points, so we are gonna test drive it. Remember that your visual try can be spot bonded to the teeth and the patient can wear that as long as they can clean incidentally, that is a test drive and so we can test- [Jaz]And that’s a bisacryl material, that kind of stuff.  [David]Where we do the visual try-in, but we actually spot bond it rather than just shrink wrapping it onto the teeth and the patient can go away with that to test drive it. And we are gonna test drive it.  [Jaz]How long for typically, ’cause people are thinking, how long was it reasonable longevity to expect from something like that?  [David]Well, I’m not a big fan of doing that, but it’s an option that we have. And if I do a  visual try-in and as I think we touched on last time, I like to be able to take it off to show the patient, but I think you could expect to do that for a week. But also the important thing is that’s before we’ve prepared the teeth, but even if we are preparing the teeth or when we prepare the teeth, we’re still gonna test drive it in our trial smile, in our prototypes, in our provisionals, and then you have the option if you are concerned about lab made provisionals. But those are definitely gonna be on for a month. And could be on for longer if you want to test drive for longer and the transitionals as you say, absolutely, I’m happy to do it in composite, but it’s gonna add more cost to the patient. So if you are idealizing the occlusion and you know through your diagnostic steps that we can give them an ideal occlusion. In that sense, I’m then not concerned because I know that I’m down a very predictable path. But for our colleagues who are be, aren’t maybe as experienced, we have those stepping stones to use along the way. But I know that if I’ve got my diagnostics right, I’ve proved it to myself as much as to the patient, but proved it to myself with my visual diagnostic trying that I know with my bisacryl that I can get to where I want to. It’s then a question of being able to execute that, which I’m quite comfortable I can, so I’m not so concerned, and I think you make a good point that it’s less adaptation and less cost, but we have those steps or those interim steps should we feel there’s a need for them. I’m not advocating always rushing to final restorations. But in my hands, I am actually comfortable proceeding to final restorations most of the time, if not all of the time.  [Jaz]One thing I didn’t actually mention, which actually, may relate to when you’re testing with the visual try-in and you gain from when you hear them speech and whatnot, but we’ll talk about do’s and don’ts at the end, but one relative contraindication to the limit of increasing vertical dimension is if you open the vertical dimension and then they lose their lip seal. When the patient close together. Lips must touch together first, then the teeth exactly. And so, kind of anatomical that long face patient, right? If you get a patient who’s got a long face, they’re not so amenable to opening vertical dimension. And I’m sure we’ll talk about that in the do’s and don’ts, but I just remember that. I think it would be a good point now, David, to maybe discuss a typical case and then, because I know you wanna bring in the fact that how it’s planned with a technician and then at what stage do you scan. If you just talk us through a typical case journey as an example, obviously the example you’ll give us can’t incorporate every single scenario, but it’ll give us a bit of a flavor. [David]Absolutely. So we’re obviously gonna do a diagnostic wax up, and we’re waxing up at the open vertical. So the first question is, what extent of the vertical are we opening? And we really want to be taking a CR bite record because once we’re in CR we’re on a hinge axis, and then we can open the pin quite comfortably knowing that we’re in we repeatable grounds. So ideally I’d have someone deprogram, so they’re in CR. And then-  [Jaz]What’s your preferred web poison of choice for deprogramming?  [David]I find that a lot of the time I can, with bimandibular manipulation, get a patient into CR ’cause actually what I’m after is their CR contact. And if I can have a record at that CR contact, then that’s enough for the lab to be able to mount the models in CR and then open the pin. But that isn’t always possible. So then we are looking at a few different options. We’ve got-  Interjection:Hey guys. It’s Jaz here with an interjection, right? So these interjections have been designed, we’ve been going for about maybe five or six episodes. Now, as per your request, just to, sometimes I don’t want to disturb the guest. I also feel like we just need to explore a topic a little bit more to make it tangible. That’s the mission of Protrusive, right? To make things tangible. So he mentioned lucia jig. Some of you already know what it is. You made some before. But to a lot of people, they might not know what a lucia jig is. So let me describe it, right? Classically, it’s like something acrylic, that you make and like you make it to a right shape and you put it on the central incisors, like for example, the upper central incisors and you create like a flat plane. And then when the patient bites together, now the back teeth are separated and they’re sliding around the front on this, what we call lucia jig. So it’s made out of acrylic. Classically in the past, something like Duralay could be used, which is like a red acrylic. You can use any type of acrylic. But actually you can actually get these preformed ones whereby you inject the bite registration paste into, and then you can pop it on the teeth. It’s got like this little plastic unit that sits on the front teeth, and the whole purpose of it is to separate the back teeth and allow the lateral pterygoid muscles to release and relax and allow the patient to find centric relation i.e. the joints, the condyles will seat, the balls will go into the cups as my analogy of the condyles seating into the fossae. And when you get the patient to go grind left and right and grind forward and back, they’ll keep returning back to the same place. It’s kind of like a gothic arch tracing if anyone knows that from complete dentures. But essentially we’re able to find this repeatable position that’s comfortable and then we know that the muscles are relaxed and this is essentially their centric relation. Now, for those of you who are watching this, then you’ve seen me like kind of play in the background a clip showing a lucia jig in action. It’s not so important ’cause a lot of people listen to this while they’re running chopping onions, whatever they’re doing. So I hope that made sense. But if you want like a videos of different ways of deprogramming, then one of the lessons we have in OBAB, our occlusion online course is a deprogramming masterclass. So I show you all these different ways of deprogramming the patient including the leaf gauge to a lucia jig using a chin point lift technique, which I think the best is a hands off approach, right? So lucia jig is great. Leaf gauge is good, and there’s different times you might consider each one. Potentially, the goal is to seat the joints and find that repeatable, reproducible, and comfortable position, AKA stable condyle position, AKA centric relation. There we are. Let’s return back to the episode. [David]Leaf gauges. We’ve got a lucia jig, or we have the Kois de programmer, which is effectively an upper removable appliance with a flat bite plane just on the palatal of the upper anteriors, which is similar to a lucia jig. It’s gonna deprogram the muscles. So of those probably I most prefer a lucia jig, but alternative in my next would be a leaf gauge. So the two different ways is that if they’re deprogrammed, then you can use, the fact they’re in CR to then open them up to the extent that you want. And certainly that’s when a leaf gauge becomes useful because you know you’ve got them at that first point of contact and can put by registration pace at potentially the desired opening. But the flip side of that is we don’t always know how much we’re going to open. So the most important is that you have a bite record at CR and then the technician is going to work out what space they need. And anything I provide them with is an estimation until they start waxing up the case. Whether that’s a typical analog wax up or absolutely a digital wax up. And so two different ways, but for the less experienced, the safest is to give the lab a bite record at your proposed increased vertical by making-  [Jaz]I write that down now, that is that exactly.  [David]But that isn’t always possible. And if, but as long as they’re in CR, the lab can adjust that because they’re gonna work out what is needed. And then they’re gonna make a bite jig at that increased vertical. Effectively, I like to think of it as almost like a lucia jig at the front. And we’re gonna come onto-  [Jaz]On the articulator?  [David]On the articulator. Yep. Before they wax up or after they’ve waxed up. I need that jig because when it comes to the technique that we’re using, that’s my most important part, apart from the putties that I have to make the bisacryl. So it is a question of how we decide on the extent of the opening or in CR. So they’re in hinge access and then our anterior jig. And we’ll come onto that in the techniques of how we then use that. But that’s gonna give our extent of opening. And then the lab, we’re gonna wax up, we’re gonna do our visual try-in, and we’re gonna check that we’ve still got an oral seal. And that goes back to what we were saying about making sure we don’t have overly long, lower anterior teeth. And so we’ve worked it all out and then we could sort of come onto how we do it. Unless you have any other questions about the balance.  [Jaz]No, no, no. I’m happy for you to just talk, ’cause that’s a good point about the jig. And then importantly how you then use that in the clinic once the technician made it.  [David]So assuming we’re doing a upper and lower full mouth, I’ll have the anterior jig in and that’s gonna tell me my occlusal clearance because that’s what we’re trying to work out. The preparation facially, whether it’s full coverage, something we touched on in the previous episode. But I wanna know the amount of opening now when it comes to doing an increased vertical. Some colleagues prefer to do one arch one day, the other arch the next day, and that’s fine. I’m quite comfortable going through a very long appointment. That’s a full day appointment, and the advantage for me is that I can work out which is upper and which is lower. [Jaz]What do you mean by that? Sorry.  [David]So how much I’m adding to the upper, how much I’m adding to the lower where the distribution between the extra occlusal coverage between upper and lower, and doing that as a same day case. I find that easier to work out. But basically the anterior jig goes in and I’ll do a posterior sextant on one side. Let’s say it’s the right hand side. I’ll then work out the distribution of that increased vertical or how much we’re adding occlusally to the upper, how much we’re adding to the lower on our prep upper and lower  sextants. And I’ll make temporaries for those upper and lower  sextants with the jig in knowing that I’m in the correct vertical, I’ll then prepare-  [Jaz]This jig. Sorry, one thing, David, like this jig way of doing it, so I imagine this is not flat plane, this is indexed ’cause it guides them into the exact position you want, right?  [David]It is indexed, but I want to be sure that that is at CR and ultimately what you can do is once you’ve got it indexed, once you’ve removed the posteriors, you can remove those indentations and you’re effectively convert it from a jig that’s actually physically indenting into the teeth, to a lucia jig.  [Jaz]And then you’re observing that they’re literally biting together, and that gives you so much confidence. [David]Exactly. So it’s effectively acting as a de programmer as well as a jig down the line. But I’m not using it until I’ve made posterior sextants right hand side and then left hand side, because then I actually want to equilibrate those posteriors, and if you then flatten that anterior jig out to remove the indentations, it’s acting as a deprogram so that your posteriors are in the ideal position vertically, but also equilibrated. So that may we know the patient’s in CR. We can then take out-  [Jaz]Interested to know the following. Actually, sorry for interrupting, but think there’s so many questions, which I think will be helpful to everyone, is what percentage of the time do you put the posterior in? So you’ve got the left and right posterior with the bisacryl from your temporaries, provisional. Basically within bis-acryl ’cause in our pretend full mount scenario, you’ve got the anterior jig, you’ve now flattened it out, and then you find that, whoa, the lab have nailed it. Your CR record was amazing. The patient’s occlusion is spot on. Versus I need to do some adjustment. So is it that 99% of time there is a bit of adjustment needed or more that actually there’s not adjustment needed? I’m just trying to give those young dentists to know what to expect when they come onto this kind of dentistry. [David]You’d be surprised how much the lab often do nail it, but I would expect some minor adjustment, but not significant.  [Jaz]Yeah, if a significant adjustment, that means there’s a huge issue with your bite record.  [David]Yes, absolutely. But again, having gone through the diagnostic process, I’m already a step ahead of that because I know that isn’t the case because I’ve already done a visual try-in to confirm where I’m up to. [Jaz]So yeah. And then like you said, you did the visual try-in and you took a putty and then that guides lab for this provisional stage. Very important.  [David]So yes, if I’ve made more adjustments, I’m making new putties, but I’ve gone through that process, so am I expecting some adjustments? Sometimes that isn’t necessary, but often some very minor adjustments, very, very rarely, if not at all, if never to have significant adjustments. [Jaz]I think this reminds me of something that Ian Buckle taught me, which is centric relation is like playing golf, right? You’re not gonna get a hole in one, right? So sometimes you get like a little bit closer, like with your bisacryl, visual try, you get, there’s a bit adjustment to do then, right? And then you take a putty, and then on the day of personalization, you’re a little bit closer still. And then at the delivery you’re a little bit closer still, potentially, so, or there, you wanna be in the, you definitely want the ball inside then.  [David]And that’s a very good point ’cause even when I fit, I’m not expecting to have to do no adjustments. There are always gonna be some adjustments, but they get less and less. And I mean, we’ll touch on how we record that for the lab. But yes, not expecting a lot of adjustments. So we’ve rated our posterior sextants, sorry, left and right. Then we can take out our anterior jig. And we then have our clearance anteriorly so we then know how much we’re preparing. We’ve already done the diagnostic of whether the uppers are full coverage. And certainly in an unrestored case, I’d be ideally not wanting to go full coverage. So my amount of vertical opening would be to give me the length of the lower incisors that I want to, because I don’t want to have to prep the political of those uppers ’cause then technically they’re crowns. I’m talking about a new case. A full mouth rehab will be a very different situation. So effectively we’ve prepared and we have six lots of temporaries, three upper sextants, three lower sextants, which are all removable in their own right.  [Jaz]At this stage, you tend to favor using acrylic like shells or you like bis-acryls. What do you prefer?  [David]I’m still very comfortable with bisacryl. If it’s palatal uppers, then we are less concerned about the upper anterior temporaries because it’s our lower anterior temporaries that give us the extent of the vertical against the upper palatal. If the uppers are full coverage, then bisacryl is gonna work fine. So in that sense, with the uppers as veneers. It’s maybe harder to have a temporary, you can take on and off, but it’s less of an issue. Ironically, in that situation and when they’re full coverage, I will have six anterior crowns that I can take on and off because the next crucial aspect is how do we record that vertical for the lab? Bear in mind, I’ve equilibrated my posteriors. That’s allowed me to equilibrate my anteriors so my bisacryl are all equilibrated at my new vertical. I will then take out my posteriors for my bite registration, and I’ll have my anteriors upper and lower or certainly lower if it’s just an upper veneer case in place. And then I can just put bite registration paste in my posterior. And I’ll do that both sides, and I’ll do it three times because I want three bites. So we’ll do that and keep those separate. And then I’ll take out the anteriors and I’ll fill that in. So I have a full occlusal registration equilibrated in CR at our new vertical dimension. And I’ll do it three times. And when it goes to the lab, we hope, and most of the time, all three of the same. If not, you’d hope that two are the same. If all three are different then, then maybe, but you’d be amazed that all three are often exactly the same, but certainly two of them. So we have our prep to prep bite registration at an increase vertical.  [Jaz]And what I love about this is that, sometimes our concern about using stone bite Futar D whatever you’re using, at this stage you have plenty of thickness and rigidity of that because of the space we have and that gives you so much more confidence. [David]Absolutely and bite registration material. There are many around Futar D is is a great material for me. It’s a little bit hard. I prefer blue moose, but I get extra fast ’cause otherwise it’s a long time to set. But speak to your lab technician. Often they will be trimming that down because they only want the very cusp tips in there. So the rigidities, less of an issue because you are gonna have a quite a thick, sturdy bite registration. But I mean, it goes back to, not on topic, but when we do a single restoration, you won’t really wanna do a bite registration over the other teeth because that’s when it gets in the way. But we are talking a different scenario where we have a much thicker bite registration and so therefore the material for me is less, less of an issue. But I’m comfortable with Futar D, blue Moose, DMG, do a great product O-Bite. Not to be confused with LuxaBite, which is too hard for a bite registration pace, but is great as a splint or a sort of a liquid Duralay that we can inject and splint together, implant impression coping. So certainly in full arch cases. So we’ve got our bite registration material as a full arch, and that would be our prep to prep. I will also do a prep to template registration. And a temp to temp bite registration, which is allowing our lab to cross mount our preparation models and our provisional models so that they can work out the space distribution and work out everything is the same when it comes to making the permanent restorations.  [Jaz]And at this stage, you are taking a new face bow record for your technician?  [David]Absolutely. Onto the prepared teeth. So that’s my workflow, to do the preparation and to get the bite registrations. And we’ll have three lab bags, and inside one of those lab bags, there’ll be another three bite registrations. So there’ll be three prep to prep, there’ll be just one prep to temp and there’ll be just one temp to temp bite registration.  [Jaz]Your assistant has to be so switched on to make sure the labels are there, and then everything has to be nice sealed boxes. Not in like flimsy Ziploc bags. You need everything protected. You don’t want things to be shattering by the time they get into the lab. Do you ever use custom incisal guidance tables?  [David]The answer is, I have done, and I’m quite comfortable with using them. If you are reproducing the guidance that you have. And the lab may choose to make one from your temporaries to help them reproduce it. And again, it’s a way that we can record our, the steepness of our incisal anterior plane for the technician or for the technician to be able to reproduce that. Whether that’s from something you are wanting to copy in the patient’s natural dentition, or wanting them to copy from your provisionals. So it has a place, but if the technician’s done the digital wax up and it’s all in house, that they’re probably gonna be able to copy what you have. But it’s always an option as an extra tool to confirm that they’re copying what you have. But I think we must always remember that we have to be able to be adjusting in the mouth because the best articulator is the mouth. And so we don’t wanna give patients overly steep incisal guidance because, but it needs to be steep enough to give us posterior disclusion. And a custom table can be useful to help confirm that if nothing else.  [Jaz]Wonderful. Those are my main questions. Wanna just talk about any do’s and don’ts that you wanna just come to mind on the clinicians who are starting their journey to just remember to save them for getting in trouble?  [David]I think it’s a fairly classic one. Don’t try to run before you can walk. And absolutely don’t be doing work that’s beyond your scope of knowledge. And so, initially, get a good foundation in occlusal training. And if you are used to doing equilibration, if you’re used to adjusting flat plane appliances, I think that’s a very good start because it’s gonna give you the confidence to be able to move forward, be comfortable and confident in your restorative and your preparation skills. Going back to Schellenberg, knowing how to prep is definitely very important and don’t do anything beyond your skillset. But going through the pathway, especially if you’ve had your occlusal training, you are comfortable doing equilibrations, you’re comfortable adjusting your flat plane appliances. We’re not doing anything massively different from that. And with the whole planning stages that we have gone through, we are not taking steps into the dark because it’s a very predictable process. We’ve gone through that. We know the aesthetics, we know that we can achieve the function. It’s then just a question of taking your time. For me, this is a full day appointment. Patients are instructed, wear company clothes, have a good breakfast, bring some music in to listen to. It’s gonna be a long day, but you can have a break and be aware that you can split it into two days if you’d rather and fully inform your patients about what’s involved would be my list. [Jaz]And the last thing you want is a patient like, what the hell just happened? You couldn’t imagine that. Oh, David, thanks so much for, so sorry. Go for it.  [David]We just, with the dahl process, the patient is aware of what’s happening. They’re fully invested, they understand their level of dental knowledge has gone up because they have to be aware of what they’re going into. And it is a long day and patients invariably get very, very tired at the end of the day, but the results, that memory fades very quickly When you give them the mirror and you give them the functional aesthetic result that they’ve wanted.  [Jaz]You forget about the flight and the ear pain that you had when you have your pina colada at the beach.  [David]And our wives and our female colleagues, if they have gone through labor, they will probably tell us the end result is worth it. [Jaz]Well, that’s a great point to end on. David, thank you so much. But there’s early morning session. We covered a lot of ground there and I think, kudos for really covering a complex topic like, wow, like this is such a big topic and I’m really happy with the rabbit holes we went down. David, please tell us more where can we, what are the channels that I can get Protruserati to learn more from you, my friend.  [David]So as we touched on last time, there is gonna be a website, ppcontinuum.com. Sorry, I can’t let you have that one on chat as you asked last time. But there will be some resources on there for myself, but from other colleagues and Kushal Gadhia at ace, I do run the additive program for veneers and minimal invasive dentistry. And you’ve inspired me, Jaz, that I’m gonna put together a program for doing the open vertical as a course as well. But I haven’t got that completed yet.  [Jaz]But let me know when you do. I’ll put it in the show notes, my friend. someone experiences you, you know that it’s a great skill to learn and to have that will be wonderful. [David]Thank you. And I’ll be doing that I think as a hands-on with Kushal Gadhia at. Ace and obviously you can Google me. I’m happy to help in any way I can. And another point that is not just with me to find a mentor because one thing we didn’t touch on is that you can do this sort of a case with someone as a tag team. So you’re both clinicians together and working it out with your mentor where you treat the patient together and your mentor might treat one side, you might treat the other side and that would give you the extra confidence to-  [Jaz]That is a rocket fuel. That is rocket fuel for your career. Honestly, great point. [David]And I know you are working on the mentoring program and I think doing the case together will give you the confidence that it’s the first one, the first few that obviously, understandably anyone’s gonna be concerned about, and to give you the confidence to get through that, that’s also an option.  [Jaz]Amazing. David, I’ll put the links there for you. Got for you guys to learn from. David, thank you for your time again.  [David]Thank you very much, Jaz, and well done to you.  Jaz’s Outro:Thank you. Well, there we have it guys. Thank you so much as always, for listening all the way to the end. What I did do in this episode is I put in a few interjections. I don’t always do this, but when you have a very confusing topic, like vertical dimensions, multifaceted, I hope those interjections were useful, and if they were, if they weren’t, please could you comment? Please could you let me know whether you’re watching this on Protrusive Guidance or on YouTube, or maybe you’re gonna go on Instagram at Protrusive Dental. You’re gonna DM me. Let me know. Were those additional injections, were they’re helping you or are they hindering you? We love your feedback on Protrusive. This episode is eligible for CE or CPD depending where you’re on in the world. We are a PACE approved education provider and on our platform, Protrusive Guidance, you have access to over 350 hours, including our masterclasses and on-demand webinars. And our mission really is to make dentistry tangible. So check out www.protrusive.app and maybe start a free trial today. As always, any links that we promised, I’ll put them in the show notes. So scroll down if you want the premium notes, which is like a PDF summary of everything we discussed. It’s like revision notes, like really good revision notes for every episode. Again, they’re accessible under the episode. If you’re watching on Protrusive Guidance or in our Protrusive Vault at the time of recording today, we have over 3000 strong community of the nicest and geekiest dentists in the world. And so Protruserati, thank you so much. I appreciate your support and for returning. And if you’re new to the podcast please do hit that subscribe button. It really means a lot to us. I wanna take a moment to thank my team. Our CE queen is Mari, who’s the one who issues your certificates, and this episode was edited by Gian with collaboration from Krissel and Nav. Thank you to my lovely team for doing all that work so I can be a father, be a dentist, and be able to watch IPL Cricket on Sky Sports. As always, I’ll catch you same time, same place next week. Bye for now.

How do you manage patients that have ultra high expectations? What’s the best way to communicate cosmetic outcomes before the final result? How do you balance your aesthetic vision with what they see? Dr. Brandon Mack joins Jaz for a deep dive into the realities of cosmetic dentistry—from subjective perceptions of beauty to practical tips that make or break a case. They discuss how to navigate aesthetic stress, manage patient expectations, and even go into Brandon’s favorite veneer cement and occlusal philosophy. Plus, Brandon shares key failures that shaped his journey—and how you can avoid the same pitfalls. https://youtu.be/s7puDNP3d7U Watch PDP231 on YouTube Protrusive Dental Pearl: When discussing smile design with patients, especially in high-end cosmetic cases, set the right expectations early by using this memorable “Eyebrow Analogy”: Central incisors = Twins (they should be as symmetrical as possible) Lateral incisors = Sisters (not identical, but related) Canines = Cousins (more individual) This helps patients understand that perfect symmetry isn’t always natural or necessary — especially for lateral incisors! Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Cosmetic dentistry as a lens through which all treatment should be approached—balancing patient autonomy with ethical care. Managing expectations begins before the patient sits in the chair. It continues through structured checkpoints: from initial consultation to provisional feedback and final delivery. Temps aren’t just placeholders—they are test drives. They align expectations between the dentist, patient, and lab, reducing surprises and improving satisfaction. Some dentists may under-diagnose due to fear of rejection—not out of true minimalism. Thoughtful planning can make “more treatment” actually less invasive. Patients often want teeth that are both ultra-white and natural-looking. Brandon developed the concept of believability—a visual balance that delivers a wow-factor while still appearing real. Creating a mathematically perfect smile can make natural facial asymmetries more obvious. Dentists must weigh beauty against harmony. Social media and filters have distorted patient self-perception. Dentists must learn to identify signs of body or tooth dysmorphia and respond ethically—not just clinically. Building relationships with ceramists over time—expecting 15–20 cases before finding synergy. Each technician has unique strengths and should be matched accordingly. Composite veneers are accessible and beautiful—but extremely technique-sensitive. You become the ceramist. Brandon admires them but uses them selectively due to long-term maintenance concerns. Panavia Veneer Cement – Translucent for its predictable handling, strength, and minimal risk to thin ceramic restorations. Highlights of this episode: 01:35  Protrusive Dental Pearl 03:11 Dr. Brandon Mack’s Journey and Philosophy 09:19 Managing Patient Expectations in Cosmetic Dentistry 14:23 Choosing the Right Technician 21:13 “Undersell and Overdeliver” Philosophy 25:12 Conservatism in Cosmetic Dentistry 26:48 Overcoming Failures 33:15 Body Dysmorphia in Dentistry 37:28 Occlusal Philosophy and Techniques 38:30 Fake It Till You Make It? 40:38 Veneer Cement  42:07 Composite Veneers 44:17 Upcoming London Event and Final Thoughts 🌴 Coming Soon: Occlusion in Dubai 🌴A luxury course experience at Atlantis, The Palm — yes, the one with the famous waterpark! 🦷 Learn practical occlusion during the day👨‍👩‍👧‍👦 Bring your family for a fun, relaxing getaway📍 World-class location, world-class content 🎟️ Coming Soon: Brandon in London (February 6th and 7th, 2026) – Soho Hotel Two-day immersive aesthetic experience aka ReturnofTheMack Rewire how you think about cosmetics with Dr Brandon Mack Participants will learn how to create personalized smile transformations that harmonize with each patient’s unique facial features, moving beyond generic smile designs to achieve truly customized results that enhance overall facial aesthetics. Bigger picture and smaller details in 2 days: transition zones, light interaction, surface modulation For new grads and seasoned dentists alike→ “It’s like re-reading a great book. The content didn’t change — but you did.” Discount Code: PROTRUSIVE for £100 off (case sensitive) If you enjoyed this episode, don’t miss PDP129: 4 Rules of Planning Aesthetic Dentistry (Ortho-Resto) #PDPMainEpisodes #AdhesiveDentistry #CareerDevelopment This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A, B, C, and D AGD Subject Code: 780 ESTHETICS/COSMETIC DENTISTRY (Tooth colored restorations) Aim:  To enhance the clinician’s ability to manage patient expectations, communicate effectively with labs, and deliver predictable, high-level aesthetic outcomes in cosmetic dentistry through philosophy-driven protocols and reflective case-based learning. Dentists will be able to – Understand the importance of managing patient expectations in elective cosmetic procedures. Recognize the role of provisional restorations as communication tools between dentist, patient, and lab. Reflect on how personal failures can lead to clinical growth and stronger aesthetic outcomes. Click below for full episode transcript: Teaser: What is cosmetic dentistry? It's not really a specialty. The way that I look at cosmetic dentistry is essentially a philosophical approach to dentistry, and that's it. Like a lens that we look at everything, how can we be comprehensive? And at the center of that lens, there's two things that need to be balanced. Teaser:Number one, why people don’t want to take more creative risk. It boils down to fear. And this idea as dentists we’re so type A that we feel like everything is a Super Bowl. We have to get it right on the first attempt. When you are in the process of doing this, you have to understand the level of anxiety that comes with it on the patient’s part, because everything that we’re doing is semi-permanent, right? Nothing lasts forever, but this isn’t a hair dyeing or a haircut. When a patient says, I want really white teeth, but I want it to look natural. That is a horse with stripes. It’s not a zebra. It is a horse with stripes. I think that for the young dentists embracing every failure, no matter how big or how small, and understanding that every one of those lessons are an opportunity to put you in a better position to treat the next person better, it’s going to make the next person’s case better, every single failure. So there’s always five checkpoints for patient expectation. Patients are demanding certain things, and so how much do we balance patient expectation and autonomy, what a person wants for themselves? I think it all boils down to one thing.  Jaz’s Introduction:Cosmetic dentistry is tough. Think about it when you’re removing caries, is there a way to make that objective? Like some of caries removal is obviously subjective because how much I would remove is different to how much you might remove. But with something like caries detector dye, we know that we can turn this procedure and add a degree of objectivity to it, and we have some guidelines that we all work to. Now, in the world of cosmetic dentistry, there is the lens that the dentist wears, and then there’s a perception of the patient. And as they say, beauty is in the eye of the beholder. Now, add to that the ultra high expectations that patients can carry today and the very nature of cosmetics and beauty being subjective. This is tough. This is what makes cosmetic dentistry tough. So I’m absolutely honored toast today, Dr. Brandon Mack from Florida. He is one of the biggest names in cosmetic dentistry and we have a really geeky session today. I asked him how he manages those ultra high expectations patients, so big level stuff. And I also ask him little details like what’s his favorite veneer cement? What is Brandon’s occlusal philosophy? And one thing I really love is I ask him to tell us about his failures. And I always appreciate colleagues that share their failures and what they’ve learned along the way. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. If you’re returning to the podcast, maybe you’re watching this on the Protrusive Guidance app. Thank you so much for coming back. If you are new to the podcast, you picked a really awesome one to join us. I said on the podcast, I actually really enjoyed Brandon’s flamboyant vocabulary. He’s full of energy, and these are the kind of episodes that really get you feeling good before a day of work. Dental PearlNow, every PDP episode, I give you a Protrusive Dental Pearl. Today’s Pearl is actually inspired from this episode. It was actually something a patient taught me that I’d like to teach you that very much goes in tandem with a theme of this episode about ultra high-end cosmetics and meeting expectations. And something I talked to Brandon on the show so you’ll hear it later, but I had this situation where I’d done some ortho and bonding and I was really loving the result. Okay? I was actually genuinely happy that I had delivered a nice aesthetic result, but my patient was hung up on one lateral incisor, and yes, it was not symmetrical to the other lateral, but laterals aren’t usually symmetrical, and so this is what you should say, right? You should remind your patients right at the beginning, at the consultation when you’re gauging expectations, is that central incisors are like twins. They should be pretty symmetrical as much as possible, and they should be the dominant part of the smile, right? Having that central dominance. Now, lateral incisors should be like sisters or siblings. They should not be identical twins and canines are like first cousins or something like that. Now, when I said this, my patient finally got it. And yes, I just did some adjustment and I tweaked it and I think it did look better. But when I described it this way, my patient says, ah, it’s like eyebrows. She said that when you get your eyebrows done, something I know nothing about obviously, apparently you are told that eyebrows are like sisters. They’re not twins. They’re like sisters. And I was like, yes. It’s just like eyebrows. And so happy patient in the end. And a nice little way to communicate with your patients and to get across the correct expectations. So feel free to use this eyebrow comparison analogy. Call it what you want. And hey guys, enjoy this episode. It’s really good. And look, be sure to hit that like button, hit that subscribe button. If you’re on Protrusive Guidance, do drop a comment. Catch you again the outro. Enjoy the episode. Main Episode:Dr. Brandon Mack. I wish this wasn’t your first time on the podcast. I wish it was your second time so I can play Return of the Mac Song, but it’s the first time for Brandon Mack. Welcome back my friend. Welcome to the show. All right. It’s so, so cool to have you. I’ve recently discovered your presence online world, thanks to Barraj and oh my God, I’m blown away by the standard of your work. The episode, I called it provisionally Ultra high-end Cosmetics. And my goodness, what you deliver on a day in day out basis is very inspiring. So I’m very excited to learn from you. So for our guests all around the world, Brandon, please tell us about yourself.  [Brandon]So my name is Dr. Brandon Mack. I practice here in Tampa, Florida. We also travel to New York a couple times throughout the year to do cases. And one of our focus is on understanding cosmetic dentistry and its impact, I guess, a world with an egregious appetite for instantaneous gratification. And we are trying to carve out a particular niche where we’re guiding patients to optimizing aesthetic outcomes while looking through a scope of comprehensive dentistry. I love what I do. I’m having a good time doing it, and I’m really just trying to change the narrative for tapping into a sense of authenticity and really tapping into a passion for what we do. [Jaz]Nowadays, so many clinics offer cosmetic dentistry. What do you think when the nature of the clientele, you see, they hand pick you, they carefully seek you out. What is it that they see from what you put out there that think that, okay, for all the dentists I could choose, I’m gonna travel all the way to see Brand Mack. What is it that you think that they’re expecting, why do you think they’ve picked you? What is the promise that you try to deliver? What is your USP?  [Brandon]You know, in a world where there are so many options. I feel like what speaks to a patient the most is gonna be a multitude of things. When it comes to social media, most of our patients are gonna find us from other people talking about what it is that we’ve been able to do for them. And social media has also been a huge marketplace for people to discover us and discover the body of work and what we put out to the world essentially is focusing on a sense of transparency on how we craft the product and how we put passion into what it is that we do. So patients that are selecting us, while there are so many good cosmetic dentists across the world. I have my list of favorites, but I think more importantly, what they are coming here for is an alignment of energy and an alignment of who we are as people and what we’re putting out to the world. Not necessarily just the work, but I do think that our work speaks to a particular population of people who are seeking someone who focuses on the micro details. I always have this saying that, a patient or a person can never have higher expectations than we have for ourselves. So people who are aligned with that concept or that principle, or they want someone who is gonna deliver energy and love in the work that they do, and have that translate into something that they can enjoy, I think those are the people that are selecting us and what separates us from the pack. [Jaz]I mean, making it relatable to general dentist. Some advice I’ve always received, Brandon, is people never buy treatment. People never buy the dentistry they buy you. I see that very much in when the kind of stuff you put out there and what I’ve seen of you. But your rise to the top of cosmetic dentistry from what I’ve seen, I’ve been very impressed. Can you just describe your journey? Have there been any blips along the way? Has it been very linear or have there been a few curve balls along your journey?  [Brandon]You know what? All started out when I had a friend, we were hanging out in my building and this kid was from Abu Dhabi. He was like, hey, my dad has a finance company. We’re looking for dentists to come over. And that was my initial push to seek out CE at a high rate of acquisition. I wanted to just do as much see as possible because there were certain requirements from the Ministry of Health that they required for dentists to come over. You either needed two years previous experience or you needed to have a certain certificate or specialty, and I had neither one of those ’cause I was just starting out my journey. And so I went on this quest to consume as much continuing education as possible. And I ran into a couple of people that changed my life forever. And one in particular, this guy named Miguel Ortiz from Argentina. He was a Harvard trained prosthodontist. I went to take a photography course with him and this lab named Midwest Dental Arts with Justin McCroy down in Sarasota. And when I saw these guys and what they were doing in dentistry, it completely blew my mind and opened my mind up to a whole nother world of possibilities. There was this guy, Eduardo De Agüiar from Venezuela. I saw he had this picture. It was a needle and thread, and the name of the picture is when the pictures really matter. And that sat with me because I had never seen dentistry photographed at such a high level, at such an artistic way. I had never seen it in dental school. None of my friends were doing it, and it intrigued me. And you get on a journey where passionate people are passionate about everything that they do. But I was lucky enough to also discover my passion through this journey or quest to seek out continuing education to try new opportunities. Now, my career, it kind of went in a different way, but it really came down to being very passionate and being compelling, which is a quote from Joe Plumeri, this guy who comes to aesthetic advantage to speak on occasion. But he always says there’s two things about people who are gonna be successful, is that you have to be compelling and you have to be passionate. You have to be obsessed. And so those things, I would say catapult to the next level.  [Jaz]You don’t fancy going to Abu Dhabi anymore?  [Brandon]Man, you know, I still wanna go. Abu Dhabi, it seems so incredible. Are you kidding me? Everybody wants to go down Abu Dhabi.  [Jaz]Well, you know what? This really cool thing that we’ve set up, I haven’t advertised or anything, or put it on social, it’s just through our email list, but we’re setting up this, we call it the Dubai excursion, right? The deluxe occlusion. We’re doing an inclusion course in Dubai, but it’s like I’ve seen it in US. A lot of educators, they do this, their courses at Disney World, right. And then they encourage everyone to bring their family along, right? And so we’re kind of making this thing happen in Dubai. We’re encourage at the Atlantis who’s got the waterpark and stuff, and a mixing family and passion. So if you wanna come and join us next year at April, man, come to Dubai with us. You can-  [Brandon]I would love to.  [Jaz]You have the whole seminar day yourself.  [Brandon]I’d love to.  [Jaz]I digress. You already mentioned some mentors. You already mentioned the role of being inspired by someone, so that’s great. The next thing we wanna tackle with you, Brandon, ’cause there’s so much we could talk about. I just wanna really understand the mindset of someone operating in the way that you do. Some of the cases you do, some of the themes of meeting patient expectations, right? This thing really keeps up dentists at nighttime like that, sleepless nights over it. This is a source of anxiety for dentists and when I look at your kind of work you do, like your patients must have high expectations. They’re coming hundreds of miles, they’re coming see you. Exactly. So my question to you is, what systems or techniques do you employ to help with that? For example, some dentists might have a very strict selection criteria, so they’ll actually dismiss a lot of patients and they pick the home runs other one, the most classic one. Since day one of dental school, we are taught undersell over deliver. Okay, so I wanna know, how do you manage the crazy high expectations that you must get?  [Brandon]Man, you hit a lot of points. Make sure that I come back to that undersell over deliver concept. Expectation management, I think is the key of cosmetic dentistry. And if you really think about it, what is cosmetic dentistry? It’s not really a specialty. The way that I look at cosmetic dentistry is essentially a philosophical approach to dentistry and that’s it. Like a lens that we look at everything, how can we be comprehensive? And at the center of that lens, there’s two things that need to be balanced. Number one, patient autonomy, and also doing the right thing, right? We took a Hippocratic oath in order to become doctors, and so there’s a certain balance, as we know in the world of social media, and now people are taking a accountability for guiding their own oral health and their total health in general. People want to be in the car seat and drive the car. Patients are demanding certain things, and so how much do we balance patient expectation and autonomy, what a person wants for themselves? I think it all boils down to one thing, having a very clear and dry practice philosophy that governs every decision that you make. Okay? And so when I think about meeting a patient’s expectation, I wanna first sit and be a very good diagnostician. I wanna be able to understand exactly what I’m dealing with so that I can communicate with a patient in a way that’s very digestible so that they can understand. But we put it in the framework of their expectations and it starts with just listening and understanding how can we become a translator? And that is the biggest challenge. And I think we are equipped with certain tools that allows us to communicate effectively. Not just with the patient, but once the patient does accept treatment with the labs and creators that we collaborate with. And one of these things are tools that are the center of everything that we do is being able to handcraft temporaries that tell a particular story because now the patient has an opportunity to test drive what it is that you did for them, but they also have an idea for direct feedback. Did you translate the vision that I have for myself? One of the things that we have in place is that 24 hours after doing a case, I bring a patient back. I sent them down in a new environment. We take photos, videos, same records we do in the beginning, and we analyze ’em. We give the patients an opportunity to give feedback, so there’s always five checkpoints for patient expectation. When a patient comes in and fills out the paperwork and tells you their chief concern, the patient isn’t usually involved in a mockup or digital design. That’s more for inter-office communication to verify, hey, are we on the right path? Is everybody on the creative team on board with this? The temporaries day one, when you’re doing the preparation, this is an opportunity for us to deliver the vision that we’ve aligned ourselves on, that the patient has told you, this is what I expect from a functional and aesthetic standpoint. After that, the fourth checkpoint is when the patient is gonna give feedback, did we deliver? And if we did deliver, fantastic. Now you have to manage that expectation again because it is very difficult, as you know, even with the tools and technological advancements in dentistry to copy a set of teeth, one-to-one. And so over the years, I have changed my language. I don’t say that we’re gonna copy the temps. What we’re doing is we are creating a framework for aesthetic and functional interpretation from the partners that we work with. And so we have a lot of different labs. And one of the difficult things is when you’re working with different creators, different ceramics from Romania, Brazil, Los Angeles, New York, London. If you’re working with those team of people, how do you have a unifying body or a certain aesthetic voice that communicates to the patients? That consistency is going to give you trust from the patients. And that is going to help manage the patient’s expectation. Their expectations are being managed before they even meet you. Are you consistent? Do you have a consistent aesthetic voice? And what is your philosophical approach? Are you a doctor that I do what the patient wants? Or are you a doctor that says, hey, let me hear what it is that you expect and let me translate that into something actionable within a framework of what I’m comfortable doing. And so there’s so many different approaches that you can take, but I think managing the expectation starts with listening, communicating and being aligned on an agreed upon vision.  [Jaz]Let’s just talk with the lab, ’cause you said it’s a very difficult thing to do an exact replica, which is why creating a framework, it makes sense. Do you choose the technician based on who’s a good match for the patient or like some other clinic, what they do is they kind of give the patient a brochure. It’s like, here are the five labs I work with. You pick the menu of the day. You pick the signature dish, you pick the ceramics that you like the most, and their work. Like how do you become that decision?  [Brandon]First of all, I love your energy, brother. You got me fired up this morning at 8.45. It is a delicate dance when it comes to choosing the technician, and I heard this thing on social media the other day, and it was about being magical, right? And so when you have talent, and you do something and it just comes out great, those people who have talent that they’re just born with and they’ve fostered over the years, they’re able to be magical. But when you can take that and apply science or an algorithm to it, now you have something that is just undeniably exceptional. And so when it comes to selecting a technician, we’ve boiled it down to, alright, this particular technician, he does color very well. He works on preps with homogenous prep shades very well. His interpretations of shapes tend to have more sharp line angles as opposed to another interpretation of the temporaries tend to be a little bit more soft or rounded. And when you have a certain vision for a patient, the final result, the beginning, you have a ceramics in mind. Who is going to maximize their skillset to deliver that kind of interpretation of the product. And so I’m always thinking from the beginning consult from first meeting a patient. It’s like, oh wow, this is a great case for Chris. Oh, this is a great case for Rico. Oh, this is a good case for Calvin. Danny. Boom. And so we selected based on which ceramist has the skillset to deliver on that particular case type? Some of my ceramics are very, very good at mixing different material selections. Feldspathic, mixed with layer zirconia, or some are really good at using lithium disilicate. Some are very good. When we start talking about changing vertical dimension, which we’re gonna talk about later on the pod, I believe. It really depends. All of my ceramics have a particular thing that they do very, very well, and I like to connect with them so that we can exchange energy. I believe in having two sets of creatives on a case versus me being the only person there and they work for me, so I like to have feedback, and we’re gonna talk about that in the future.  [Jaz]And when you were discovering these technicians to have that flow, who aligns with you? I mean, you’ve named about four or five different locations. You must have been through at least 20 different technicians until you settle on the five of your A team or whatever. Tell us about the journey of working with many technicians or going about to discover who best aligns with your practice or your values of aesthetic dentistry?  [Brandon]Investing energy and risk, and building genuine, authentic relationships. That’s what it’s all about. The first thing that I do when I reach out to a ceramic or they reach out to me, I tell ’em about my approach and how I like to work, and I ask them, is this something that you would be interested in? And what is your vision for yourself? How do you like to work? Some people, they want to be the artist. They wanna have a lot more creative control of contours. When you’re early in your career, it’s nice to have ceramics that can guide you through the process and kind of, be the training wheels for the case to make sure that it goes as you plan, as you progress in your skills and your aesthetic vision and your functional capabilities to deliver, you start to wanna have more creative control over the case and then you wanna match that energy with someone who can deliver what it is that you see. And so the conversation changes over time. The cost change over time. And as you vet different ceramics, it’s more about who is the most willing to communicate in a way that I like to communicate. The minimum standard is, is the work good? Do they do good model work, and are they passionate? If they have those three things, they can come to the table to work. Now, from there, how do we communicate? What’s the energy? What’s the alignment? Do we enjoy working with one another? Are we on the same wavelength? What is it that you see? Am I learning from you and are you learning from me? All those things are very, very important. But yeah, we’ve gone through at least 20 ceramists and some really good ones too, and you kind of settle in the people that you actually enjoy working with, not just because the work is good, because you enjoy the energy exchange that happens there in creating something special, and there’s a certain power that comes with that. I love that part of it.  [Jaz]That’s brilliant. Now, when I talk to many dentists, younger colleagues, they always ask me, oh, how do I choose a lab technician? Or which technician do you use Jaz? And the mistake they’re making there is that, we’re very sheepish in dentistry. Like, for example, you start working in practice and whichever lab that practice has been using for the last 15 years, he just said, oh, this is who we use for dentures, and this is who we use for crowns and you just go with that. But to go through that uncomfortable period of actually having a conversation with a new technician and actually seeing that A, they are communicative. And they are responsive, which is what we need in this world. And then eventually you will find someone who is similar to you, really great denture removal process specialist Dr. Finlay Sutton in the UK. He recommended once in a podcast to find a technician who’s kind of like a similar age to you. And that you wanna like bounce off each other and then you grow like together over the years. And that always really resonated with me. And it’s really nice to have those open communication channels. Like sometimes my wife will look through my phone and the WhatsApp messages and exchanges and or voice notes between me and the technician. She’s thinking like, what’s going on here? You speak to him more than you speak to me, kind of thing.  [Brandon]Yeah, I know that. Listen, I’m up at like four in the morning sometimes talking to the ceramists because we’re at different locations. I think that you said something there, and I think it really boils down to the fear why people don’t want to take more creative risk. It boils down to fear and this idea as dentists we’re so type A that we feel like everything is a Super Bowl, we have to get it right on the first attempt. What many people don’t understand is that even when I’ve identified someone that I would know as being the best in the world, it takes a minimum. And I don’t even think this is an overstatement. I think it’s an understatement, a minimum of 15 to 20 cases to dial in a particular language until there is a certain homeostasis that’s happening there where you are just in the zone oscillating back and forth. And a lot of people have to be okay with taking that risk. They have the fear that we’re not gonna get it right this first time. It’s like there’s certain indicators. How do they fit, how is the communication? Are they open to feedback? Do they give you feedback? Because if you have that type of relationship, exactly, like your mentor told you, that the prosthodontic technician, it is about getting with someone that you can grow with. And I think it takes 15 to 20 cases to build a body of work. And now you can reference those cases when it comes to color and texture and design. That’s really important.  [Jaz]Brandon, you have a very flamboyant vocabulary. I love it. I just wanted to put that in there. Now we mentioned undersell over deliver and I wanna hear what you say on that, but before I let you go off on that, another thing it reminded me of eight, nine years ago I was, there was lecture. And this dentist, he was teaching us that when you try in a crown, let’s say you try and crown on upper premolar, okay? And then you show the patient in the mirror to check the crown. And then he was saying never say, what do you think? Because his thing was, you’re just inviting feedback. They say, oh, it’s a bit fat. Or is the color okay? Then he was like, you’re setting up yourself up for failure and revisions and that kind of stuff. Now that was, you have to understand the context where that was coming from, Brandon. That was coming from someone who’s head of a corporate and he wants the fits to go in the first time and therefore less remakes. Therefore, profitability is highest in his corporate chain practice kind of thing. Whereas what you described was like multiple checkpoints, multiple times of checking for alignment and accepting feedback and hearing feedback and trying to get there. And so going back then to what the opposite of that, but also going to undersell and over deliver, which is what we’re taught as, what we’re taught in dental school is undersell over deliver. What is your philosophy on that approach?  [Brandon]I think confidence comes through humility. And what I mean by that is that you have to have the humility to analyze your work and know that there’s space to get better. And by getting better consistently, you become confident through time. And that confidence comes off in the consultations. And so with me, my approach is being very aware, self-aware about one’s own’s ability is very, very important, and it’s okay to communicate that and be honest about that with the patient, whether it’s good or bad. I think that it is a tricky thing. I talk to my team about this all the time. When you are in the process of doing this, you have to understand the level of anxiety that comes with it on the patient’s part, because everything that we’re doing is semi-permanent, right? Nothing lasts forever, but this isn’t a hair dyeing or a haircut, what we’re doing, we intend for it to last a very long for time. And just about everything that we do in dentistry, even if it’s a zero prep veneers irreversible, the surface of that tooth will never be the same again. And so what I talk to my team about and everybody in the process is that our job is to control. What are we controlling? Their trust in the process and everything that we do, it is geared towards that. Number one, did we give them the space to talk in the consultation, did we listen? Thoroughly? That way the body of work is gonna procedure you. They’ve seen the work already and so I don’t like to get into the weeds about what they want things to look like in the beginning because now you’re introducing the opportunity for the wheels to fall off of the thing. Their feedback comes from that post-op, and I don’t like to just give them a mirror when they sit up because that is a very intimate thing when they look at themselves for the first time. I don’t wanna be involved in that process. I don’t wanna be involved and I don’t want my team involved. I want that to be something intimate that they experience. Over the course of 24 to 48 hours themselves where they don’t feel judged and now they can have honest feedback with themselves and come the next day or the next two days and give that feedback. And so what I’m doing is I’m taking the photos and I’m studying the case so that once we come to post-op, I want them to speak first, to make sure that we’re aligned. We’re seeing the same things. If they see what I see, this is a home run if you can execute. Right? But if they’re seeing something different, it’s like, let’s take a step back. Let me understand where you’re at. And then now you go in there and you deliver. Oh, that answers the question. It is a very tricky thing. It is tricky, especially when you are asking a patient, what do you think? One of my mentors, he always said he would do one side of the temps one way, the other side of the temps another way. It’s like, what side do you like best? So the answer is always positive. No, I’m just kidding. But he did say that. That’s one of my mentors. This is Dr. Larry Rosenthal. He’s a funny guy.  [Jaz]Okay, that’s interesting actually. I like that. But I mean, I think the undersell over deliver concept, therefore, in your practice you don’t really practice that ’cause you are prototyping everything and you are, you are checking every change and so they’re gain to get what you see is what you get to a large degree because you’ve tried everything in the prototype. Is that fair to say?  [Brandon]Well, I have a question for you. This is why that resonated with me. How do you feel about this concept of conservatism for the sake of being conservative? Undersell over deliver. I know where you’re going with it, but this is why it struck a chord with me. And it goes back to kind of understanding occlusion also and functionality. I think a lot of the problem in cosmetic dentistry is that we’re not given the patients the opportunity to explore what is possible. A lot of times we undersell a patient by under diagnosing because we don’t want to hear no, we’re afraid they may say, no, maybe this is too invasive, but what is really invasive? Think about a patient who has wear from, let’s call it bulimia, and they wanna explore the concept of cosmetic dentistry, and a new dentist recommends doing 10 teeth on the top and then 10 lower veneers on the bottom. How invasive does that have to be? How much tooth structure do you have to cut if they already have acid wear and now the occlusal surface have the little acid dimples on the cusp tips. Now, if we were to consider opening the vertical dimension or the bite by mounting the case in CR for prosthetic convenience, how much more conservative could we be by treating a few more teeth in terms of saving the total amount of enamel that’s being cut for this case? And the amount of time that we can preserve the entire system, you know? And so I think about that a lot. I know you were going a different place with that question, but that’s what popped into my mind when you talked about, I guess the under promise, over deliver.  [Jaz]No, but I like it. That gives it a very good perspective. We are afraid of rejection.  [Brandon]Oh, very much so. [Jaz]No, that sits perfectly with me. When you were going to like, through process of setting everything up in your systems, obviously everything that you’ve been doing over the years. It informs your system and you’re gonna make this tweak and you’re gonna do it like that, and eventually it takes years to build these systems and therefore, managing expectations over the years. Are you happy to share a couple of hairy scenarios where expectations work difficult to meet for whatever reason? Or some failures along the way that you can pass on some lessons to us. Seeing you where you are now, it’s nice for the little guys to say that, hey, you know what? We can still all mistakes and learn and grow together.  [Brandon]This plays in the why it’s great to have amazing mentors and be very open to helping your community. Because I remember a particular case was referred to me from a periodontist. This sweet lady came in and she was in the process of doing some other cosmetic surgery, facial enhancements and such, and we were gonna do her teeth. And at the time I thought that I understood the nature of where we were from a cultural standpoint with aesthetics. Meaning when we talk about natural teeth, what does that mean for people? What does that mean for dentists when it came to color, what white teeth meant to patients versus what it meant to dentists? And we did this case where a patient, we thought we hit a home run. The case was like an 0M1–0M3 at the time we showed it. We didn’t show the shade tabs because that’s what was taught to me. That is what I learned is that, oh, we don’t show a patient a shade tab, but we have them select a color based on the temporaries. It’s this good. Is it too white or is it too dark? That was what I learned. And so in this particular case, it was one of the best cases that I thought that I had treated, and she came back to me and we mismanaged the case so poorly. When she asked, she said, hey, do you think these teeth are white enough? And I remember looking at the centrals thinking, it’s like they do look a little warm, and we tried to convince her. I wanted to convince her because I was so attached to the amount of work that was put into delivering the case. And that was one of my best lessons for me to remove myself. If you put in so much work and you hit 99% of patient expectation, you know that you put in the 99%, but that 1% is what it took to meet that expectation. You have to be in a position where you can stomach that level of failure. And be okay with saying, hey, you know what? I see what it is that you’re saying. I’m gonna go back and we’re gonna replace this case. Now, when you’re getting into a game of elective dentistry, it can get a little hairy. You have to be okay with understanding that everyone’s opinion about what is beautiful or what meets their expectation is gonna be different. And if you don’t manage the patient well throughout the entirety of the process, their expectations can shift at any point. And you can be upside down on a case, meaning it doesn’t matter what you do technically. If you mismanage the patient and meeting their expectation, it can go sideways, and you have to have systems in place to predict when that’s going to happen. Understanding personality types and patient psychology when you meet somebody and really respecting your decision, am I going to take on this patient? Can I help them get closer to what it is they want to access? Or am I not the provider to guide this patient to meeting their expectations? Should I recommend that they have a second opinion? I think those are things that I learned early on in my career. I also remember there were cases when I used to think that OM3 was the whitest that I would wanna go because there was this, certain dentists were regarded in a way if they made the teeth too white and too opaque, and patients were asking for it. Early on I was a little bit fearful of going wider and wider. I didn’t want to take those type of risks from thinking that I wouldn’t like it. And so as you go through your career, you start to understand who you are. It’s like, is it about me pleasing myself and feeling like, oh, I did a great job and I love it. Or is it about pleasing the patient? Where is the balance? And I felt like that was the, at the center of a lot of my early failures as well. And that’s something that’s very difficult to talk about-  [Jaz]That the patients wanted to go whiter?  [Brandon] Correct. You know, you have some dentists that say, hey, the patient wanted this, so I did it and I think we leaned, I used to look at dentists who said that as like, hey, that’s just an excuse for accepting a low standard of what should be done. Patient standards are so incredibly low, you could do just about anything and make them happy. But if you don’t have a high level of standard for yourself, then at least that’s what I used to think. Right? And that was the excuse that I would make. And now it is a little bit different. I’m more open to taking more risk and understanding how can I achieve what it is that they want by doing what I’m comfortable with. And I’m talking purely aesthetics. Now, is it possible to give an unrealistic level of whiteness or value to a set of teeth and still have it have elements of believability? And because of all of those failures early in my career for color, that’s where the concept of believability came from. It’s not natural when a patient says, I want really white teeth, but I want it to look natural. That is a horse with stripes. It’s not a zebra. It is a horse with stripes. These are two conflicting things that I felt like, it didn’t exist. And so it forced me to have more open lines of communications with my lab partners to ask them how can we press the boundaries of giving something that could be believed as being real, but also have elements of wow factor? And so over the course of like two to three years, I was able to develop that concept, and it came directly from failures to communicate expectations around color, opacity, fluorescence, reflectivity, absorbing teeth, and all of these concepts you learn along the way. And it modulates how you prep a tooth based on prep, shade, material, thickness, material choice, all of that stuff. And so I think that for the young dentist, embracing every failure. No matter how big or how small, and understanding that every one of those lessons are an opportunity to put you in a better position to treat the next person better, it’s going to make the next person’s case better. Every single failure.  [Jaz]In this case, it’s all about just doing right for the patient, but the two words that, I’m just screaming in my head based on everything you said there. And the whole mention of the psychological status of the patient and everything is some clinics, they may employ a initial screening form for I know, psychometric analysis or something like that. You know, the two words I’m thinking of, right? Body dysmorphia. Have you had body dysmorphia patients? ‘Cause I can imagine, that can drive you up the wall, right? Because you want to do your best. But they keep changing their mind. They don’t know what they want themselves. And then you end up in this perpetual cycle and that’s very toxic for everyone involved. So do you have a way of screening for that so that they can get the correct medical help potentially before you do the other element of it? Or has your experience been otherwise?  [Brandon]You saw how hesitant I was to say the words body dysmorphia or tooth dysmorphia because that is a very real thing. And we have to ask ourselves as dentists, are we contributing to it or are we making it better? So I think that also boils down to that personal practice philosophy. In my office, I think about that when every time I sit down and do a consultation, does this person have body dysmorphia? Can I meet their expectations and are their expectations realistic? Yesterday I had a patient come in, she says, hey, my friend treated me with orthodontics. And this lateral won’t move. It won’t turn. And they did Invisalign go on me. And then they told me, oh, we should have done Invisalign comprehensive care. And now they’re telling me I need 32 more trays. And I sat down with the patient and I told her, I said, listen, you’re gonna walk into 10 offices. Out of 10 offices, and every one of us is gonna tell you, wow, your dentist did a phenomenal job. I see what you are saying about the lateral being tucked behind the central. But these teeth are gorgeous. They look absolutely phenomenal, and they were stunned. She had a stunning smile, very natural, had very nice depth, central dominant lateral setback. But she was looking for this perfection that it doesn’t even exist in nature. And I heard something once that there are no straight lines in nature and I’ve been very pressed to find one. And so I was trying to explain to her this concept of balance and embracing asymetry and embracing the characterization of the teeth because I think she was suffering from body dysmorphia or tooth dysmorphia where she was looking for a level of perfection that does not exist. And if we were to introduce perfection into her smile, it’s going to introduce a certain level of aesthetic stress because her face is asymmetrical. And now with that perfect smile, it’s gonna have us focus on, look, the interpupillary line is off. This eye is a little bit low. This side of the jaw is a little bit longer and more prominent. So I think it’s something that’s very difficult to deal with. And I don’t think we talk about it enough in dentistry because I think a lot of the world profits on body dysmorphia, and it’s something that we should be talking about a lot more to help pick populations of people, and I think social media has a lot to do with it. We are more self-aware of how we look. Filters has a lot to do with it. Us being able to change and modulate the way that we look, and then if we see ourself through filters over and over and over again. And then we have to juxtapose that to what we see in real life. It can create body dysmorphia and then who has to deal with it. [Jaz]I loved your use of the word aesthetic stress, the whole concept of facial flow and aesthetic stress. And I really like that, it reminded me of an interaction with a patient a few weeks ago. Similar issue, like I did her Invisalign, I did her a bonding, and I was in love with it. It’s very important for the operator to be in love with it because though if you are like fitting something right? And you’re like, you are not in love with it. Then the two years later they come back and they say, I don’t love it. You’re like, yeah, okay. Yeah, I see what you mean. Now you can’t, you have to fall, you have to be in love with it yourself. And so I was in love with it first year, so it ticked the first box. But she was saying this lateral and that lateral and the thing that saved me, I guess, or but got her to understand, okay, because I was really liking this, right, is something that apparently is used eyebrows, women’s eyebrows, right? They say eyebrows, they’re not twins. They’re like sisters. Okay. They’re slightly different, which I really liked because I always explain to the patient, look, the centrals should be like twins, right? The laterals should be like siblings, and then the canine should be like cousins, first cousins. And she was like, oh, so it’s like eyebrows. Eyebrows should be like siblings. I’m like, there we are.  [Brandon]I love that. I’ve never heard that about eyebrows, but I do. I see it. I use something very similar, except I say the essentials are like fraternal twins. They don’t have to be boy and boy, but man, I love it, man. I love it. Yes. I bet you bring a high octane energy to your patients brother and I know they love you for it. [Jaz]I appreciate that very much. Means a lot, coming from you. Okay, cool. We’re now into the occlusal philosophy. So, Brandon look. You do all these cases. You mentioned already about raising the vertical dimension and that bulimia case. It’s a tough question to ask someone, and so good luck. What is your, in a nutshell, what is your occlusal philosophy? [Brandon]My occlusal philosophy is I look at a patient, is the bite stable or is it not? Is it a destructive bite or is it stable? If the bite is stable, then we should consider restoring them in their comfortable bite or MIP. We leave the vertical dimension the same, and we’re gonna shoot for canine guidance on a case so that the back teeth disclude when they go in the lateral excursive movements. If the bite is destructive, we have to decide a starting point and mounting the case and CR, and then understanding how do we alter the vertical dimension based on prosthetic convenience and occlusion. And so it really boils down to that.  [Jaz]I love it. And let’s just keep it back. ‘Cause I love the simplicity. Occlusion is this thing that’s over complicated. Just having a few, ’cause we can talk for like seven hours on one topic of vertical dimension stuff, but I’m happy with that. So Brandon, I appreciate that very much. I always want to ask a cosmetic dentist this, right? To what extent do you agree or disagree with the following statement? Fake it till you make it. [Brandon]Next question. No, I’m kidding. I disagree because I did my career in reverse. I tried to put in the work first and then I wanted to make it. Now you see a lot of the young dentists, they come out celebrities, and they’re very, very popular. But there’s a lot of pontification that happens, and I, I don’t think it’s pontification because they want, I think it’s pontification because they don’t know that they don’t know. Some of the things, and I don’t believe that we should fake it till you make it, because there’s a lot of harm that could be introduced in this industry to patients, and we are dealing with something that is very powerful. And I always say this, if you have a product or service that is so powerful as hope, love, and something is addiction, right? Those are magnetic forces. And the power that we have to change a person’s life or the idea that we can change their life, it is a magnetic force that must be approached with responsibility. And I think that the fake it till you make it is something that’s very prevalent in our industry, and I think people should focus more on getting the proper training and building up a certain skillset before we try to jump out and have that type of approach because it is very dangerous. Patients, they don’t know better in some instances, and they want a product because it is powerful. We are unlocking a level of freedom for people. They wanna explore, experience, empower, and express. And the teeth is the cornerstone of facial beauty, or it can be. And it’s also connected to how we look at ourself, our self worth, our value. And so if you have the power to deliver that to somebody, or they think that you can. Faking it till you make it can be a very dangerous concept in my personal opinion. That’s why I said, hey, next question. This may have to be edited out because hey, I’m the dentist. Dentist and I’m here for us.  [Jaz]Last couple of questions. Very like technical geeky kind of stuff, right? Because obviously we’ll talk about your London visit. Very exciting next year, and we’ll talk about the kind of things that we’d be talking then, but everyone will probably want to know like such a stupid little thing, like what’s Brandon’s favorite veneer cement?  [Brandon]Panavia veneer cement, translucent. And it is something about when you do a wet trying with a veneer and you have a very nice prep shade, all right? If you are doing ultra thin veneers, we all know that both the ceramic, the substrate and the cement are gonna contribute to the final color. If you have a veneer that’s thicker, it’s really the material and a little bit of the substrate that contributes and the cement has a little bit less of an effect. But with these ultra thin veneers that we’re doing, the cement has a certain effect on the final result. And I love using the Panavia veneer, translucent cement, and I tell all of my labs, this is a cement that we use so that they can do these little custom prep tabs. And then they can do a veneer, and now they’re gonna know how the cement influences the ceramic and have like a little bit of a standard. And so I love that. I really like using the same cement for a case so that I don’t have to modulate the final color with the cement, that translucent cement from Panavia, it handles well, cleans well, and it has a really good viscosity that doesn’t fracture thin veneers when you overly pressure to it. Sometimes with something like a RelyX veneer cement, it’s a little too thick, and so if you have too much pressure on a ultra thin veneer, it can be susceptible to fracture before curing. So that is my ultimate favorite of all time.  [Jaz]As a Panavia fanboy myself, I’m very happy to hear that. What are your thoughts on composite veneers? Because they’re all the craze, right? And I know a lot of American dentists, they say compo-sh*t and so they don’t believe in it and stuff. Whereas other people are really, that’s all they do right? Day in, day out. They’re doing resin veneers. What’s your stance on that? You are looking at all this happening. What’s your philosophy on this?  [Brandon]Everybody wants to be a bodybuilder, but no one wants to lift the heavy weights. The best cosmetic dentists in the world either start on or they know how to manipulate composite extremely well. You have to be talented. An extreme level of talent to use composite, well, composite veneers, in my personal opinion are one of the best things that has hit dentistry because it offers a very nice solution at a little bit lower of a price point. The challenge is, and why a lot of Americans don’t do it is because it is technically demanding. For most, it requires that you have a high level of skill. There’s no one to save you. There is no lab or designer to save you, even though we have digital design and you can do the suck down method where you do every other two TEFLON it off. But they have some very talented dentists that are working with composite veneers, and I’m a huge fan of it. Now, in my hands. I don’t like to use it just because from for long-term maintenance. And being the level of you gotta be really good. And I love working with composites. I feel like my experience with doing composite veneers or class four restorations early on, learning from Dr. Adamo and Dr. Amanda Seay out in Charleston, that is what gave me my initial boost and getting fired up about cosmetic dentistry because you are essentially the ceramics now. It’s up to you texture, the layering, looking how colors interact, understanding the achromatics and how teeth look when they hydrate or dehydrate. I mean, composite is amazing. I think it’s a wonderful material. One of my closest friends, Jeff Trembley outta Nashville, he plays with the composite veneers. Dr. Marshall Hanson in Utah’s good. Felipe Verde. I don’t know how to pronounce his name properly, please forgive me. Huge fan kidding monsters in a good way. Rhodri Thomas, Australian, I believe.  [Jaz]Rhodri Thomas?  [Brandon]Yes.  [Jaz]He’s Welsh. He’s from the UK.  [Brandon]Yeah, he is stellar.  [Jaz]Look, you’ve answered all these questions brilliantly. The time has really flown with you, my friend, but we need you to tell us about your trip to London. Baraj connected me with you. He says, you know, Jaz you gotta check out Brandon’s work. And I’m so glad he introduced me. I know it’s a two day, it’s quite intense two day thing. He showed me the images of like the cinema type thing. I dunno if I’m allowed to say the venue and that kinda stuff, but the photos look amazing, but more importantly, you are putting on an educational package. You’re doing a live demo. What is that the dentist gonna gain from this experience with you over two days in February, 2026?  [Brandon]I think the biggest thing that I want to communicate is changing the way that they approach cosmetic dentistry. Changing and unlocking their mind and what they think about how they communicate with the patient and with the lab, and equipping them with tools to focus on understanding the impact of provisionalization and what it means to use that as your primary tool between A to B and B to C, meaning between me and the patient. And then me in the lab and the patient in the lab so that the flow of information is consistent. And then taking those concepts and figuring out how do we actually execute on it? Taking the information that we know, how do I do what you do? How do I create the transition zones? How do I communicate the stroke of a line angle? What does texture and modulation of surface anatomy do to how it interacts with light? I think using these tools, I think is gonna be one of the biggest takeaways from the course. Changing and unlocking the way that we think about how we approach dentistry and then giving them actionable items to actually execute on the biggest communication tool that we have. [Jaz]At what level are you pitching this in terms of are you gonna be able to serve dentists who are like, brand new, or people who’ve been in the game and doing some aesthetic dentistry for the last five, 10 years? Like, who’s the ideal dentist?  [Brandon]For the new dentist, it’s going to unlock what is possible. And for a dentist that has dabbled, either in some cases or a lot of cases, especially someone who’s dabbled, in some cases, in a lot of cases, there are going to be certain takeaways or AHA moments that every time that I go to a lecture, I can go to the same lecture three times and there’s always a new takeaway because my level of work that I’ve seen is increased, and there’s always nuggets or pearls that are like, wow, this is massive. And now I can put that connection together. I think it’s gonna serve both populations, especially the younger dentists. And people who have already dabbled in doing aesthetic cases and aesthetic dentistry.  [Jaz]It’s like reading a good book, right? And then when you read it again the next year, like it hits you completely differently. Now, the book didn’t change, but you changed, right? And so some people will come into a course like yours and if their practice is built around cosmetic dentistry, right, they’re gonna be like seeking validation, but also, oh wow, Brandon does it this cool way that I hadn’t considered and introduced these technicians that you might use or workflows. And then sometimes it’s about those tiny nuggets that make a big difference to your practice, whereas a new grad might come and just be like, wow, how do I make sure that in the next five years I can make a treatment plan and trajectory to get to some way towards what you’ve achieved? And so I’m very excited for this. I’m gonna put all the links. Now that you’ve been on the podcast. The link will be protrusive.co.uk/returnofthemack. So I can remember it and that will take him to the website to do the booking. So we will do that ’cause that’s fun to do. Brandon, thank you so much for spending some time with me. I know you’re a mega busy guy and I’m so glad our calendars could align in this way. You brought a lot of value. You’re very real. It’s been an absolute pleasure to talk to you. Any last words for all the audience out there?  [Brandon]Jaz, I appreciate you guys. I appreciate the love. I’m an energy guy. I felt the energy here was great. I’m looking forward to seeing everybody in London in February, 2026 and the world is yours and everything in it, brother. I hope that you guys are well and it’s been a pleasure having this conversation with you. Thanks so much for having me, and it means, it means a lot to us.  [Jaz] Thank you, buddy. Catch you soon. Jaz’s Outro:Well, there we have it guys. Thanks so much for listening all the way to the end. Yes, indeed. Dr. Brandon Mack is coming to London. I think it’s Feb, sixth and seventh, 2026. It’s in a central London location. Some of my friends such as Bal Sohal are flying Brandon into London to deliver a two day experience. They have given the Protruserati a discount code. As always, it’s protrusive and it’s gotta be with capital letters. I’ll just make it very clear that I do not have a financial interest in this at all. But having spoken to Brandon today, I’m sure you enjoyed his appeal and his energy. I think there’s a lot we can learn from him. So if you’re interested in this event in February, head over to protrusive.co.uk/returnofthemack. That’s protrusive.co.uk/returnofthemack. Mac we’re spelling MACK ’cause that’s his name. I’ll put that in the show notes of course. And this episode was eligible for CE or CPD. We are a PACE approved education provider. Answer the questions, get 80%. Look, you’ve done all the hard work. You’ve listened to an hour of dentistry, you deserve a CE credit and the only place to get that is on the Protrusive Guidance app. If you haven’t got an account yet, head over to your web browser. Go to protrusive app. And you get to choose a paid plan that suits you best. If all you ever do is listen to the podcast, you’re gonna rack up 40, 50 hours of CE every year just from listening to our weekly podcasts. And we have a plan for you. If you want a bit more than that, and actually watch all our clinical walkthroughs and premium clinical videos and masterclasses and the live monthly webinar that we do, that you get CPD for. Then we have a package for you as well. It’s all tax deductible, of course. And as far as education’s concerned, it’s one of the best value dental education subscriptions out there. So if you want the full fat experience, head over to protrusive.co.uk/ultimate and join the nicest and geekiest community of dentists in the world. As always, I wanna thank Team Protrusive for all their hard work behind the scenes. Some of the recent infographics we’ve been making are absolutely killer. We share them in our email list, we share them on Instagram, but the number one place to check them out are on the Protrusive Vault. And again, that’s on the app. And so with that, I’ll catch you same time, same place next week. Bye for now.

We use articulators to help ‘mimic’ our patient’s jaw movements, to ultimately do less adjustments/revisions in the future. But are digital articulators there yet? Or is analog king? Or is digital dentistry just flashy tech with no real-world benefits? Can a virtual articulator truly match the movements of your patient’s jaw? Is a CBCT really better than a facebow—and WHEN should you use which? In this cutting-edge episode with Dr. Seth Atkins, we dive into the world of digital articulation—exploring how tools like virtual articulators, CBCT alignment, and 3D-printed provisionals are transforming clinical workflows. You’ll learn how to combine analog wisdom with digital precision, improve lab communication, and make full-mouth rehabs more predictable and efficient than ever. From mounting accuracy to motion capture, this episode is your ultimate guide to articulating smarter in the digital age. https://www.youtube.com/watch?v=fT31Ecf_kDo Watch PDP230 on YouTube Protrusive Dental Pearl: Always send your lab the color version of your digital scan — the PLY file — not just the STL. STL shows shape, but PLY shows color — like markings and tissue detail. Ask your lab: “Are you seeing color, or do you need the PLY?” Better scans = better results Need to Read it? Check out the Full Episode Transcript below! Key Takeaways: Digital methods can enhance accuracy and patient outcomes → but only when used intentionally. Understanding both analog and digital techniques is crucial → they complement each other, not compete. Mentorship plays a significant role in advancing dental education → experience accelerates clinical confidence. Digital workflows can significantly reduce chair time → and improve patient comfort in the process. The integration of CBCT with digital workflows enhances diagnostics → giving clearer insight into static and functional relationships. Digital provisionals offer a cost-effective and efficient solution → saving time, money, and frustration for both dentist and patient. Axiography is essential for capturing patient motion accurately → because real movement matters more than assumptions. Highlights of the Episode: 00:00 Introduction 04:00  Protrusive Dental Pearl 05:32 Interview with Dr. Seth Atkins and his Journey into Digital Dentistry 08:06 The Evolution of Digital Articulation 13:38 Digital Workflow and Mentorship 20:01 Accuracy and Efficiency in Digital Dentistry 22:32 Static and Dynamic Relations in Digital Dentistry 31:01 Interjection 1 36:05 Practical Guidelines on Integrating CBCT 37:15 Interjection 2  40:59 Clinical Observations in Dental Rehabilitation 42:29 Interjection 3  45:21 Introduction to Axiography 46:40 Advancements in Digital Dentistry 49:33 3D Printing in Dental Practice 53:31 Motion Tracking on Digital Articulators 57:30 Cost Efficiency of Digital Tools 01:01:10 Alternatives to CBCT 01:05:52 Involvement with AES and Future Plans Check out the study mentioned: “Comparison of the accuracy of a cone beam computed tomography-based virtual mounting technique with that of the conventional mounting technique using facebow” 🎓 Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES). 🗓️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician”  📍 February 18–19, 2026 · Chicago, Illinois Don’t miss Dr. Jaz Gulati and Dr. Mahmoud Ibrahim as featured speakers, presenting on “Occlusion Basics and Beyond.” If you loved this episode, be sure to watch Basics of 3D Printing, Milling and Digital Dentistry – PDP224 #PDPMainEpisodes #OcclusionTMDandSplints This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcome C – Maintenance and development of knowledge and skill within clinical practice. AGD Subject Code: 610 – Fixed Prosthodontics – Emerging techniques and technology Aim: To provide a comprehensive understanding of how digital articulators can enhance clinical workflows, improve occlusal precision, and minimize restorative complications through accurate static and dynamic articulation. Dentists will be able to: Differentiate between analog and digital articulation methods, including their benefits and limitations. Apply digital workflows to provisional restorations, improving efficiency, patient experience, and predictability. Recognize cost-saving and diagnostic advantages of digital design in restorative and full-arch treatment planning. Click below for full episode transcript: Teaser: I got into some of the digital things initially, more for selfish reasons. The key there is not necessarily digital for the sake of digital. It's how well can we do analog? Teaser:Do you think the new grad, the new generation coming through, all they’ll ever know is digital, is that a bad thing or is that a good thing? Yes, and the reason I say that is I think it’s the correct answer for both. Yes, bad and good. Are you at any point picking up your analog facebow and then working on analog articulators to wax up, or have you got to a point now whereby the trust and the faith you have in your digital workflow means that you can do it fully digitally? The biggest thing that a lot of people don’t understand is-  Jaz’s Introduction:Analog versus Digital. Are we there yet? How on earth does a digital articulator work and what’s the point? And are there any real advantages to the digital workflow other than it looking cool and pretty on the screen? Can it help you be more efficient, more accurate, more predictable? We’re gonna cover all those things with our guest today, Dr. Seth Atkins. I tell you, this guy is a wiz. He’s part of the organizing committee of the AES, that’s American Equilibration Society, and this is part of the AES takeover. We are promoting the AES 2026 conference, which has got some of the biggest names in occlusion, comprehensive dentistry and TMD over two days in Chicago. The date is 18th and 19th of February, 2026, and it’s called the Evolution of the Oral Physician. The lineup, I tell you, is absolutely phenomenal, and also it’s a privilege to be one of the speakers alongside Mahmoud Ibrahim. We have the 8:00 AM slot on Thursday 19th of February, so it’d be great to see as many of you there as possible. Hello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Let’s talk about digital articulators. Now, let’s go back to basics for our students and younger colleagues. The whole point of an articulator is that we can mimic the patient on the table because we can’t take the patient home with us and design the restoration in the mouth. And then fit it the next day. We have always needed a way to mimic the patient, mimic their head, mimic their movements, mimic their bite so that we can work on the benchtop. So the analog way was to use a face bow and then feed that face bow into something like a semi adjustable articulator. Now what you see on the articulator, this analog articulate in front of you, we’re hoping is somewhat representative of your actual real patient, so that when you design the cuspal inclines of the molar, let’s say that you are restoring that when you put it in the mouth. And the patient then moves left and right, it happens, so in the same way as it did on the articulator. The ultimate benefit of that is less adjustments, more accuracy, and ensuring that the design that you intended actually works in the patient’s mouth. Now, when you talk about comprehensive dentistry and doing more units, doing full mouth cases, you can appreciate how important it is to replicate the patient. And let me tell you, this episode is all about digital. We are moving away from analog facebow and analog articulators. Now you’ll see how Seth explains why we can never probably be fully a hundred percent digital in these big cases because the final stages still need to be analog because our patient, when we fit the crown in the mouth. That’s an analog process, so we still need some analog knowledge, but how can we harness the power of digital articulators? It’s a very exciting, very geeky episode, and I put a few interjections in there to help make it as tangible as possible so that our younger colleagues, our students, can also follow along. That’s always the mission of this podcast. I asked Seth how we are now transferring the patient to the digital articulator. So like I said, in the analog world, we use a face bow and we talk about the role of face bow, but then how do we actually now use a digital face bow, if you like, and then how do we ensure that the movements are as close as possible on the digital articulator? Dental PearlThe Protrusive Dental Pearl is one that was given to me by Dr. John Cranham. As you know, I attended his lecture recently in Copenhagen, all about occlusion, cosmetics and digital. And what he’s doing with digital is amazing. Just like Seth, the top tip that can help your lab technician is as well as when you send over the STL files to your lab, what they don’t get is the color. Very often the lab software, all they get is like the digital stone models. They don’t get to see the color models, they don’t get to see if there’s any ink on the teeth, i.e. articulating paper marks. And sometimes when it’s clear when you’re looking at a color scan. What’s gingiva and what’s tooth? Sometimes when you’re looking at it on stone, it’s difficult to tell. So the tip is to also ensure that they can see the color version of the model many times. This is with a .ply file. That’s a .ply file. So our scans are STL files. The color overlaying is a PLY file. So ask your lab, hey, are you seeing what I’m seeing? Are you seeing color? Or do I need to send you the PLY file? If anything, if it’s one thing that this tip allows you to do or encourage you to do is to have that conversation with your technician. Anytime we can have more of a conversation with our lab techs about our workflows, we are benefiting. We are growing because we depend so much on our lab techs. So my friends, get in touch with your lab. Ask about the PLY file. Do they have it already or do they need it? Because it can help them, it can give them additional data. Make sure you check out the link below to learn more from Dr. John Cranham and of course, how you can come to AES 2026. I’ll put all the links there. Let’s now join the main episode and I’ll catch you in the outro. Main Episode:Dr. Seth Atkins, welcome to the Protrusive Dental Podcast. Thanks for being up at this time in the US, whereabouts, since you’re in Texas, right?  [Seth]Yes, sir. That’s correct.  [Jaz]Well, it’s great to have you, my friend. I saw you, two years ago now at the AES. A wonderful presentation. You are a real whiz. You are a, I’m sure you get called all the time. You’re a real whiz with the whole digital stuff. And we’re excited to learn from you today. But Seth, I wanna start with more about you, my friend. Tell us about you as a dentist, a family man, a practice owner, your digital enthusiasm. [Seth]Absolutely. Yeah. I mean, honestly I got into some of the digital things initially more for selfish reasons. I practiced South of Dallas, Texas, about 30 minutes, and when I took over the practice, I guess 2013 or so, my kids were six and four. And we were blessed in the sense that the practice got busy. Things took off quickly, which was good. But the last thing I wanted to be doing was working up patients after hours. And during the day, you’re seeing patients, it’s hard to have time to do it. And yeah, I’d bring my wax at home, wax at the house. My wife would get mad so I’d make a mess. All these things. And it was tough to do, after the kids went to bed. And so originally I started looking at things really more just, how could I do this more efficiently? What can I do to streamline some of these things to make it easier to be more present with my family, hang out with the kids, and do all the things you wanna do as a father and a parent in those scenarios on it. And it kind of occurred to me that it’s a lot easier to do a lot of this on the computer. I can have a laptop at home, I can wax up on the screen, I can combine the photography, do all the things that we want to do digitally, and it’s a lot easier. You don’t have to carry the stuff back and forth, it expedites that quite a bit. And you kind of quickly learn, you gain a lot in efficiency in doing it. Not only cost-wise, but time-wise. And for me, that was huge, initially. Was lucky in the sense that I started scanning back in ’07, ’08, like as soon as I got out of dental school. And so I’ve had a long time learning the scans and the pitfalls and pros and cons, but it took me a good seven, eight years before I realized we’re not really doing anything with the scans. And we’ve reached this tipping point where I think the majority of clinicians are now scanning finally. But you really don’t get the return on the technology and the leverage you’ve got digitally until you start to do something with that data. And that was where- [Jaz]More than just printing the models. The next step, the next level like you did, but you did it so early. I mean, back then, were you a little bit like worried like, am am I doing the right thing? Am I sacrificing accuracy? Were you a little bit concerned at that point?  [Seth]Well, yeah, for sure. I mean, that’s always a concern, right? Even all the literature early on it was, digital is not as good. Analog has been the standard and over the last 10 to 15 years, we’ve seen that change dramatically. We’ve got a number of systematic reviews now showing digital is at least as accurate in some cases, especially on the articulation side, some other things. It’s the best representation of the patient by far. And that’s kind of been, I think the paradigm shift for many people is depending upon where you get your training, when you were trained, all those things. We’ve got some, maybe, I don’t wanna use the word bias, but legacy concepts that permeate. And we’ve always gotta be critical in reevaluating what is the current state, where are we at? And because the point of digital is not just to go digital. ‘Cause at the end of the day, everything digital ends up analog, right? ‘Cause we’ve gotta go back to the patient’s mouth. So the key there is not necessarily digital for the sake of digital, it’s how well can we do analog? And what’s kind of ironic with that is we’re reaching the point that digital, at least in certain arenas, does analog better than analog. And that’s kind of spot where your mind kinda goes, wait a minute, what’s going on? Like, where are we at with this? And I think that’s really the take home on all of it is, some of the things we looked at with the articulation, things were meant more to bridge the gap because you had this fear, right? If I went digital, how can I go back home? Am I stuck? How do I get out of the pool if I jump in the deep end? And the reality is, I think we’ve got the capability now to seamlessly go back and forth between analog and digital. And that gets rid of a lot of the hurdles for people. Because if you can go back home to what you’re used to at any point in the process, it makes it easier to try something. The nice thing with digital in a lot of ways is that once you’ve got the technology, it really doesn’t cost you much to try something. It’s kinda like a video game, right? I grew up as a kid playing games and if you’re gonna go fight the Bosch, you save the game right before you go fight them. So if you screw it up, you just turn it off, turn it back on, you’re right back where you were. And that’s the same thing with digital. If you wanna print something or design something and you’re at a spot where you’re kind of sketchy, if this is gonna work, save it and you try it. If it doesn’t work, you reevaluate. Go back and, you know, go back to the other methodologies on it.  [Jaz]So Seth, I was at a lecture by John Cranham in Copenhagen just last week, and it was about the cosmetic occlusion workflow and then how much of what he’s doing is digital like you, and he made an interesting point, which is very relevant to what you are saying about, okay, you can still go back to analog. But an interesting observation that John made is that nowadays with the new grads coming through, because they never got to or they don’t get to go and wax things up and mount an articulator. He was worried that when they go straight to digital, that they be missing out a huge chunk in education. They may be missing out in terms of the why or the foundations of it. But actually, he concluded that it’s not really a disadvantage at all because they get the concepts through digitally and for them they kind of bypass the whole analog and that’s not necessarily a weakness. What do you think about that? Do you think the new grad, the new generation coming through, all they’ll ever know is digital, is that a bad thing or is that a good thing? [Seth]Yes, and the reason I say that is I think it’s the correct answer for both. Yes. Bad and good. For a couple reasons with it. I think understanding where we came from is important because it lets us, from a chronology perspective see how things evolved. It also gives us the capability to evaluate is something new really better or is it just new? And I think if we don’t have that lens of being able to go back and reference that, that can be a problem. And then the other half of that I would answer is right now, except for a very, very small percentage of people, analog is how we do articulation. And if you don’t understand how we do things, the analog with the facebow, the articulator programming and it’s relative strengths and weaknesses, it doesn’t allow you to manage the miss and handle that instrument appropriately. And when I say that, ’cause we’ve always used the analog articulation and it was the best that we had, but it’s not a exact representation of the patient. And so if we don’t have the capability to be absolutely accurate, we need to understand and try to control our misses. And that was basically the strategy with how we program the articulator, how check bites work, even just all of those things with the analog instrument. And to understand that basis and where that came from, I think you’ve gotta have a little bit of the analog side of things. Now, fast forward 20 years when the technology is different, and we may have digital axiography and all these things being more ubiquitous, it may be a different ballgame because I think that’s the big debate that we look at now, is instead of resigning ourselves to a certain level of inaccuracy, can we shrink that error and make it where we’re really shooting to hit the bullseye as opposed to just being on one side of the dartboard or the other. And I think that’s really the next evolution and where things are going, but that’s also where things are developing currently. Maybe the state of the art is how do we handle that? How do we think differently? How do we design differently? How do we really try to build that in to be more efficient chairside doing it.  [Jaz]Well, you mentioned axiography and so from my younger colleagues. I’m gonna just get you to define that in a moment. But just one part of your journey, which I’d just love to know is two part actually. The role of mentors in you uptaking digital and really going for it. And also your source of education and comprehensive, because not every dentist is gonna think about going home and waxing up, right? It’s really you enter the stage of comprehensive dentistry. So tell us about your background in becoming a more comprehensive dentist and the role of mentorship that you may or may not have had when you were moving digital. [Seth]Absolutely. I mean, failure is a great motivator, right? And you get out and you see something and it doesn’t work, and you try to figure out why. And initially my goal for going more comprehensive was I didn’t like redoing things, and you don’t like disappointing patients, and you wanna try to give people the best that you can. And then, we realize when you graduate, the education’s kinda lacking in a sense. I don’t mean that to be despairing, but just they don’t have enough time in three or four years to cram in just even the basics, let alone trying to figure out bigger, comprehensive things. So I started going down the road initially of figuring out, there’s a lot I don’t know, and where do I start? So I went down, ideally a comprehensive pathway. I started with Spear kind of going through that continuum on it. In looking at it, going back, just the basic training, that’s where you started looking at the bigger picture. How do I need to understand joints? And I don’t know how the education is over there on the UK, but we spend maybe two hours talking about joints in dental school. It’s abysmal. And they just basically tell you if you suspect intracapsular issue refer, and when you start looking at patients, especially the ones that need restoration, the chances of having some issues at the joint level go up tremendously. Because in my experience, people with healthy joints structurally intact, joints, good anatomy, barring a couple of exceptions, really don’t thrash their teeth. And so we’ve got stability on the back end of the system, more on the posterior determinants that nobody talks about. And so, starting to understand failure, you look at, a Monday morning situation, you go to the office and patients fracture the distal lingual cusp of a lower second molar. You see the big wear facet, you see the cupping, your brain’s looking occlusally. Like, we have some issues here. We may not have vertical at the joint. Like we want all these things. And that’s the one that’s the frustration coming out, right? Your new grad clinician, you prepped the tooth, get everything ready. A team member comes back, I’ve got no room, I can’t make a temporary. And you know you did the reduction, you checked everything out, it’s like, what the heck? And you go back and reduce some more and you’re still outta room. You do some more and you’re still outta room. And now you’re thinking, do I need to talk to this patient about endo? What are we looking at? Because we’re running outta space to reduce. And these are all conversations that I would much rather have on the front end of the system or the front end than an excuse on the back. And so it was just the school of hard knocks a lot of ways trying to figure out, okay, why did I not catch this earlier? What can I do to try to make that better? And that’s what kind of got me started on it. And then the digital side was more initially from the scanning, just the practice builder. Just nobody likes impressions from the patient perspective. And so it was initially kind of a builder to say, all right, we can get you in and we can do the diagnostics and we can take the mold or whatever we need to do and not have to have that analog experience in doing it. And with that, that was probably my initial motivation to try to figure it out is if more patients are able to say, yes, we can help more people do more things, grow the office, all the good parts that come around that. But early on, scanning was tough. I mean, it really wasn’t accurate. At times, depending on when you did it, we didn’t understand the limitations of what the machines can and can’t do. And sometimes we’re trying to fit a round peg in a square hole in the sense that, that’s not the right modality to fix the problem that we’re going after. And I think even today, that’s where a lot of people run into issues, is we listen to the reps and who’s selling the scanners and oh yeah, you can do everything with it. There’s no limitations. And then you quickly find out it doesn’t always work like you want. And there wasn’t really a support system to help people troubleshoot that. You know, when I started doing a lot of the digital stuff, there was no manual in any of it. So we try something, I would go to lab groups and look at their forums and ask questions. And sometimes in Dentaltown may have it or just honestly Googling it, trying it, trying to figure out something that did it. And my background in college, I was initially electrical engineering and computer science. So I like technology, I like all these things.  [Jaz]It all makes sense now. Every podcast with a guest, I have a a click moment where they mention something in their journey and it’s just like, oh, that’s why he’s into this. That was your click moment for me.  [Seth]Okay. Yeah. And I got to third, fourth year university and I really liked interacting with people. I didn’t wanna write code behind a computer all day. And my younger brother who’s an oral surgeon, we were, nobody in our family was in healthcare. And my dad was like, well, what do you think you wanna do? He kind of thought dentistry or medicine, and he’s all right, well go volunteer in a bunch of offices during the summers, just sweep floors, pick up trash, just watch and see what you think you wanna gravitate to. So we went to all the different kinds of offices we could find, and dentistry kind of clicked for both of us. Just different specialties in doing it. But when you look at it, you see how things work and you see the workflows and you see the inefficiencies. And that’s when it kind of started putting together, at least in my head. Okay, some of these digital things offer an opportunity and if we can implement them correctly and kind of put together a framework that allows us to do that predictably, I think that’s when it really takes off. And I think that’s what you started to really see the last five to 10 years is a lot of the wrinkles that get worked out. People have beat their head against the wall, figuring out the initial hurdles, and then that makes life easier for everybody else. If you’re willing to share and say, here’s how we did it, this is what I would avoid. How do we move forward with something in a framework that’s much easier to implement on it? And that’s really kind of what got me into it, is I was willing to play with things and check it out initially, and that allowed me to have the experience to share it with other people. Okay. If I was starting today, here’s how we do this. Where would I implement, what would I pick, what order, kind of all those things to make that a much less of a headache, putting it in and actually a benefit for the practice. [Jaz]Well, as we evolve this discussion now, I think the first thing I wanna know from you is, are you fully digital now? Let’s say you have a wear case. Are you at any point picking up your analog facebow and then working on analog articulators to wax up? Or have you got to a point now whereby the trust and the faith you have in your digital workflow, it means that you can do it fully digitally? [Seth]Fully digitally for I’d say 99% of it. Now, we’ve got some capabilities now where we bring the mounted models based off the CBCT positioning on an analog instrument, but that’s mainly for the lab to finish the final restorations. And you know, because like I said, the whole point of digital is to go analog. So we’ve gotta go back at some point. And that was one of the main hiccups is you’ve got these unmounted models and you could check contacts and things, but when they wanna do the final finishing, if they stain and glaze and all the little hand touches that they put on, we really didn’t have a good way to evaluate all that. And that’s where, we came up with the jigs and the ability to basically add attachments to the printed models that precisely replicate the position on the analog instrument that we had on the digital instrument. And that gives us a number of options we didn’t have in the past. So now predominantly for the lab to check, but early on before we had the trust, it was more to give us the capability to go back and forth when we need to. And the biggest thing that a lot of people don’t understand is whether you’re taking an analog impression or sending a digital scan at a lab, you’re probably digital either way. And the reason I say that is what is the lab doing? They’re scanning your model, the models that they make, virtually designing and waxing everything and then bringing that to you at the end of the day. And so, that was kind of initially the knock on digital was, it’s not accurate, all these things. And then people didn’t realize you’re digital regardless. You just don’t know it yet because it’s such a small percentage of labs now that are hand waxing, hand investing, doing all those things. And they realize the efficiencies that we gain doing it a long time ago, and they’re doing it at scale because they’ve got more restorations, more clients, they see more things that we’re gonna see as individual clinicians on a daily basis. And then the next reason that we did that predominantly was, if you send your scan to the lab or you’re just sending impressions in a facebow with no check bites, ask the lab how they’re programming your articulator. And if you don’t know the answer to that question, I think it’s a worthwhile. Path to go down. Because the reality is we’re giving the labs many times, part of what they need. We can give them some information to help with the static relation. But when you do an articulation, there’s two types. So you have your static, which is your relation, the maxilla to the hinge axis, but you also have your dynamic relation. That’s your programming on it. And before we had the digital axiography, the patient motion, the mod jaws, that kind of thing, we didn’t really have any good ways to derive the programming values for the dynamic side with a digital scan. They had some programs.  [Jaz]So, to clarify, talking about the condylar guidance on the articulator and-  [Seth]Correct. Because you think with analog instrument, you take check bites, right? Take your protrusive bites or your lateral check bites. When we had our mounted model, you would put those check bytes on and that’s how you program the po, the back end of the articulator doing it digitally. And my argument is the most compelling reason to go digital, quite frankly, is the virtual articulator because it’s got many more or much more capability to replicate patient anatomy than the analog. But what was simultaneously, I think is potentially its biggest strength was also initially the biggest weakness. And that the virtual articulator was great, but you had no way to program it. And because of that, it wasn’t really useful. And for a long time, even with the design softwares, ExoCAD three shape, those kind of things, labs weren’t even buying the articulation module. They would just have it purely as a clap clap type scenario because they didn’t have a way to program. And the reality with that is, and when I started looking at the softwares kind of playing with all this stuff, I quickly realized we need to know what the inputs are and what it’s capable of as clinicians, because it’s really more designed for us in the lab. Once you realize that, and I said, oh, if I give you X, Y, and Z to my technician, they can execute at a much higher level because we’re giving them better input. And that was really what kind of started me thinking, okay, how do we drive these values? How do we give the lab what they need to execute at the highest level possible? And once that happens, you start to collaborate more. You realize some of the synergies and the software, your collaboration on design goes up to another level. Because we’re no longer like taking snapshots and emailing pictures. They can send me the entire scene file, I can go through the software, change the wax up, manipulate it, do all these things in real time, and it’s much more efficient and it gives me the capability to visualize the case much more efficiently on it. You know, because really with digital, the advantage lies in twofolds. Computers are very good at aligning things and they’re also give us the capability to combine different records that aren’t able to do that we can’t do in the analog world. So that’s why you can stitch like your CT to your intraoral scans, to your face scans, your photography, and it gives us the capability to layer the patient from a diagnostic perspective. And that’s something that analog, you can’t take a pano, combine it with your CT or your articulator. They’re all different media and because of that, we lack the ability to cross over.  [Jaz]That’s what excites me the most, Seth, I mean, just that stack is just phenomenal. I’m not there yet, but in my journey, that’s what excites me the most. The fact that the capability to layer, just like you said is phenomenal. What I wanna draw now is some, some ideas for those most dentists who may be listening right now are probably analog, right? For this part. They may be scanning, but when they have a comprehensive case and they wanna do kind of a wax up, they’ll then be getting their face bow out. And the ultimate goal is to try and get the movements that you see on the screen to be somewhat identical is a strong word, but similar to the real movements that you have in the mouth. We all know the TMJ is the best articulator, but when the mandible, the digital mandible moves to the left, it moves in the same way that the patient’s mandible moves. So now that you’re using a digital workflow, please explain, instead of using a analog facebow or an ear bow, what are we using to capture the relationship of the maxilla to the condyle? How are we doing that digitally so that we can actually, get represented cans and whatnot on the digital articulator? [Seth]Sure. Well, and there’s a couple different ways to accomplish that. When we talk about, you know, ’cause you’re asking about static relation there, which is gonna be the first part of the articulation, the mounting side. And when we talk about static relation, it comes in two flavors. We’ve got an anatomic relation, which is purely relating condyles to the hinge axis. Then many times we’ve got an aesthetic relation, which is relating things to the horizon, and those are both important because they allow us to do different things. The patient, if you’re trying to get the instrument to mimic the patient anatomy as best you can, you ideally want an anatomical relation, right? Because we want to get things as close as possible to the anatomy. But with their technicians, many times we send ’em a scan and that’s all they see. They don’t really know where the horizon is, they don’t know where the cant is. We’ve gotta give them more information to capture that and that’s where the aesthetic relation comes in. You know, Dr. Kois did a lot of work with the Kois boat and it’s not necessarily, it’s an average value relation anatomically, but what it does to do is correct the cants so that you can wax in a way that gives us aesthetic results that are coherent with facial anatomy and what we’re looking at from that perspective. Interjection:Hello again guys. Another interjection for this episode, Kois Bow. What is Kois Bow? It’s named after the legend, John Kois. And I try to like find some visuals or clips for those who are watching. Obviously for those who are listening, I’ll make sure you can follow along. But I have to tell you that the video I found is like it needs an update. Maybe I didn’t look properly, but the video is from John Kois and it’s like from a long time ago, and we know it was uploaded 12 years ago, but it looks like it’s from a lot longer. And it literally looks like someone is doing like a facebow transfer or a facebow recording on what someone who looks like John Travolta basically. And that’s what I’m seeing at the moment. And so essentially, you know that fox’s guide plane we used to use for like dentures, right? Complete dentures. You get that fox’s guide plane, make sure the cant is good. You look from the front and then you check the occlusal plane from the side. Well, it kind of is what a Kois Bow is like. It’s actually properly called the Kois’ Dento-Facial Analyzer. And you don’t need like a traditional face bow if you’re using this. But the real advantage of this is that how it prioritizes the aesthetics, because you’re looking from the front, you’re making sure it’s all level with the eyes and you’re looking from the back and you can use an aesthetic plane. So you truly are using the aesthetic relation rather than the anatomic relation. And now in combination with the Kois reference classes, the Kois group are really taking this to the next level. So this led the ideal of using the aesthetic reference back to the episode. [Seth]We did that with the ear bow for a long time. And we’ve got a lot of literature with the regular face bow that on a good day it’s gonna get us within five millimeters of the true hinge axis, which sounds like, okay, we’re pretty close in doing it. But now that we’ve got this digital data and more things at our disposal, many times now we’re using a CT initially to do that hinge access relation and it makes sense. ‘Cause you know, the facebow, the whole point’s to capture the maxilla relative to the condyles. If you have a CT of adequate volume, you’ve got the condyles, you’ve got the maxilla. If you take that scan in a seated position, all the anatomy is there that you need for the relation. So how I’m doing that today in the digital side, if we’re not doing axiography, and I’ll kind of get off on the nuance of that in a second. You’re aligning an intraoral scan to your CBCT, and then once you do that in the software, you can move them as one cohesive unit. So then I’m overlaying that on the virtual articulator and you just position the condyles of the patient over the articulator condyles, rotate it till you- intraoral planes parallel to the upper member. You’ve got all the information you need done with it related now that’s gonna give you.  [Jaz]That’s the ultimate then. Using the CBCT to use, essentially got the skull of the patient, the maxilla, and you are manipulating the articulator relative to that. And you can see the condyles. There’s no guesswork. That’s amazing. And so that is, would you say the most accurate, is that what the evidence is saying as well?  [Seth]So we’ve got literature now. There’s a paper that was just released that was interesting. They were comparing clinicians and they were given a multiple trials, I think it was 15 times for each clinician and they, versus an analog facebow positioning it. On a reference model and then translating that to the analog instrument and then doing the same thing with the CT and aligning the scans and transitioning. Once they did it, they scanned the final mountings on both and overlaid all of them to get an idea of how repeatable is each one, and also how close to the hinge axis of the analog of the reference instrument. The final results were. And what they found is they confirmed with the ear bow still five millimeters, it was like 5.2 millimeters plus or minus two. What was interesting is that you had better repeatability and closer to the actual anatomy doing it with the ct. So they found that the rare, there was only two and a half millimeters plus or tip minus a little. So they cut the variance from the hinge axis in half doing it on the digital side already. And I’ve got that article. I can’t remember if it’s pre-press or it was just published in JPD, but it’s interesting ’cause we’ve already cut our error in half. Just going through that method with it. It’s also something that’s easier to store because you don’t have to worry about, if you take your facebow records, some people don’t wanna mount it in office, they wanna send it to the lab. It gets beat up, distorted in the process, the wax melts. I mean, any of the things that go into potential sources of air and doing it. And that’s one of the other nice parts on the digital side is record storage becomes much easier. That record on the CT, if we align, it’s gonna be equally as accurate 10 years from now as it is right now. And not that you would need it that far down the road, but it gives us the capability to keep things on hand, replicate things with a higher level of accuracy. And it makes that aspect from the maintenance side much easier to do. And so CT, if I’m on that respect, I think already is cutting the air in half. Now I know sometimes you can’t get the CT and then there’s concerns on your radiographic exposure, things like that. And many times if I have a reason to get it, that’s where I’m using that as well as kind of an ancillary benefit. But the other part we talked about was the patient motion, and you’ve got ways that you can do the articulation now that don’t require-  [Jaz]Before we get to the articulation, ’cause I’m really enjoying this bit on the static relationship. You raise an interesting point there about the radiation, right? So I think where I’m getting from you is that if the sole reason for the CBCT is to help you align it on the digital articulator, then that’s probably unjustifiable or justifiable. But if you’re also applying some implants, you might as well just get a bigger field of, you get the condyles in and for that sake, a little bit more radiation. You’re getting a better programming. Can you just give us some clear guidelines on what you are practicing?  [Seth]Sure. Well, let me maybe backtrack just a little for reference. So, we talked about allowing the CT, the intraoral scan in overlaying that on the virtual instrument. And the virtual instrument is a carbon copy of the analog. Everything is identical. Same programming inputs, same dimensions. They move the same if you have models in the same positions with the same programming. So in a sense, interchangeable in that regard. And when I started overlaying scans of patients on the instruments, you very quickly realize they don’t match very well. And that was kind of a light bulb moment for me. If you look at the semi adjustable instrument, at most, every intercondylar distance is set at 110 millimeters and you start to unpack where did that number even come from?  Interjection:Hey guys, it’s Jaz with interjection number two. semi-adjustable articulators, okay. Briefly, right, that 110 millimeter value is from like one condyle on the articulator to the other, condyle on the articulator. And this is where some inaccuracy comes from. ‘Cause you know, if you look at the average person, fine, they might be close enough. But we have a huge variation, lots big heads, small heads. And so this is a source of error and just getting very primitive for the function of a semi adjustable articulator is that its purpose is to replicate the mouth. So when you’re doing a wax up on the articulator and they transfer it to the mouth, we hope that because you use an articulator to create the jaw movements, that it will be similar in the mouth, therefore, least adjustments as possible. But we all know the best articulator is the TMJ. And now obviously this episode’s all about digital articulators, which will eventually fully replace these physical articulators. But when you understand things like this fixed distance of 110 millimeters, or the fact that in a semi adjustment articulator you can change the condylar guidance angle to help improve your accuracy, these are some things that we should know about analog articulators. Back to the episode.  [Seth]It was kind of an artifact originally on the Lee panographs that were courting elements on those back when they were doing the old school fully adjustables were at 110 millimeters. So when they moved it over to try to make the analog instrument match the patient tracings, they put the condylar heads at the same width so that they could make sure the movements were one-to-one in doing it. What’s interesting is you start looking at actual patient anatomy. Nobody’s at 110, and I’m talking even at the lateral poles. Generally, if I’m doing my virtual articulations for splints and things, I’ll measure from the midpoint of each condyle ’cause I think that’s kind of probably the middle of the road. If you take in a heat map of activity with lateral and rotational movements, it’s probably somewhere in the middle. But even then, on a lot of patients that need restoration, the articulator at 110, they’re at 75, 80, 82. And you start thinking, okay, you got 30 millimeters of shift. When you start to model that digitally, it’s interesting. So you can take a model on an articulator. Have the 1/1oth intercondylar distance and if you’re measuring the distance from each condyle to like midpoint between the maxillary centrals, changing the intercondylar distance to correct it to let’s just say from 110 to 80 will shift that link to the central seven or eight millimeters on each side. And so what initially got me looking a lot of this is, yeah, I’ve got a practice that we’ve got a fairly heavy joint based diagnostic component to it. And so I see a lot of patients with compromised joint anatomy and invariably we make these patients appliances at times to see if we can change the load at the joint level to facilitate adaptation and healing as best as we can before ruling out surgical intervention, those kind of things. And I would go through the same process in every patient, take your ear bow, facebow, get everything done, have a splint made. And sometimes the splints were 20, 30 minutes easy for like a flat plane group function appliance. Other times it was an hour and a half and I’m like, what’s the difference why are some of these so much faster than others and you start trying to investigate that. ‘Cause initially you think, okay, the lab screwed it up. I’m gonna do it all myself. Started making ’em myself. Same thing, same variability. It wasn’t until I started overlaying these scans on the articulator and comparing the patient anatomy to our instrument that I realized some match better than others. Some are more average than others. And the patients that were a better match to the analog instrument, the adjustment times were lower. The ones that varied more, we were working with poor data on the input, which is makes perfect sense while the output doesn’t match. And we see the same thing clinically. There’s times, you’re doing a rehab and you insert it and you’ve got minimal adjustments, and then you’ve got the other, where it looks great on the analog instrument or the articulator, but you go to the mouth and the guidance isn’t right and you’ve gotta go in and grind a bunch of things. And we’re getting a more compelling body of literature that there’s not a single restorative material on the planet that benefits from adjustment. [Jaz]That’s very true.  [Seth]And with zirconia especially, if you sue on them, had some date, literature out that the minute you touch it with a bur, if we don’t refire it, we’re losing 50% of the strength. Then they probably, if we’re not firing it to heal ’em and maybe 1% of people are re firing everything after adjustment. It just doesn’t make sense from a practicality perspective. So all these benefits that we’re seeing with zirconia being the strongest material and all these things, you take half the strength away, we’re below Emax immediately. And you start wondering, okay, maybe that’s why we’re seeing some failures in certain places we didn’t expect. And there’s a number of factors that play into that. But the take home there was many patients don’t match our instrument. And especially the ones that I see that need more comprehensive restoration, when the joints aren’t structurally intact, the growth gets to be altered and you lack projection. They end up being class two. It’s the same difference in orthodontic practice. 80% of ortho patients are class two. And the reason is the back end’s not growing like it should, which leads to compromises on the tooth position, on the front end of the system.  Interjection:Hello, Protruserati. Jaz here with some injections, right? So this episode, because it’s about occlusion, because it’s about our articulators, we need some interjections just to make sure everything’s really tangible. So the point Seth is making here is that many class two patients, class two, meaning, large overjet classically in a class two div one. But if you think about the causes of a skeletal class two, well, it’s either that the maxilla is too big or it’s the mandible that’s too small. That will create you a class two skeletal pattern. And so what Seth is saying, and he is totally right, is that the main cause of class two is that the mandible is too small. Not necessarily that the maxim is too big, but the mandible is too small, it’s too set back. It is retrognathic in nature. It’s smaller and set back in nature. And, and the final distinction here is he said poor posterior growth. And what he is referring to is the condylar growth and the health of the TMJs. So someone who does a really good job of talking about this is Dr. Jim McKee. Jim’s a previous guest on the podcast, Jim McKee, came on the podcast before, talked about piper classification, but he’s brilliant at talking about this stuff. And essentially if you have a destruction in your TMJ, in your growth years, during childhood, during teenage years, then that condyle and that posterior mandible will not develop normally. If that doesn’t develop normally, then that will contribute to a class two because it’ll make your mandible deficient. So just making that important distinction. Once again, if you’re enjoying these and these are helpful, please comment, let me know. The last few times I’ve done this, everyone’s been saying good things generally, and so we’re kind of keeping it in the podcast, but there’s still time to say, no Jaz, this is not good, so you gotta let me know. Back to the ep.  [Seth]My wheel spinning on that was, okay, how do we make things better match the patient? Because at the end of the day, that’s the goal. Legacy concepts, if you look at how we did things, it was more about making our patient fit an analog instrument. It’s a fine point, but instead of making the instrument fit the patient, we are making the patient fit the instrument and trying to control where the screw up was. And I think that’s where I was kind of alluding earlier that I think is the biggest difference we’re going to see is we’re switching the order now. We’re actually truly trying to make what we’re doing digitally truly match the patient as opposed to forcing them into a box that they may or may not conform to. [Jaz]So with the digital articulator, then that intercondylar distance, can you just simply just plus, plus, plus minus, minus, minus, and change that seamlessly?  [Seth]So on some, yes. Some programs, yes. Some you can. Others you gotta be a little more adventurous and maybe go into the code and tweak it. Like ExoCAD does it let you do it off the rack. But there are ways to go about it, but the digital axiography side overcomes that limitation as well.  [Jaz]So tell us, what is axiography tell us the definition. What is axiography?  [Seth]Sure. Yeah. So initially in the analog world, it came from the fully adjustable articulators where they would go in and they had an apparatus that went on the face that attached to the lower jaw. And as it moved, it made physical tracings on paper, on recording elements. And that’s how they use that to program the analog instrument. They would use that to find a hinge axis and you could actually change all the parameters on the D5A Denar and some of the old, fully adjustable articulators. And it was a great way to match the patient as best we could, but it was cumbersome. It took a lot of time and it a lot of effort. And what they found was most people weren’t gonna do it. So we started going then to semi adjustable where you only have a few things to input, but you try to manage the miss so that the analog instrument is designed to, as a general rule, be flatter than the patient’s anatomy. And that’s a benefit, right? Because if the instrument’s flatter as we grind everything in the accessory, cus pipes are shorter. So when you go to the mouth, you have a steeper disclusion, you don’t have interferences. And that works great if we’re trying to execute canine guidance where you only need to have one plane steeper than the others and things come apart. But when we start having to do these progressive group functions and other things where patients may need more support at a joint level, it gets a lot harder to accomplish. So what we started looking at on the digital side is we’ve got ways now to capture all that data much more seamlessly. And these would be like Zebris or Mod Jaw or the different, you know, digital axiography or sometimes term patient motion that you see. And what it really is, honestly, it’s a high speed camera that sits in front of the patient. There’s reflectors that are fiducials that get attached to the lower arch. And as the patient moves, the camera’s just purely articulating and capturing those movements at very high resolution relative to a tiara they wear that gives you the reflectors for that upper arch. And once you have this data, it can be brought in seamlessly into your design software, like ExoCAD or 3Shape, and it comes in fully mounted. The articulator gives you programming, so you’ve got all your programming already done. And where it overcomes the analog, the virtual limitations is you actually have the movement on the screen. So I can take you through protrusive closest speaking space, left and right, para function. You can even have the patient chew and eat and masticate. And what you start to see is, articulators mainly on the bench work inside out. You start it static and you go into discursive this way. Where the form really meets function is when patients chew. They’re not starting in and going out. They’re coming out on return stroke in, and there’s a lot more variability and a different dynamic to that than we’re used to thinking about. And because of that, that’s just data we weren’t able to capture ’cause you can’t replicate on analog instrument, any of that. Where we now, when we start to see it digitally, one of my preferred workflows now in any case is we virtually wax the case up ahead of time. We go to prep. And when we’re doing our provisionals, I’m not relining provisionals or doing shells or doing full arches anymore, we’re virtually combining our definitive prep scans with the virtual wax up and 3D printing. The provisional is fully contoured. So everything is two year definitive margins. There’s no reline. It allows us to do like full arches of single units now, which is huge for hygiene staging. It makes life so much easier ’cause now you know, if you’ve got a full arch maxillary restoration or provisional. The worst call you get is Ms. Jones calls one of ’em chipped. Okay? Which, where? Where did it break? What do we gotta do? There’s nothing more inefficient to try to patch or take off a full arch provisional. Doing it as individual units is massive because now which one chipped number five. I can have number five reprinted before the patient gets the office. The characterization is done. We verify that the scan was accurate initially when we did it. So I mean, I hardly even have to see the patient. We can go in. Assistant can see the provisional, make sure everything’s good. I’ll come in, double check the bite, figure out what went wrong. And it’s just a huge time savings doing it. [Jaz]And these 3D printed provisionals are like a temp bond, placed in. Is that how you’re doing it, like temporary cement and then you are giving some time for adaptation and checking whether you are happy that the patient’s TMJ is articulating as you planned for everything in the design stage? [Seth]Yeah. Generally, I like Duralon for the 3D printed provisionals just because I think I’ve had better success with that, but just from a long-term maintenance perspective on it. But exactly that. And it gives you the capability to one, verify everything, right? Especially on the aesthetic side. Do we like the tooth form? Do we like the shape, do we, is function what we want it to be? And even though you can plan everything digitally, I feel very to very high level. The patient articulator is always the final judge. And because of that, I still always want to give them some time to evaluate and check and make sure we’re on a path that we like. I also like it from a phasing perspective because, I mean, that’s the biggest issue that we see a lot of times is, if a patient is of more modest means, affording a full arch at once can be very tough. And so it gives us the capability to phase cases differently. So as opposed to, let’s just say they’re in an insurance environment, they can do two crowns a year. We can initially get the case stable with the 3D printed provisionals, get everything where we wanted as individual units. Well you’ve already got a fully designed crown, you’ve already got your master scan, your margins are done, everything’s done. I don’t need to bring that patient back in to prep and press two crowns a year. I can send those to the lab, have them turn it to our definitive material, bring the patient in, pop those two off, put the provisional, their definitives on a ceramic. They’re not having to come back to the office to repress, they’re not having to do any of those things. So now my chairside efficiency goes dramatically in doing it. I also like it because it’s easier to maintain those patients ’cause if you wanted to maintain a phase a case over two or three years. If you’re doing it splinted, you worry about hygiene, you worry about can they get in there to clean all the different things. As well as, two years is a long time to trust any provision without something going wrong. And going in and remaking a full arch provisional could be three, four hours by the time you get it off, clean it up, have everything redone. Now it’s literal 20 minute visits ’cause you know, individual, which unit broke you can accommodate for all that. And the next objection or question that sometimes gets asked is, well what if they wear change over time? Well if that happens, you just bring the patient in and re-scan for the occlusal changes. The lab can combine that seamlessly without having to redo all the other parts. And you can adapt very quickly to anything that happens when you do it. And that’s probably, honestly my best part of doing this digital now is I really don’t, it’s taken a lot of the stress off full arch provisionals, bigger case temporization, and even the stress on my body doing it. ‘Cause now a lot of times we’ll do in demand design with my lab technician. So if I’m gonna prep the maxillary arch at eight, I may tell them to definitive scan by 10:30 or 11. I send the scan off, the wax ups done. I can go have a coffee, hang out, take a break. My designer will virtually combine the two 30, 40 minutes later, all the files go to my inbox, drop ’em on the printer. It’s a 15 minute print, 20 minutes to characterize, which I can have my team do that in the back and I’ll come back 30, 40 minutes later to see all of ’em when we do it. And so, huge difference. And you could go see another patient if you wanted to. I prefer to sit and take a break and I don’t, prepping is tough. And it, and to me, if you want an argument on why to go digital doing it, that’s it. I mean, it’s huge and not that you yet necessarily have to start at the full arch level. Take the scenario where a patient comes in, they chomp down number 19 and shattered existing crown. So you’ve got no crown, new patient, no matrix. And that’s always a time consuming deal, right? Because you’ve gotta figure out, okay, did I put a stainless steel crown on and take a matrix? How do I get something to make a provisional crown for this patient? Well do it digitally. Get everything prepped, get everything where you want it. Pack your core, take your definitive scan. You can virtually wax the tooth up in two minutes, put it on the printer like the Midas now from SprintRay, you know, seven minute print and then five minutes post-processing and you’re ready to go. I mean huge efficiency perspective.  [Jaz]I mean this concept of putting your cord in and scanning for the definitive has so many advantages. Like you said, I mean, I guess there was a phase where people might have been doing the rough prep, then putting temps on it and then going back and refining it. I mean, what a service to our patients, not only just time, but comfort. This whole digital workload you described really is fantastic. But one thing we touched on was yes, getting the static right, and then we touched on axiography, and you mentioned about motion collection. But in terms of actually the articulation, what are you currently using? You described all these, I mean, are you using a module at the moment? How can we make sure that when you put it on the digital articulator, yes, you’ve got your CBCT and the condyle and you’ve lined that all up to give you sort the best idea. You’ve got the cancel correct, but now the actual motion, what metrics are you using or what can we be recording chair side to make sure that the kind of checks that we have so that when you move the mandible on the screen, it’s like the patient moves.  [Seth]So two ways of looking at it, one is we try to match the patient precisely, and that’s where I think you’ve gotta have the digital ay side of it, just because there’s no way to capture those movements, mod jaw, debris, any of those that allow you to capture. The other is we get the better static relation using the CT. So we’ve got a better initial starting position, but we still have to use analog check bites. That’s the only other way to derive those values. And the way that we would do that is we’ve gotta get the model in the identical position on the analog and the virtual instrument. So if I’m not using Mod Jaw on these scenarios, what I would do is take my CT, align that to the analog instrument and my project, a few years ago I was working with AD two, which is an articulator company. It actually came out of AES. it was maybe four or five years ago at AES and I was taking a break walking through the vendors and Dave who owns AD 2, was at the booth. I saw he had a jig in the back. It was kind of, one of the jigs for putting a printed model on an analog instrument. It was kind of more akin to what Dr. Kois and them were doing with their analog jig, with their average value jigs that they had. And we started talking shop a little bit and I said, if you figured out how to position the jig coordinates, where it loads relative to the virtual instrument as opposed to the model. And that was what I was working with ’cause initially I like ExoCAD for doing a lot of this, but ExoCAD has a different global coordinate positioning system than 3Shape does. Where 3Shape positions, everything relative to your scan. ExoCAD has a global positioning relative just to that reference. And that sounds like we’re off in the weeds, but the significance of that is I was able to encode the positioning of a virtual attachment in ExoCAD. Not relative to the scan, but relative to the articulator. So when you add this virtual attachment, it loads in the same position relative to the virtual instrument, not the model. So the benefit of that is when you use the CT to position the model, the attachment loads relative to the articulator. So as long as they intersect, when we print those as one unit, it puts it in the identical position on the analog instrument with the same jig.  [Jaz]So you don’t need to get the mounting stone and that kind of stuff, right? [Seth]No, never that. Exactly. And what that allows you to do is, we talked earlier, we have the same programming, same dimensions, same instruments. If the models are the same in both, I can now take my check bites on the analog instrument. So take your protrusive bites, take your lateral bites program, the analog, and I can plug those values directly back into the digital. So now we’ve got the dynamic movement programmed without having to guess. The downside to that is we’re still resigned to the same miss, right? Because the analog instrument can’t precisely replicate the movements. So we’re gonna have accurate programming on the analog to give us the flatter movements, the things we’re desiring, but it’s not going to be the highest level of replication of the patient. And so, depending on where you’re at in the process and the adoption, and to be clear, yeah, if somebody was asking me today, what order do I get these things in? The motion side is the absolute last thing you need. You need to be scanning, you need to be comfortable with the software, you need to be 3D printing all those things. Because if you don’t have those tools in your tool belt. You can’t really take advantage of what the motion offers in that scenario audit. So from that perspective, that would be where I would tell you to start is if you’ve got a scanner, you’ve got one of the more expensive pieces of the puzzle, but you need to get comfortable with software because the software is what’s going to allow you to manipulate the data and actually do something with it that’s productive, both from an efficiency and an ROI perspective. Because when you send to the lab, you really don’t gain much. But when you’ve got the software in-house, if you wanna 3D print the provisional, that’s where you gain the time on. And the other deal I didn’t even talk about is 3D printing than the provisionals is less expensive than using bisacryl. [Jaz]Oh wow. I didn’t know that.  [Seth]Which is huge. Yeah. The average bisacryl in the US is about a 1.50, a provisional. I can print them, if you’re using, depending on the resin, it’s usually 60 to 75 cents per. So you’re already cutting your cost by more than half.  [Jaz]Something that’s stronger and better fit and all those advantages for something that’s way less that, I didn’t know that. That’s amazing. [Seth]And that’s where you start to actually pay for the digital stuff, right? ‘Cause when you buy a scanner, the rep’s always saying you’re gonna save $20,000 of poly vinyl. Well, yes, but over five years. And they don’t tell you the monthly fee on the scanners and the maintenance. And what if things break when you’re just scanning, you’re really neutral at best in terms of the financial side of things. But when you start doing provisionals, okay, now we’re saving 75 cents to a dollar every time we print one. You do a splint, a digital splint from a labs 150 to $200. It costs you $7 to print a model is $4 to print, which sounds okay. It’s cheaper on its own than doing mounting stone and all the others. But now when you’re doing a wax up. A wax up in the US is 50 to $75 a unit virtually, it costs me $4 just to print the model for the stent. And so a 10 unit wax up, 700 versus four. It doesn’t take you long to actually start to pay for all the technology you wanna bring into practice. And that’s something that many times isn’t talked about because as clinicians we’re always looking at what’s best for the patient. But the reality is we have to run a business because if we can’t be profitable, we can’t pay our team and pay our staff and do what we need to do to learn the things we need to learn to handle our and take care of patients. And that’s something that isn’t touched on very often. Or I guess it’s, I would say it’s more rare that usually when you bring in something new, you’re doing it at an expense for a clinical benefit, right? So I’m gonna be more accurate doing this, but it’s hard to make it truly cash flow and make a good business decision. And I think that’s where digital really has the potential to differentiate itself, is you can bring in all these technologies and all these synergies come in and you actually have a way to make it a good business decision. In addition to enhancing your clinical outcomes, and that’s where I think it’s special in that regard. [Jaz]And for many of us, Seth, think of how much fun you can have, right? Think it’s the intersection of technology and dentistry. I mean, you could stand, you can see from how you speak about it and your presentation at AES man, like. For, many people, right? This may not be their cup of tea ’cause they just hate it. They very much love the analog world. They hate anything digital, I get it. But for most of us, we actually embrace this. We went to scanning because of the problems it solves and patients love it. They love when they can move their models around. And then when you’re able to give them that level of service that you’re describing, and then the amount of fun you can have with it as well, it makes our job so much more satisfying, so much more rewarding. So I think that alone has a huge benefit and always, always gotta keep learning, right? If you keep it fresh, keep your mind stimulated, then that’s another wonderful reason to look into digital. Last question before we just talk about how we can learn more about the AES and the exciting things coming up with AES 2026 is for those of us who don’t, I mean, we’ve got a CBCT at our practice, but many clinicians around the world don’t have access to CBCT. I’ve seen whereby a good way to perhaps replicate the static detail, the cants and whatnot is aligning the digital articulator with the patient’s photos. So using that as a tool for the lab, can you describe that workflow, whether you think that is the second best or is there anything else that is perhaps inexpensive and something that we can use to get digitize the patient without using face scanning? Without using CBCT?  [Seth]I mean, photos give an opportunity right now, the problem with the photo side is it’s two dimensional. And so if you’re using a straight on and a side photo to try to do it, you can get some idea of it. But there’s some wobble in the system on it. In those scenarios I would tell you go with the analog facebow and used the traditional method to do it ’cause that’s inexpensive, easy to do. And we can then digitize that and work off that framework very easily doing it. And so that’s the other way to look at doing it is, you can take measurements off the analogs and plug those into the digital and use that for your positioning and you’re going to be probably as good as the photos, if not better doing it for sure.  [Jaz]So essentially just so I’ve got the workflow right, it’s as an alternative to the photos, it’s doing everything as we usually do, face bow mounted and articulator at your desired bite. And then how are we getting the articulated models? Is it by scanning the positions or just taking like ruler measurements and then plugging those into the software?  [Seth]You can do both. So, if your lab has a lab scanner, you can send that mount to model to the lab. They can easily digitize the articulator and that allows for the alignment of it. The other way to do it would be, and that’s actually how like one of my favorite splint programs is a program called D3 Tool or D3 Splint. It was written by a dentist who also was a coder, or he also did commercial software design. And I like it from that scenario because he understands what we’re doing as clinicians, but it’s also very intuitive and it’s dirt cheap. I think it’s 600 US one time fee and you own it. But in that program, there’s arrows that you can drag and draw, and it basically has three measurements ’cause to position something in space, you need an X, Y, and a Z coordinate. And it’s a measurement from each condyle to the central point between the centrals and an angular measurement from the infraorbital through the condyle down. So you’ve got right condyle to central point, left condyle to central point and an angle. Well, that gives you your three coordinates. So all I would do if I wanted to do that virtual articulation, you can use a ruler. So measure, just put that face bow record on the analog instrument. You don’t have to pour a model, you don’t have to do any of that. And just take a linear measurement condyle to there, condyle to there, and use a protractor. Between those that you can put in the digital splint program and immediately go in and do your virtually articulated splint. Now you have a little wobble for the can and there’s some finer points that you can do to tweak that, but you’re gonna be much closer than you otherwise would’ve been arbitrarily throwing that in. And so that’s kind of the very easy, low cost MacGyver way to get there doing it. But there’s other methods that you can do that obviously increase complexity going down, but that would give you a starting point. For sure. And I would tell you that’s a great place to learn to trust it is make two splints, have one done, starting it with better values at on the input and have one, do it done as average and start to see where’s the difference in doing it. And that was really kind of one of the nice things digitally is when it only costs me six or seven bucks to make a splint, I can do multiple proposals. Same thing with wax-ups. Usually having three or four aesthetic proposals is cost prohibitive ’cause it costs you too much to the lab. Well doing it now with virtual libraries and only costing $4 to print the difference, you can actually have so much more flexibility and it lets us see, have the patient see these proposals ahead of time. There’s less guesswork. More likely they’re gonna be happy with the initials which is less time remaking, less time starting over, just everything gets more efficient in that scenario.  [Jaz]I think the thing to emphasize here for those listening is what Seth has done is because of the fact that it doesn’t cost much more to change a few variables and print it, you’ve been able to test and test and test, what if you change this? What if you change that? And really your workflows now a representation of all those near misses and failures, which were inexpensive failures because you were able to make that adjustment, spend 10 minutes to print it again and get it corrected. And what a service to your patients. So that again, is a huge advantage of digital there. Tell us about your involvement with AES, Seth. How did you get involved with AES? You’re on the squad of AES in terms of organization. What role do you have with AES and how did you come into that and what have we got in store for AES 2026?  [Seth]Awesome. Yeah. I had a couple cocktails one evening and started talking up in one of the suites after the meeting. And the next thing I knew, I woke up the next morning and was gonna be involved in planning the 26 program, which sounds funny, but that’s kind of how thing it goes down occasionally. And it’s been a great opportunity. Jim McKee was the one who originally got me involved with the organization on it and had never planned a program before. So first time coming in as a program chair doing all that. Yeah, I would’ve been blessed. The fantastic co-chair Liz Turner, who is awesome. And she and I were kind of charged with executing the vision for the current president’s meeting, which is Bobby Supple. And Bobby is very much an occlusion nerd. He’s very much tech scan digital guy. So he was trying to put together a meeting that would bring a lot of these concepts together. And one of the nicest things about AES for those who aren’t familiar is they make it a point of trying to bring different vantage points into the same room and letting ’em talk it out. Which this panel discussions and things where the point is to let everybody see what’s out there and then try to figure out what you believe is the best truth going forward on. And so for 26, we’re looking at a lot of different things. There’s a very heavy digital component, but we have a lot of sympathetics and airway and all the different things coming together that are problems for us clinically today. So we have, example Jeff Rouse is coming in and looking at the etiology of wear patterns and maybe he is gonna look at, is it more of a global thing as opposed to a toothpaste level deal. We’ve got Tracey Nguyen, talking about airway on it as well. We’ve got Mark Piper, Nick Yiannios talking about the roles of Sympathetics, how they play a role, ’cause the sympathetic nervous system I’m finding in my practice is something that makes a huge difference in a lot of cases, but it’s something we were never taught to look at. Alter alterations and sympathetic tone. How do you diagnose it? How do you figure out if that is part of the problem? And I’ll use an example. We have these patients that maybe have an asymmetric response to procedure pain wise. So you go in, you think, man, the tooth popped right out. It shouldn’t be a problem, and I’m hurting the next day. And three days later, they’re hurting, and a week later they’re hurting. And then they don’t look like they have a dry socket. You can’t figure out what is going on. Well, you start looking at these patients and the apnea patients and the airway patients and people who have systemic inflammatory diseases, their sympathetics are cranked up all the time. And we start looking at substance P and pain response. And they’re just, they respond differently. And I had a patient where I was curious that they had increased sympathetic tone and we were taking out two teeth, 18 and lower second molars bilaterally. And there’s diagnostic nerve blocks you can do to kind of turn off the sympathetics to see if they play a role. We do that a lot for the joints. But so outta curiosity, I told the patient what we were doing and I was gonna do this block on one side and not do the block on the other. Taking out both teeth, same teeth, symmetric, same side, the two, the side where we block the sympathetics, uneventful, healing, no problem at all. The side that we didn’t had that asymmetric pain response, it hurts dry socket, I can’t get it to go away. All the things. And at that point, my mind was like, there’s a piece to the puzzle we’re missing here. And I think that’s what Mark and Nick are gonna really focus on is maybe a different way of seeing the same patient and using that to factor in our diagnostics, our discussion, our treatment planning, setting expectations for where we’re gonna go. We’ve got Lukasz Lassman coming in who I think was on the podcast last week?  [Jaz]Just yeah, just yesterday was published.  [Seth]Insanely smart guy. And he’s looking at vertical dimension and how we alter it. Maybe some of the conceptions and misconceptions we may have on the literature and what that supports. He’s even gonna look at the role of the sympathetics and how does that play in? There’s a lot of things that tie in. I think at the end of the day, it’s going to be a very interesting meeting and it’s a fantastic time to come check out the whole dental world in terms of the States is in Chicago at that time. There’s eight or nine other meetings going, you have lab day, all the things. It’s a cool way to come spend a few days when it’s cold in the middle of February. Not much else to do.  [Jaz]You know what, it wasn’t so bad that when I came two years ago, the weather was actually really good, but I know it can be very variable. But what a beautiful city. What a beautiful city. Chicago and honestly like, what you guys are, are bringing together all these top level clinicians is phenomenal. So I’m just wanna champion the event you guys are running. And so it’s been a great pleasure to host yourself, Jeff Rouse, Liz, Lukasz in terms, and Dania Tamimi. We recently published our episodes-  [Seth]Oh, I forgot Danny. Yeah.  [Jaz]And so, so many superstars and so many learning points. So I really encourage you all, if you’re able to come Feb 2026, make it the conference that you attend. Seth, thanks so much. Your hard work and organization so far. But the best is yet to come. The hard work is yet to come still. But for now, we want to just spread the good word and honestly keep up the amazing work you’re doing in the digital side. Like, my mind is blown in terms of the possibilities. And may you continue to be, this super nerd in a nice way possible. Like honestly, you are. You’re very clear, you’re very passionate and really intelligent. So, thanks so much for the good work you do. And I appreciate your time today on the podcast.  [Seth]Absolutely. I enjoyed the visit. Thank you very much.  Jaz’s Outro:Well, there we have it. Guys, thank you so much for listening all the way to the end. Hope you enjoyed the injections, but my goodness, Seth is some sort of wizard. I appreciate him very much for allowing us to use his slides during this presentation. But don’t worry for the audio listeners on Spotify and Apple, you didn’t miss out because the whole conversation happened without any visuals. It was just to enhance what we’re doing. Now if you’d like to get CE, this episode is very much eligible. There was plenty of juice in this one. Protrusive Education is indeed a PACE approved education provider. The episode is eligible for one hour of CPD or one CE credit. Head over to our app Protrusive Guidance. It’s also home to the nicest and geekiest community of dentists in the world. Click on this episode in the all episodes and CPD section, answer the quiz. And if you get 80% Mari from Team Protrusive, our CPD Queen will send you your certificate. You’ve done all the hard work, you’ve listened. You might as well get that certificate. We’ve crossed the threshold recently so that now if you tally up all the CPD and CE available and Protrusive Guidance, it’s less than a dollar. So imagine getting a CE certificate for this episode for less than a dollar. There is so much good stuff on there, and just the network and the community that’s on Protrusive is absolutely amazing. We’ve somehow attracted the nicest and geekiest people in the world. Head over to protrusive.co.uk/ultimate. That’s protrusive.co.uk/ultimate to get a free trial to make sure that you are happy with the education that’s on there. As always, thank you to Team Protrusive for their hard work in putting this together for the visuals of premium notes and to ensure that the mission of making dentistry tangible is totally accomplished. Thanks again, my dear friends, I’ll catch you same time, same place next week. Bye for now.

Are you considering the airway in your treatment planning? Could centric relation (CR) be compromising your patient’s breathing? When you open the vertical dimension, are you making the airway better—or worse? Welcome to another AES 2026 series episode, this time with LEGEND Dr. Jeff Rouse as he joins Jaz in this eye-opening episode to explore how airway, aesthetics, and function are deeply interconnected—especially in prosthodontics. They discuss key clinical scenarios like vertical dimension changes, examining how your choices may impact the airway—sometimes in ways you didn’t expect. With practical insights and examples, this episode will help you make smarter, airway-conscious decisions that elevate both your functional and aesthetic outcomes. https://youtu.be/-Ut-qme7Vcg Watch PDP229 on Youtube Protrusive Dental Pearl: Plan your breaks 12 months in advance to avoid burnout and ensure quality time with your loved ones. Prioritize rest and connection before reaching exhaustion—your body, mind, and heart will thank you. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Airway health is crucial in dentistry, impacting aesthetics and function. Understanding airway issues can lead to better treatment outcomes for patients. Breastfeeding plays a significant role in childhood development and airway health. Interdisciplinary approaches are essential for effective adult treatment. Aesthetics and function are key factors in airway prosthodontics. Most patients are unaware of their airway issues until they are addressed. Early intervention in childhood can prevent future airway problems. Combining orthodontics and prosthodontics can enhance patient care. Airway management is crucial for overall patient health. A great bite is not just about teeth alignment. Pathway wear can indicate deeper dental issues. Vertical dimension changes can negatively impact airway. Understanding joint positions is essential in treatment planning. Continuous education is vital for modern dental practices. Highlights of this patient: 02:22  Protrusive Dental Pearl 04:34 Interview with Dr. Jeff Rouse Begins 09:05 Understanding Airway Prosthodontics 15:58 The Role of Cone Beam CT Scans 17:58 Treating Children and Early Interventions 24:50 Addressing Adult Airway Issues 29:43 Multidisciplinary Approach in Dentistry 31:46 Patient Transformations and Airway Focus 34:42 Understanding Pathway Wear 41:32 Impact of Vertical Dimension on Airway 48:55 Exploring Different Occlusion Philosophies 51:34 A Sneak Peek at AES 2026: Dental Wear Patterns Of The Airway Patient 55:25 Upcoming Events and Resources Explore the world of sleep disordered breathing with Prof. Ama Johal in PDP033: “Airway – Dentistry’s Elephant in the Room.” 🎓 Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES). 🗓️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician”📍 February 18–19, 2026 · Chicago, IllinoisDon’t miss Dr. Jeff Rouse as featured speaker, presenting on “Dental Wear Patterns Of The Airway Patient” 🎓 Learn more with Dr. Jeff Rouse on The Spear Education Online #PDPMainEpisodes #CareerDevelopment #BreadandButterDentistry This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A, B and C. AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Sleep medicine) Aim: To deepen clinicians’ understanding of airway prosthodontics and empower them to recognize airway-related dental issues across all age groups. Dentists will be able to – Differentiate between anatomical airway dysfunction and sleep-disordered breathing, and understand the unique role of dentistry in addressing each. 2. Explain the principles of Airway Prosthodontics, including the significance of tooth position in facial space and its impact on breathing. 3. Recognize signs of airway compromise in both pediatric and adult patients, including atypical wear patterns, bruxism, reflux, and chronic fatigue. Click below for full episode transcript: Teaser: They don't want us playing in that world either. They don't. Their world is completely different than ours. And you as a dentist, you don't want to be in that world. It's an ugly, ugly world and most physicians would love to be dentists nowadays, 'cause we have so much more freedom to change and to act and to care for our patients than they do. Most people don't know what they don't know. They just call it normal. Teaser:A woman I was visiting with earlier today had had orthognathic surgery and she said, I didn’t really realize that I never was able to breathe and I never slept until I had the surgery done. People that are constricted in their bites like this, their maxillas are constricted. And if their maxillas are constricted and their nasal cavities constricted, they can’t breathe well through their nose. And so if you go from giving a small piece of cheese or beef jerky or a peanut to chew, they can manage their airway, have ’em bite into a sandwich with a bunch of bread and a bunch of stuff in it. They can’t, so their chewing cycle will move forward and they’ll hit their front. For me, airway is just established the aesthetic position of the teeth first and the functional position of the teeth. If you get those things normalized, then we help the patient normalize what they do, which is close the mouth and breathe through their nose. That’s dentistry and the success of that treatment is does the patient have a beautiful smile and a great bite? That’s success. Not did I reduce the apnea level? We’re treating 26 month old as the youngest I’ve ever heard, done Invisalign first to expand, start expansion early, but at four you can start to see if you’re leaving them in a constricted pediatric arch that the permanent teeth are gonna erupt outside of the housing of the bone. So the orthodontist never moved the teeth outta the bone. They were never in the bone to begin with.  Jaz’s Introduction:How does the airway relate to aesthetics and function? Interesting concept ’cause we think about aesthetics, we think about function, but are we necessarily thinking about the airway when it comes to our treatment planning? Related to this is a scenario like, let’s think of complete dentures. When we deliver complete dentures, the joint position that we usually select is centric relation or seated condyle position. Now the question is, is this position adversely affecting their airway? i.e. by moving their condyles in into centric relation, which usually means they’re moving their jaw a little bit further back. Is that necessarily worsening their airway? Well, we answered that in this episode. And how about when we’re opening someone’s bite? Well, in prosthodontics, when we open someone’s bite, there are some scenarios where you are at risk of making the airway worse and other scenarios where you’re probably not gonna make the airway worse. And you’ll learn this episode exactly what those two distinctions are. I’m joined today by the Dr. Jeff Rouse absolute giant in our profession. What a lovely guy he is. Author of one of the best dentistry textbooks there are Global Diagnosis. He’s also a very prominent educator with spear education and the impact this man has made in airway and dentistry and prosthodontics is just absolutely amazing. So it’s real privilege to host him today as part of our AES takeover. See, Jeff Rouse is one of the speakers at the AES Conference, 2026 in February, and that will be held in Chicago. And we’re trying to shine a light on this conference because it’s based on occlusion, right? It’s related to occlusion, but it’s so much more than occlusion. In fact, the theme of the AES conference next year is the Evolution of the Oral Physician. Let me say that again. The Evolution of the Oral Physician. So it really looks more than just the occlusion. When I attended a few years back, they really are a comprehensive, holistic group that brings together all the occlusion camps and me and Mahmoud Ibrahim, have the privilege of being able to speak there. But we are a small piece of it. You know, some of these giants, like Dania Tamimi that we had on previously, Lukasz Lassman, Jeff Rouse, who you’ll hear from today, is gonna make a really great conference. We’re shining a light, so check out aes-tmj.org, that’s aes-tmj.org to learn more about this conference in Feb 2026. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl, and quite often the pearl I give depends on my mood and my context and what I’ve been doing that day or the few days beforehand. And whilst this episode’s being published, probably six to eight weeks later, it’s actually Easter Monday today. And so Spank Hall in England, I’m just reflecting on this Easter break that I’ve had. And honestly, it was just very, very special. For those of you who’ve been listening to every single episode, you may remember I had pneumothorax, a spontaneous pneumothorax. My lung collapsed in February. It canceled our family holiday, like a first world problem. Yes, it was not nice. It was devastating actually. But there’s a reason for that. For me and my wife holidays are very, very special. It’s really quality time with our kids. It’s a time where I switch off and so we couldn’t go away in February. And so I was really nervous about flying in April and thank goodness, I survived and everything’s fine. And honestly, it had just the loveliest 10 days away in the sun with my wife and two kids, and I’m feeling really great. And I guess the pearl is, please make time to rest. If you have a young family. And if they’re at school age, then yes, school holidays are expensive time to go away. But even if you don’t get away, just having that time to reset and connect with your family and making time for that is so special in my opinion. And the reason I’m having to mention this is too many times I’m having conversations with dentists and they’re burnt out. And I always ask ’em, when was your last holiday? And they keep saying to me, ah, you know what? I’ve been meaning to book something, but I never get round to it. And I get to a point where I feel like I need a holiday right now, but I can’t actually book anything because of practice commitments, blah, blah. So something I’ve said over and over again on the podcast, and I make no apologies, do you plan your breaks 12 months in advance? So I do. It’s why I’m able to be so organized in my diary. I know exactly when I’m taking a break from teeth, paying attention to family or things that are important to you. And the next thing is really quite celebratory. Like for the first time in probably 20 years, I managed to get eight hour sleep for about 12 days straight. That was absolutely transformational for me. So Protruserati, please make time for your loved ones. Plan those breaks well in advance so you don’t have to wait until you’re burnt out to book a holiday. You always have something to look forward to. So I’ve said it before, I’ll say it again. Look after your body, look after your mind, and by spending more time with loved ones, look after your heart. Let’s join the main episode now and I’ll catch you in the outro. THE Dr. Jeff Rouse. Absolute pleasure to have you on the Protrusive Dental Podcast. How are you, sir?  [Jeff]I’m wonderful. Thank you. Thanks for having me here.  [Jaz]I’m so stoked. I told you this before we hit the record button. Your reputation, what you’ve done, your contribution and dentistry already just been phenomenal and I’m so excited that you’ll be speaking. You are such an established educator, your work with spirit education, your own stuff you do and you’ll be speaking AES as well. It’s gonna be amazing. And as part of the buildup and excitement of that, it’s so great to talk about some key themes today. But for those younger colleagues who perhaps haven’t heard about you, tell us about you, your journey and what inspired you to take the route that you did take? [Jeff]It’s strange you asked me that question, Jaz ’cause and by the way, thank you for having me on. I know the Protrusive podcast is worldwide and so it’s such a treat to actually get a chance to talk to you. It’s strange you asked me that question ’cause I was, today, I was sitting around thinking like, what a weird route I’ve taken to get to where I am. How some of the things that happened to me, if I had made a different decision, there’s no way I’d be in the position I’m in right now. So for all those people out there that were horrible and undergraduate and dental school, there’s hope you can actually make it to a podcast one day ’cause I was terrible in school. I had no passion for it. I didn’t really understand what dentistry was all about. I went into dentistry because a friend of mine wanted to be an orthodontist and I lost my desire to go to medicine. And I say lost desire. I would’ve probably never gotten into medical school. But I didn’t want to get into medical school, but I didn’t know what else to be. And so a buddy of mine said, you want to go to dental school? And I said, yeah, whatever. And I must have done well on the exam ’cause I got into dental school somehow ’cause my grades were horrible. Got to dental school, the guy there said, C equals DDS. And so I just said, well, that’s easy enough. I can make Cs. And so I did. And the last year in school I met a professor, Bill Robbins, who I later ended up working with and writing a textbook with. But I met him and he showed me the dentistry could be more than what my local dentist was doing. And that there was science to it and there was an art to it, and that allowed me to go to a residency. And so I did a two year GPR came back and went to general practice, practice as a general dentist for 14 years. And once again, Bill and I were working together. We were writing textbooks together, we were lecturing all over the world. And I knew there was something different or something more that still I was passionate about. And so I had an opportunity where I could work my practice and go to prosthodontic residency at the same time. So it took me four years to do it, but I did, and I became a prosthodontist. And after that, then I had opportunities that would’ve never happened had I not taken that, which is I got to work with Greg Kenzer and Frank Spear up in Seattle. And from there ended up teaching at Spear. So a handful of decisions of just saying yes to hard work and saying yes to the fear that was accompanying it and it paying off. So I think we get comfortable and I’ve always gotten anxious when I’m comfortable. And so for those of you that think there’s more, there is, you just have to be willing. Like I tell my kids, you have to be willing to take a deep breath and take that leap, even though it’s scary. And in many ways I got lucky, but in a lot of ways, it was just being able to say the word yes, I’m gonna do that. So that’s how I ended up getting here.  [Jaz]Wonderful way to start the podcast. Richard Branson says, if an opportunity comes along that just really, really good, say yes and then figure out how you’re gonna do it later. And so this is the same Bill Robbins that I think spoke at AES two years ago on global diagnosis.  [Jeff]Yeah. That’s what we wrote here.  [Jaz]And I met- and that was all work together. And what a charismatic chap he is. What a lovely human being. And just his charisma. It’s just oozing, it’s just pleasure to see him.  [Jeff]There are very few people in the world that you’re better, you as a person are better off having been around him. And he’s one of those people that just being around him and being in his presence creates such a benefit to you. Like the energy coming from him just feeds you. And yeah, I was lucky enough to work with him for four years and he’s my best friend in dentistry for, I don’t know, 30 years now. So it’s awesome. [Jaz]What a story. And yeah, that was definitely palpable when I met him a few years ago. Today’s topics we’re gonna take lots of little detours and stuff because to do a topic like this justice, you have to kind of like build the context into it. And I want to help dentists understand a few key things related to airway based prosthodontist. Some people may be thinking that’s a new term for others who maybe done your classes and stuff, they may be more familiar. But what I was thinking was when we do our restorative dentistry, let’s say. We can do something that may affect the phonetics, and we think about that. We think about the tooth length and thinking, oh, that might affect the phonetics. We plan our restoration. So we think about the cleansability. You know, we often opt for certain designs, so there’ll be cleansability, but sometimes perhaps we may be guilty in dentistry of not thinking about how our dentistry, obviously more and more with your good work, people are becoming more aware of this, but how might our dentistry affect the airway? So I guess I’m gonna let you really lead the direction on that. But when it comes to the decision making and the kind of dentistry that we deliver, what kind of situations where may we be impacting the airway without perhaps realizing?  [Jeff]Yeah, good question. Let me back up a step so that everyone is clear. The biggest confusion that I run into when I’m speaking today is when you used the word airway and you used it properly, in my opinion. The issue that I run into is people, at first when you would go to lectures would say, my patient has sleep apnea, or My patient has a sleep problem. And then myself and other people kind of following the same course started utilizing the word airway to differentiate it. And now if you go to a lecture, you’re gonna hear people say, my patient has an airway problem. But the next thing out of their mouth is they went in for a sleep study and their apnea level is 24. So they’re using the term incorrectly. Airway, the way that you were using it was about anatomy or changes to anatomy that could affect your ability to breathe. Tooth position, vertical dimension are some of the things that you were outlining. And that’s where we start. So back in the day, I came up with the term airway prosthodontics, just to differentiate it from sleep dentistry. So we were clear, but it still hasn’t become clear. So let me see if I can create some more clarity to it. [Jaz]Because what I’m thinking immediately is will not, the first part, will not, the airway based prosthodontics that will also impact our sleep. And so they are connected in a big way, right?  [Jeff]They are, but I would go to an easier step because if you connect it to sleep and say sleep apnea, let’s say, the moment you connect it to a medical problem, your markers for success change dramatically. The minute you say my patient has sleep apnea, in order for you to be successful, you have to make that go away. Right? It either has to, success is reducing the apnea level by half and being under 20, cure is under five and the apnea hypopnea index, right? So the minute you establish the standard for care or your metric for care as apnea, you’re playing in the medical world. I don’t wanna play in the medical world. I don’t want anything to do with that. And to be honest with you, I had a physician in my office, an ENT in my office for five years, and they don’t want us playing in that world either. They don’t. Their world is completely different than ours and you as a dentist, you don’t want to be in that world. It’s an ugly, ugly world. And most physicians would love to be dentists nowadays because we have so much more freedom to change and to act and to care for our patients than they do. So with that in mind, that was my original goal, was how can I use this to integrate medicine and dentistry for the first time, let’s work together as a team. And the more I did it, the more I figured out we don’t wanna do that because they’re gonna take over. And if we are treating to the apnea level, it’s medicine. And medicine then wins and every decision. And I don’t want to be there. So came up with the term airway prosthodontics, which actually could impact the apnea, but doesn’t focus on the apnea. That’s not our central theme. Our central theme is doing the two things that we’ve taught at either in global diagnosis or facially generated treatment planning in the spear world, which are where do the teeth belong in the face and how do you get ’em to function correctly? Those are one and two of every system that’s ever been developed that you’re using for treatment planning. So when we look at aesthetics, there are three main areas of aesthetic tooth positioning that happen on a wax rim before you ever set a tooth, which is you’re gonna get the transverse dimension correct. You’re gonna get the AP dimension correct. You’re gonna get the vertical dimension correct. So you get all those three things established, and then you start setting the teeth into ideal position. The vertical, the transverse, and the sagittal dimension and position of the upper arch are all key airway factors. And so if any of those anatomic factors are irregular, you will have more difficulty breathing during the day and at night when you go to sleep. So aesthetics in the maxilla is number one, not only the way we’ve always thought about treatment planning, but it’s number one for airway because it’s connected to the nasal cavity and changes in those dimensions. Orthodontically, orthopedically, orthognathically will make you breathe better. How much better? We don’t know. No one will ever be able to tell you in advance, but we know it makes you breathe better. The second is function. By the way, function used to lead back in the day when I learned it, function was the leader. It was all occlusion. It was a lower arch dictated treatment. And even in ortho, lower arch dictated treatment. Tweed orthodontics take teeth out, put the lower interiors over the ridge, move everything to it. Lower arch gnathology, Pankey-Mann-Skyler, everybody was lower arch. The upper arch just sort of sat there and you worked around it. Today, if we established a maxilla first, the aesthetics first, and then do the lower arch the same way we would do a denture when we get the lower arch in the proper location to inter interdigitate, the airway is also better at that point. So are there other factors beyond that? Yeah, sure there are. There are soft tissue issues or tongue ties, large tongues. Adenoids, tonsils, deviated septum, which actually come from constricted maxillas. There are lots of things that could be added onto that. But the two main factors that make you breathe better during the day and at night are aesthetics and function. They’re exactly what we need to do in treatment planning. So for me, airway is just establish the aesthetic position of the teeth first and the functional position of the teeth. If you get those things normalized, then we help the patient normalize what they do, which is close them mouth and breathe through their nose. That’s dentistry, and the success of that treatment is does the patient have a beautiful smile and a great bite? That’s success. Not did I reduce the apnea level. So that’s the big difference between the two. [Jaz]When you’re assessing that in a patient in the medicine world, they use the, yes, apnea hypopnea index as a marker. You said that aesthetics and function, are you also using cone beam CT scans and they look at the volume of the airway? Is that a metric that you use as well in terms of, okay, by doing our prosthodontic intervention, we’ve improved the airway by volumetric percentage?  [Jeff]Yes, but I don’t treat to a number that way. Do I look at it? Yes. You know the interesting thing about cone beams, the thing I look at most often is we now know that if you do a cone beam and do slices at the first premolars, so we’re doing AP slices first, premolars, then go back to the first molars and do the same thing. Measure from bone to bone on the palate. We know the widths that you need to be healthy so I can take a CT of you or any of your patients. And I can cut it and go, you’re too narrow. You’re gonna be sick. And you look at me and go, well, I don’t snore, I don’t have this, I don’t have that. I go give it 10 years or 10 pounds. And you’re gonna, so why would you wanna wait around the way medicine does until you’re sick? Why don’t you treat it in advance ’cause we know you’re gonna be sick. And the closer you are to that number, the more risk you’re gonna have. We also know, if we look from the side, sagitally, we know that distance. We know that from porion, which your ear hole, if you drew a vertical line off it, an a point which is up under your nose, if you drew a line measuring between those two points, 97 millimeters is a number, you have to be greater than if it’s not greater than 97 millimeters, your odds go up dramatically with or without obesity. Your odds go up because cranial facial is more important than weight. And we also know that vertical, people that grow vertically, VME patients. Those are airway patients. They’ve always been airway patients. We’ve called them adenoid faces forever. We called them that for a reason. So we know if your anatomy is off, you’re gonna be off. So yes, I do use cone beam and I use it that way. I like cone beam even in children because I can see the nasal cavity, I can see any deviations, any issues in the nose. I can see the adenoids. I can see the tonsils in 3D. So we get a nice view of those structures also. So if I can get even really, really little kids, they have those quick cone beams, the four second versions, if you can get one of those, then even like four year olds, it’s awesome ’cause you can see anatomy you wouldn’t otherwise be able to see. And in fact, we now know another, there are many reasons why you wanna treat kids very, very young. We’re treating 26 month old as the youngest I’ve ever heard, done Invisalign first to expand, start expansion early. But at four you can start to see if you’re leaving them in a constricted pediatric arch that the permanent teeth are gonna erupt outside of the housing of the bone. So, the orthodontist never moved the teeth outta the bone. They were never in the bone to begin with. So.  [Jaz]Well, that was actually gonna be my question. My next question is that, okay, based on what you’re describing, what percentage of your dentistry is for children, and then what percentage is for adults, let’s say someone in their forties who seems to have minimal dental issues, but you’ve made these diagnoses and you know these metrics and they’re gonna run trouble. At that point for an adult, it’s very much, I’m guessing, gonna be surgical orthodontic or a combination of both would be the mainstay of treatment, would you say?  [Jeff]All right. Let me answer the first part, which is children. Children are absolutely the key. I ran a family practice before I went back to pros. I don’t enjoy treating children anymore. I did ortho on kids. I did all that. It just wasn’t something that I enjoyed, and so I stopped. If I had to do it over again, I would continue. It was, the reason I stopped is I had one case that the patient went away for six months and the wire was active and I didn’t know how to recover from it. And so in my mind, I was like, I don’t know how to deal with that, so I don’t wanna do anymore. And so I gave it up. I just gave it all the orthodontists. In hindsight, I should have just said, I don’t know enough. I need to learn some more. And instead of thinking, I knew it all, you know, right up front, and if I did, I would still be treating kids and I would have a bigger impact on my community because I would be treating young. That’s where the problem needs to be dealt with. The problem needs to be dealt with in newborns. Newborns that are tongue tied. And having difficulty breastfeeding if you can’t breastfeed as a child, if growth discrepancies are huge. So breastfeeding is absolutely the best thing you can start. And if the mother doesn’t want to do it, that’s fine. But what I find and just hate to see is when the parents come in and I look at the kid a little older and their tongue tied and lip tied, and I ask ’em about breastfeeding, they go, yeah, they weren’t good. They didn’t latch well or it hurt, or whatever it happened to be, well, they wanted to do it, but there was this anatomic restriction, which now we’re having to play ketchup because they didn’t get to grow normally as a kid. So breastfeeding, what they eat, how they eat, lots of things that we can do to make kids grow and we start intervening way earlier. We getting ENTs involved to look at tonsils and adenoids in an earlier level. We don’t require apnea before those things are removed. We require symptoms, attention deficit, grinding their teeth, reflux, wetting the bed, thumb sucking beyond early years, moving around in the bed, sleep, talking, sleepwalk, any of those things. Start promoting the idea of getting tonsils and adenoids out, and then also expanding arches. And so, yes.  [Jaz]This is very relevant to me, Jeff. So I’m sorry to intervene, but just to let you know that my son’s gonna be two tomorrow. He’s gonna be age two tomorrow. But since he’s never been a good sleeper, since he was born and I knew something wasn’t right ’cause I hear snorting and sometimes he would stop breathing and I knew something wasn’t right. And we have so many healthcare challenges around the world and getting diagnoses and stuff in the UK in particular. So I managed to see the right person that got this sleep test and lo and behold, he was diagnosed with moderate sleep apnea at age 18 months. And he’s on the list for eventual when he’s like healthy enough for adenoidectomy, which actually my elder had as well. So I’ve seen firsthand why my interest grew in this ’cause I wanted to help my own son and he was breastfed. And he was breastfed fine. In fact, my wife made it to one year. And interesting stat is that in the UK, and I dunno what the US or rest of world stats are, but in the UK only 1% of mothers are breastfeeding at month six, only 1%. So my follow up question will be, do you think this has been a huge player in terms of the why we are seeing so many more of these issues?  [Jeff]Yes, there was a perfect storm of problems that happened in the late fifties, early sixties. Antibiotics started being used instead of surgery for tonsils and adenoids. Part of it was, it used to be if, like, if your brother got his out, you got yours out, which is wrong. So they were overdoing the surgeries. Then they went completely the other way. Women went back into the workforce at really high numbers. And so breastfeeding went way down. Gerber introduced soft foods and mushy baby foods instead of the natural course was six months minimum breastfeeding, and then introduction of solid foods after that. Gnawing on solid foods grows your face. There’s crap in the air, crap in the water. I mean, there’s all kinds of different stuff in our food, right? Everything plays a little bit of a role in what we call epigenetics. And so it’s environmental factors that are altering natural growth and development. In addition, and this is totally a guess, there is some science to this, but not enough to be causative at all, but somewhat correlational, folic acid in prenatal vitamins, decreases neural tube defects, but the tongue ties are neural tube issues, so they close earlier than they should have. And so we get a lot more tongue ties than we used to in the past. So yeah, it was a perfect storm of bad things that happen. Interestingly, I think it will be interesting to watch that percentage because at least in the states, people are starting to take an approach of what can I do to be healthier? Can I have clean foods? Can I do supplements? And in the space of taking care of children, there’s a refocus on breastfeeding I think. So we’ll see if that number grows, but that would be a good thing if it does.  [Jaz]Absolutely. I mean, it’s much high in some of the Scandinavian countries, like 33% and whatnot. But yeah. Interesting. Six months. It was 1% in the UK so well done to my wife. But yeah, sometimes not possible and stuff, so I wanna make this about, make anyone feel guilty and whatnot. But no, I think as a fact we know that if you can, you are able to breastfeed your child. Yeah, it’s the best thing. I mean, a stat I had at the time was something like 20 times less likely to have some sort of orthodontic issue properly to do with your palate dimension, I imagine.  [Jeff]Absolutely decreases sleep disturbed breathing issues and it reduces malocclusions prematurely born children are absolutely gonna have sleep disturbed breathing issues ’cause they’re so far behind in growth and development and breastfeeding is the best way to catch them up. ‘Cause you can almost get them caught up to normal kids growth and development through breastfeeding. The nice part for, to sort of file away for people is whatever time you do it is good. If you breastfed for a month, the numbers are significantly better at eight years for your kid. So whatever you do is good. Your question then was about getting the older patient, the 40-year-old- [Jaz]So that scenario described where you take a CBCT and then you notice that the dimension from first molar to first molar and the palatal bone and it’s not meeting a minimum number. And they say to you they don’t have any issues because they’re now an adult, they’re fully grown. What kind of treatment interventions are available to these patients?  [Jeff]Part of your question that’s interesting is they say, I don’t have issues. But most people don’t know what they don’t know. They just call it normal. Woman I was visiting with earlier today had had orthognathic surgery. And she said, I didn’t really realize that I never was able to breathe and I never slept until I had the surgery done. And she said, you told me that about all this stuff, but I did it ’cause I didn’t like my profile and so aesthetically I thought it was gonna be a nice change. And she said, I just didn’t realize it. And now like it’s a different world. So part of our job as dentist is to, well, airway, like I said, airway’s just putting the teeth where they’re supposed to be is for aesthetics and function. So if a person says, I don’t have a problem, I don’t necessarily have to argue with them about it. If we can come to some agreement, your teeth are in the wrong place and your bite is off, and that’s all I’m doing, then I know I’m gonna make your airway better and I don’t have to focus on it ’cause in the end, what success you have a pretty smile and you have a good bite, so, I don’t need you to believe you’ve got an airway problem. The time it becomes important to get you to believe you have an airway problem is if you have ugly teeth and a bad bite and you’re not really wanting to do a whole lot about it, but you know that there’s an airway problem and a bad smile and a bad bite, the airway problem is the one that you can have a conversation about easier than any of the other ones. I find it extremely difficult to have a conversation with people to say, oh my God, you’re ugly. Right? I mean. You don’t walk into a room and go, oh man, look at that. That’s hard. Even when it is like they got a crown on a central and you go, wow. Like, whoa, we can make those look like teeth nowadays. I don’t know if you knew that. So you see that, or you look at their bite and it’s just totally messed up and they’re chipping teeth, breaking teeth. Oh no, I do fine. I eat right. Those two things for me are really hard to talk about, but if I can talk about health and link all of those things together, now I give them something they’re interested in, which is being healthier for a lifetime than they are right now, or would be in the future without any care. But I get, what I get from it is I get to do all the cool dentistry I always wanna do, which is put the teeth where they’re supposed to be, rather than camouflage it with ceramics and stuff, put ’em where they’re supposed to be and then make ’em beautiful. And then, you know, put the bite together. And a lot of times I do less dentistry. I mean, huge advantages from a dental perspective, great smiles, great bites, maybe less dentistry. Maybe if I have to do the same amount of dentistry. At least it’s the right shapes of teeth. I mean, they’re anatomically correct rather than warping teeth around and stuff. So what do you have to do? And you’re right, typically orthodontics plays a big role in this, but it doesn’t necessarily have to jump all the way to to orthognatic. There’s a middle piece nowadays that is surgical based orthodontic therapy. And the surgical base, orthodontic therapy is not orthognatic in nature. The two main ones are, well, I’m gonna lump into surgery for a second, but it’s really not surgical. The two main ways of expanding arches are surgically facilitated orthodontic therapy where we make corticotomy and cuts in the bone and add bone. That’s like adding base plate wax, so you get a little change in the anatomy, right? The other one is MARPE, so, so mini implant assisted rapid palatal expansion. Now, I said you have to do a surgical intervention. That’s a non-surgical intervention, but it is an intervention, right? You have to put Tads in the palate and expand off the tads. Today, I’ve kind of gone the whole route on this. The original MARPE that we used was MSE, so four Tads, small, little tiny screws and such. Today we’re using custom MARPE, so we’re using 6, 8, 10 long Tads, big solid MARPEs. And so we can split anyone open up to the age of 70. So you walk in my office and you need expansion and some AP, we can do all that non- Interjection:Hey guys, it’s Jaz with an interjection. So we’ve got two interjections for this episode. Let’s talk about dual bite. Okay, so dual bite is basically a scenario whereby you have a patient who when they bite together, their teeth fit together well. Right. So they have their dental home, their maximum intercuspal position. The relationship between the teeth. Now this patient, right when you seat their condyles, their jaw drops right back like distalises, and they also have a bite in that position. So this patient is said to have a dual bite, okay? They have a bite where they have like a dental home, and then they have the bite where they have a skeletal home, i.e. the condyles are in the Fosse, or I like say the balls are in the cups and in this position, their teeth also have a bite. So they have a bite that’s further forward and a bite that’s further back. And this is a dual bite patient. If you routinely start to check your patients for where their centric relation contact point is, or where their stable condylar position is, whether you deprogram your patient or use a leaf gauge or whatever, then you’ll start to identify these dual bite patients who have this very large slide. So that’s what we mean by a dual bite patient. [Jeff]Surgically, and then orthognathic comes into play only in my office when non-surgical expansion with MARPE and SFOT on the lower ’cause the lower dictates how wide I can make the upper go. That doesn’t resolve whatever the problem is. My smile doesn’t look good, my bite doesn’t look good. But the main one is I’m still don’t feel good. I’m still grinding my teeth. I still have reflux, I still have TMD issues, I still whatever. And in that case, we’ve gotta move forward and any big protrusive movement in particular mandible has to occur surgically. So orthognathic comes into play at that point in time. [Jaz]So what you do is very, a lot much multidisciplinary, right. Orthodontics, oral surgeons, what you do is very much a team-based approach.  [Jeff]Yep. I’ve got a practice where the first visit I ought to have like a rotating front door ’cause they come in, they see me and they go right back out to see other people. It’s just in and out from other consults. So I have most of my new patients that are interdisciplinary in nature.  [Jaz]That’s really the whole-  [Jeff]But you know, if I was, like I said, if I was smarter back in the day, I would’ve stayed doing ortho and I could have done a bunch of this ’cause I would’ve, the skills at this point in time to do for sure 50% of it, if not 75% of the stuff I’m talking about. I don’t think I would’ve ever taken on an  orthognathic surgery case. I think that would’ve always scared me to deal with those cases. But I actually personally did the SFOT surgery and I put MARPEs in so that I can expand. So I’m expanding people.  [Jaz]So you’ve had all this done to yourself? [Jeff]No, I had the SFOT done to myself, but I do it to other patients now.  [Jaz]Okay.  [Jeff]So I just, the other day, I always get this question in the classes, which is, where do you find somebody that’ll do that? Like, I don’t have any in my community. And the answer always was, well, if the guy that’s doing it right now doesn’t do it, go find someone. Go find a younger guy, that’s hungry and has some new knowledge and such, and would like to establish his practice based on this and get a chance to work with you. I bet they would love to do it, but a lot of the people I teach, the orthodontist comes in once a month and does ortho in the town. Right? So if that orthodontist says no, who are they supposed to go to? And so I got to thinking about that, like I’m spoiled by working in San Antonio and I am spoiled by having so many great teammates. And so I’m speaking from this position of well just go down the street and find another one, right? And so it hit me one day and I was like, well do it yourself. And then I thought, well, if I’m gonna tell somebody to do it themselves, then I better be able to do it myself. So, I started doing a few and it’s not that hard. So.  [Jaz]What kind of changes have your patients experienced that you look back? A lot of my colleagues that I look up to that have been practicing for years, they say, the full mouth rehabs they did when they come back, 15, 20 years later and everything’s working well and it makes ’em really happy and dentistry and their smile looks great and whatnot. That’s the kind of stories I’ve heard. With your focus on the airway, what kind of changes have you experienced in your patients?  [Jeff]All right, so first thing is your colleagues are lying to you. Nothing looks good at 15 years. It’s still in the mouth and it’s not broken in 15 years.  [Jaz]Yes.  [Jeff]Ceramic ages. It always, you look at it go, ugh. So yeah, I don’t get much of a thrill at seeing rehabs. I always tell the story. Back when I was in dental school, people were so grateful. They’d like, you’d put these ugly crowns that you made and residency or in dental school, you’d put ’em in and, and in hindsight you go, man, those were ugly. People were crying, they were bringing you presents. They’re like, oh my god, my whole life I’ve always wanted white teeth and you gave me, there is just like the greatest day ever in dental school, right? And then you get out and you charge a fair fee for it and they start like, wow, what about that edge right there? I don’t really like that. So they complain a lot. The nice part about the airway is if you do it the way I am suggesting is you are transforming their lives in multiple ways. You’re giving them a great looking smile. You may be giving ’em a great looking face, right? You send ’em out for orthognathic. By the way, if you do that, custom MARPE, their face will look better as well ’cause they’re midface will fill in because you’re actually expanding the whole maxilla up under the eyes, the zygoma everywhere. So you give ’em a great smile, a great face, you give ’em a great bite, they can function wonderfully and they feel good. And then you give ’em this great airway. And the way they know great airway is whatever the thing that triggered you to say, you probably have a bad airway like bruxing, reflux, TMD headaches. Those are gone. And because it takes a while to get ’em through the whole treatment, a lot of times they forget. And so in the end I have to remind them, hey, you still get those headaches? And they’re like, no, those have been gone for a while. Oh, that’s so good. So yeah, it’s very cool.  [Jaz]I manage TMD patients there, Jeff. And what I also realize is they kind of forget where they were. And so at the very first few appointments I get them to mention all their issues and give it a score out of 10 about how much it affects their life. And then oh, as we go through, they’ll score it. And then when they’re down to like a two or three as like, oh, that’s interesting. You were a seven. No, like eight months ago, whatever. So it’s very, very true to that point you raised. It’s amazing what the impact you’ve had on these patients through thinking in this way, but this level of knowledge that we need to upskill and we need to open our eyes to this and you’ve done great contribution education. I’ll ask you and again at the end, where can we learn more from you and whatnot. So it’s our duty to upskill. But two things I want to just talk about for our younger colleagues. One thing is you mentioned a great bite, so what are some features that you look for? You look at a bite and say, that is a great bite. What constitutes a great bite?  [Jeff]Well, are you talking about a restored bite or because a restored bite for me is gonna be in a seated condylar position ’cause that’s what I work to. A great bite doesn’t have to be the teeth all in the right location either. It can be a bite that the patient is so adapted to that there’s no damage to the teeth. I had an 85-year-old lady in not too long ago, and there were nowhere on her teeth at all, and they weren’t what you would call a dentoform perfect teeth. But yeah, that’s a great bite. It functions without damage. That’s perfect. now, that actually leads me to talk a little bit about one of the topics I’ll have at the AES meeting and its pathway wear or envelope of function would probably like, or envelope of dysfunction. People call it all kinds of different names. You have posselt’s diagram.  [Jaz]Well spotted.  [Jeff]So once again, just for younger people, I don’t know what term they use or where they’re in the world or where they’re in their education, but I’ll describe what we at Spear Education would be a person that actually comes in and we call it pathway wear. Pathway wear. So pathway wear is that as you chew your lower teeth, nick the lingual surfaces of your upper teeth. So the lower anterior teeth will wear at an angle, so they’ll be higher in the back, lower in the front. They typically will create a shiny wear facet there. So if you took a photograph, you’d see the light reflecting off of this shiny area, and then the upper lingual surfaces will be hollowed out and they can be hollowed out in different paths. They can kind of come in a lot from the side, or they can be tighter paths, but they can’t kind of just eat out the lingual without really taking away the length of a tooth. So the tooth still remains long. You just eat the backside out and as the backside goes away, tooth erupts. Not only does it erupt straight down, but it also erupts in. So it keeps getting tighter and tighter over time. And with that tooth loss, sometimes at the very end, it’ll chip at the edges and you can almost see through the enamel ’cause they’ve hollowed it out so much. Very difficult case to take care of because we want to do everything restoratively. That’s a huge flaw in how we’ve been taught as restorative dentists to work when teeth wear they move and if they move you need to move them back. And so we should always think in terms of orthodontics first. So a wear case walks in your office, you figure out am I gonna move them back or is the orthodontist gonna move ’em back? But somebody’s moving these teeth back where they used to be before I fix ’em ’cause you can fix ’em so much more conservatively that way. The only other option you have is open vertical dimension, in which case you’re doing all the teeth upper arch or lower arch or both arches, right? So huge amount of dentistry and most of our patients don’t need it and or can’t afford it. So we need to learn to integrate orthodontics in that regard as well. Alright, back to the topic, which is this pathway wear, where the teeth are getting worn out. So we have for years said, that’s what happens. And people just nodded and said, yeah, that’s what happens. They hit the backs of the teeth and they can’t be restored there. And so then we talk about orthodontically moving the teeth and here’s you have to put ’em back in the right. But we just made the assumption that happens, and I have this weird thing that I do, which is if I ever have a question, I go to the literature and if I go to the literature and can’t find an answer, I do experiments on my patients. Now, I don’t tell ’em really. I just ask. I got this new toy you wanna play with it. And I got a lot of patients that are really fun, been around forever, so they love being involved in that stuff. So here’s what happened to me. I heard it from a lot of people. I heard those patients being called, like they chewed like rats. So they just keep chewing. And I just wasn’t convinced that people would run into their teeth ’cause I never honestly banged into my teeth when I chewed. So I wasn’t convinced. So I went to the literature and then, you know what the literature says? The literature says that if you give people that have tight bites like that, so class two div two type patients. You give them food and they chew, they never touch their front teeth. They’ll do anything in their power including mess up their joint to stay away from their front teeth. And I’m like, well those two things don’t work together ’cause I’m being told by really famous people that they do bang their teeth. But I’m also being told by the research that watches ’em chew that they don’t touch their front teeth. So I went in and did the experiment on my patients to mimic what they did in the laboratory and I found that no one touched their front teeth. So started looking for different answers like. You know, what could it be? What could it be? Well, now airway has entered my world, so I’m now in this airway world and I kind of lose focus on this chewing pattern thing. And one night, about three in the morning, I wake up and I’m like, I wonder if those two things are related to one another. And I got on the internet and I’m searching through the literature on PubMed, and I found a group that actually did a study where they did exactly the chewing study I was talking about, and found that no one hit their front teeth. And then they said, what kind of sandwich do you want to have? Because if you think about it, all the people that break stuff in your practice, they break when they’re eating a sandwich. It always has bread involved in it somehow.  [Jaz]Always a soft one.  [Jeff]Yeah. So occasionally it’s hard foods, but almost all the time it’s like tuna fish salad sandwich, right? Something soft. And it has bread in there. And so this study did exactly that. What they found is that during a chewing cycle, you have to be able to manage your airway. You have to be able to breathe through your nose. People that are constricted in their bites like this. If their maxillas are constricted, and if their maxillas are constricted, then their nasal cavities constricted. They can’t breathe well through their nose. And so if you go from giving a small piece of cheese or beef jerky or a peanut to chew, they can manage their airway, have ’em bite into a sandwich with a bunch of bread and a bunch of stuff in it, they can’t. So their chewing cycle will move forward and they’ll hit their front teeth. In addition, apnea patients make their soft palate numb to holding a food bolus, and so the food wants to slip early on them and so they actually get out of normal chewing cycles a lot. So airway explains a lot of the reasons for tooth damage that we never had an explanation for in the past. We always just called it, this is what they do. They just do that. And we never knew why, and now we know.  [Jaz]That was brilliantly explained. Absolutely love that. And it makes so much sense. You also talked about, when I asked about the great bite, you mentioned a seated condyle position and you also said that, okay, well, in that hypothetical scenario where you have someone who has a restricted envelope function or constricted or basically a lack of overjet, deep bite, and if you open the vertical dimension, then again, perhaps overkill, where ortho is needed and just bringing all those themes together. Do we have a concern in dentistry that when we are doing a rehab type case or when we are choosing to use a repeatable joint position, i.e. stable condyle position, seated condylar position, centric relation, call it what you will, that we are making the airway worse. But from the bulk of this discussion so far, I like how you’ve been addressing it from the maxilla and you’ve been talking about the maxilla predominantly. Whereas quite often in my learning as well, I made a mistake of perhaps being a bit too focused on the mandible. And so what do you think about, if someone’s got a huge slide or they’ve got a long way to go back and that could be making the airway worse, what advice would you give to dentists? When we look at the joint position, when it comes to the airway?  [Jeff]Two things. One is you’re talking about a dual bite patient. A dual bite patient will have greater than three millimeters between their maximum cuspal position and their seated condylar position.  Interjection:Okay guys, interjection number two. What are TADS? So TADS are Temporary Anchorage Devices. They’re also called mini screws. And I’m gonna explain it very briefly like this. Imagine you are extruding a broken down premolar and the way you’re going to extrude this premolar, and actually this topic is on my mind at the moment ’cause I’m going on a course next month exactly about how to do more of these kind of cases where you take like a broken down premolar and you extrude it orthodontically. Anyway, imagine you are extruding this and you are relying on the two teeth next door to extrude. Now imagine that as an unwanted consequence. Yes, the premolar extrudes but the two adjacent teeth, let’s say the canine and the other premolar, they end up intruding. So the premolar that’s broken down, we extruded orthodontically and the other two teeth, they intruded. You could say that you lost anchorage or you didn’t have enough anchorage. Now imagine if the two teeth next door to that broken down premolar were implants. If they’re implants, they’re kind of like fused to the bone. And what then happens is the premolar extrudes. But nothing happens to the implants because the implants give you lots of anchorage. And this is how clever ortho folk, they use these mini screws and temporary anchorage devices to do all sorts of crazy movements because it gives them skeletal anchorage. It reduces those unwanted movements. Back to the episode.  [Jaz]I’m happy to talk about that, but also just generally, like, we know that for most patients, their seated condyle position will be further backwards, further distal. So how do we know which patients can be making worse?  [Jeff]But not much. So my take on this and to my knowledge, there hasn’t ever been a study, so I don’t know of a study. So I’m gonna base this on my opinion ’cause I don’t know of literature. My opinion is that the patients that you and I deal with routinely, that all we’re doing is seeding and equilibrating to and keeping the vertical essentially the same. Those patients that has no impact on their airway at all, the patient would do a dual bite. Absolutely is gonna have an impact ’cause you’re gonna drop ’em back significantly. But the one that people forget is, you were talking about doing a rehab, I would assume you were describing doing a rehabilitation in a seated position at an open vertical dimension. [Jaz]Usually yes, we need the space. Teeth are worn right.  [Jeff] So when you open the vertical dimension, it will absolutely have an impact. And it’s usually negative. [Jaz]So I guess what you’re trying to say also then is, sorry if I’m putting words in your mouth, but you know, correct me if I’m wrong here, is it’s the opening of the vertical dimension that is the sinner rather than the seating to a seated condyle position. [Jeff]Yes, unless you’re talking about a dual bite patient. Okay, so if we take that case out of play, then yes. It’s the opening of the vertical dimension that is the problematic part of it. And unfortunately it hasn’t been studied a lot, but there have been three studies and every one of them shows when you take patients with mild to moderate apnea. And you make ’em night guards and we’re talking just a classic one to two millimeter opening posteriorly, five millimeter open anterior, the one everybody makes that at least 50% of those patients are gonna get worse. And it’s usually somewhere between 60 and one study at a hundred percent of the patients. Now the a hundred percent didn’t get much worse, but they got worse. So if you have a class two patient and you open their vertical for whatever the reason happens to be, there are airways already constricted anatomically, and now you, doubling up on, ’cause they’re actually down the arc already and you’re even like really gets bad fast. Class two even worse than class one patients. So the vertical is the killer. Bill McCor taught me resolution before reconstruction. So McCor is a big gnathologist, lectured at AES and his idea was you need to get the joint healthy before you actually reconstruct. And so he would make orthotics before he would do reconstruction. And his logic was that if opening the vertical dimension was a bad thing, then the patient would react badly. Well, that logic has gone away a hundred years ago. I mean, it just, no one believes that anymore. ’cause that if a person comes in in pain, you make ’em an orthotic and you open the vertical and so you’re making the thing to make ’em better that he thinks might have made it worse, but now that we have this airway data, you go, well, maybe there is something to it. ‘Cause maybe we go old school on this and make an orthotic at a proposed vertical dimension and see how they react to it. If they’re grinding really aggressively on the orthotic, you just made their airway worse. If they get headaches, if they, whatever. I haven’t gotten there. I actually now watch my provisionals more than I used to in the past. I don’t trust my provisionals up front. I tend to stay with them longer if I’m opening the vertical a fair amount, so significant opening of the vertical dimension or more class two type of patient that I’m opening. I stay in provisionals longer just to see how they react ’cause I know I’m gonna probably be messing with their airway.  [Jaz]One school of thought that’s been shared to me is in those patients potentially with a dual bite or those who are, you are opening up significantly. So your vertical dimension increases quite significant due to the level of wear and compensation that’s happened. And because you are opening up so much, there is a concern about the airway. And then therefore you may then not be choosing to use a repeatable condyle position, a seated condyle position. You’re using what they say, an arbitrary position, which could be further protruded or the mandible be set further forward. Do you have any concerns about using such a joint position, which many people with a dual bite may function on? In terms of stability? Mostly in terms of stability ’cause I always think, okay, you build them there, but what’s gonna keep ’em there long term? Is that a way that you’ve managed your patients? What would you recommend to people who who’ve heard that advice?  [Jeff]Okay, so you had a lot of things in there. The first is people that had a lot of wear, they can either lose vertical or they don’t lose vertical, they just lose tooth structure, right? So if a person doesn’t lose vertical, just lose tooth structure, and then you open the vertical, now you’re impinging on the airway. If the person loses vertical and you open vertical, you’re actually just making ’em normal again. [Jaz]You’re reestablishing what they had.  [Jeff]Potentially. You’ve normalized anatomy rather than altered anatomy. The dual bite patient, I tend to work to the bite, to the MIP position, and I remember having this epiphany and I had two denture patients in a row that had an old denture in like a class one setup that were all worn out, and I was making ’em a new one, and I put ’em in centric relation and they fell way back. I was like, holy crap. And so I started trying to make their denture in that position and they go, I don’t like it back there. I don’t go back there. And I’m like, well, I mean, I was cocky.  [Jaz]I’ve been to this exact same thing, one year outta dental school. I remember this exact patient and how much he hated it and it was a huge slide. So yeah, definitely been there.  [Jeff]I’m the dentist. I know it was fast. I can’t control your occlusion unless I worked at this position. It was horrible. And finally, I remember in the end there were two patients in a row. It was weird ’cause it was like God was smacking me twice. You didn’t learn. Here there’s another one, there’s another, all these, keep sending ’em. And I finally learned, right? The second one, I remember one day going, just bite wherever you want. And so she bit down and I made her denture there. It was fine. So I then like went, okay, I don’t need to work to a seated position. I can work to their maximum intercuspal position. What disadvantages are there when they chew hard foods? The chewing data. Remember I said I kind of got into this looking at chewing data. The chewing data on hard foods says they seat their condyles, and so that’s where you damage second molars a lot is they put a piece of beef Turkey in their mouth. They have to load through the food, they will seat their condyles, they’ll hit posteriorly. And so I try to mount them in the seated position and see if I can adjust that on the articulator. But I worked in the MIP position, so I just see if I can provide myself a little bit of a lack of interference in the seated position. But everything else is focused up front. The other one that’s interesting is since I got into the airway part that kind of feeds into this as well, is I went and took some courses in neuromuscular dentistry. And so I started using. A TENS unit on patients that were those rat chewers, the pathway wear people that needed freedom-  [Jaz]Class 2 Div 2 type.  [Jeff]Yep. And then I married that information with MRIs on them, and what I’m finding is that the cases that work really well for neuromuscular dentistry are actually disc displacement cases where the condyle is back and down and the disc is slipped forward and is crowding the condyle out. And if I either tenses them or I can just relax ’em on an orthotic, either way they tend to get to the same spot. But we’re not working down and forward on the eminence. We’re actually centering the condyle by giving ’em the freedom to go there. So, I don’t know, the airway stuff’s kind of opened up a lot of really cool different avenues to look at for like why things work. Because you know, there are too many people that I think are smart people that do things differently than me that I just can’t understand why you would do that. And like, that’s not how I was taught. That can’t possibly work, but they’re smart people and they’re running good practices and I can’t believe they would just like do it wrong. There’s gotta be something to it and airway really feeds a lot of answers or at least can. And so little things like that, like the neuromuscular people got such a bad wrap over here and were just berated every time they did anything. And I was like, those guys, they just can’t be wrong on everything. I do think they overuse it, but I think in the right cases it’s great. It works out perfectly. So I’ve done a few cases like that as a proof of concept.  [Jaz]What you said is very validating for me personally as someone who’s always wanting to learn from the different occlusion camps. And it ties in very nicely what AES is about nowadays in terms of bringing everyone together, sharing knowledge, different camps coming together, if you like. And I always say that listen to everyone, but do what feels right to you. One of my listeners actually sent me that advice and I always like to share it. And so I always find that certain cases, some of the principles I’ve learned from the course of philosophy, they work really well here. Some things that work in this philosophy really well. Just like you notice that okay, certain patients, what you’ve learned from neuromuscular dentistry can be applied well on those patients and I really admire that we can learn from everyone and then pick the right time to use that skill where it makes sense to you the most. Jeff, we’re coming to the end of the time, I just wanna say, wow, that was just absolutely packed full of stories and interesting anatomical explorations. We focus a lot on the maxilla, which was very good for me. This is all learning for me as well, which is fantastic. Can you give us a flavor of what you’ll be talking about at AES in Feb 2026? I’ll put the links and everything below obviously.  [Jeff]Yeah, I’m gonna build on the idea almost exactly what we ended up with, which is questions you’ve always had in your practice that airway might explain and sort of a medical dental connection that the airway could be the component that we’ve been missing all along. At least in my dental school, we didn’t study how people chew. We studied how an articulator moved around, right? So we forgot the biologic part of it. And we talked about my patient, bruxist, but we forgot there’s might be like, why? Why would they do that? And we really didn’t spend a ton of time, we talked about how to make a splint, right? My patient bruxist is let’s make ’em a splint like we always are jumping to how do we fix something rather than asking why. Because if I can figure out why I might have all kinds of cool ways of dealing with the situation. So we’re gonna ask a lot of why questions. Why did this patient do this? Why did this patient do that? And obviously because of the topic and the title, the answer’s gonna be airway. So if at any point I ask the audience like, well, what do you think? Just answer airway, you’re gonna probably be right.  [Jaz]That sounds amazing. And over the years, what does the AES mean to you and why should some of our younger colleagues around the world visit this conference in Chicago? [Jeff]I have to get ’em to add it up. I’ve at least lectured five times, maybe way more than that. I probably have lectured there more than anywhere else in any big conference. And so I’ve gotten to watch it evolve over time. If I was to kind of give you an idea, actually you summarized it really well, it’s because it looks at the broader scope. It’s not exclusionary to any different perspective, even some that you would consider sort of out there. Neuromuscular has been at this conference a lot. Like the best people in neuromuscular have spoken a bunch at this conference. And the other beautiful thing about is they’ll put ’em on panels with people like you were talking about today. We talked a lot about the maxilla. Well I was on a panel with Jim McKee and Mark Piper, they’re the mandible. And so I just kept saying, you gotta get the maxilla in the right place. You know, the mandible follows the maxilla. And so we have this debate and then the audience gets to be involved in that debate. So I don’t know of any other conference that allows that unique of a format and breadth of information. Like AES. So if I was, coming to Chicago, absolutely, the AES starts the week. So it’s a Wednesday, Thursday conference, and there’s no better way to start the week than at the Equilibration Society. [Jaz]And most importantly, Jeff, where is the place to eat when they’re in Chicago?  [Jeff]So this one’s one that it’s, you need to save for a long time. Alinea is the best restaurant in Chicago, and it’s gonna cost you so much money. It’s crazy.  [Jaz]But it’s all tax deductible. It’s fine.  [Jeff]Alinea is phenomenal. It’s a, actually everyone needs to have one of those kinds of experiences and then go back to your practice and try to make your practice like Alinea, because it’s just service at a higher level and thinking about every detail instead of, you know, like I walk into my practice and every day I enter from the back, but I try to go to the front and walk through my practice as if I’m walking through as a patient. And I’m looking at everything. I’m looking at it as a trashcan full. We need to get rid of that. Is anything dirty? Is there a book out of place? Is there I looking, is there anything that a patient might see? And then I listen constantly to how do my staff talks to people and Alinea does a beautiful job. So that would be-  [Jaz]There we are another learning experience through that. Thanks for that share. I’ll make my reservation well in advance before people listen to this podcast and it’s oversubscribed on that Wednesday night. Jeff, for those who are hungry to learn more from you, I know you’ve got so much, you’ve contributed in terms of, in the form of education, so many programs that you deliver. Where’s the best place to book some of your courses and learn more from you?  [Jeff]So it’s my main place to lecture about this is at Spear Education. Spear education’s in Scottsdale, Arizona. It’s a beautiful teaching institute, and the seminars are two days long. The workshops are three days long. But for a lot of your listeners, that’s gonna be quite a bit of traveling to do. And me personally, I’m cheap. And so, although I just told you about expensive dinner, but I’m really cheap if I’m trying to make a decision about continuing education or whatever I want to know, I’m gonna have value when I get there. One of the things you can do is go to Spear Education and get in the online platform, in which case you’ll see all the videos, we produce all the courses, and you can actually watch some of the stuff in advance of coming to Spear and you’ll see the value behind the education that we give you at Spear. So that’d be the introduction I would have if I was living somewhere else. If I was in England, I would watch the online platform and go, okay, that’s something I want to do. Or, I mean, we’ve got courses and everything, so if you happen to be working tomorrow and you’ve got a horizontal root fracture and you want to know what to do about it, we’ve got courses that you just pop on, like a YouTube video and you’ll find out in five minutes what to do with that particular case. So we’ve got all kinds of things, but airway is part of it.  [Jaz]Amazing. I can definitely vouch for the quality of educational videos on Spear Education website as well. So I’ll put the links on there, especially to your stuff on there as well.  [Jeff]Oh, you know what else I got coming? Oh Jaz, I forgot about this, that global diagnosis textbook I wrote with Bill? We got a second edition coming. It’ll have airway in it.  [Jaz]When’s it coming out?  [Jeff]Oh, I don’t know. Whenever I finish writing my chapters, he just yelled at me last night about it. I’m thinking probably the end of the year. So Quintessence and handles it and so they’ll Bill announce it. [Jaz]Amazing. I can’t wait to get a copy and I’ll get signed by you personally when I see you in Feb. Awesome. I’m very excited to meet you in person, but thanks for giving up the time to speak about something that’s so dear to your heart. And I think we can all just learn more about this because the impact, like you said, will have on our patients will be so great. And anyone out there in a position of which way to pivot their career, the early in the career, which way to pivot, then what a wonderful direction to go in, with a health focus and the ability to help children in all ages actually. But such a positive influence you can have. And I think that’s something definitely I’ve picked up today. So thanks so much, Jeff.  [Jeff]Oh, you’re welcome. Thanks for having me.  Jaz’s Outro:Well, there we have it my friends, thank you so much for sticking all the way to the end. Some really great points that Jeff raised there, how the airway is there to explain so many things that are almost unexplained or unanswered. So I’m really looking forward to his talk next year. Also, highly recommend his textbook Global Diagnosis. I know the second edition will be coming out probably, I think at the end of the year. But I’ll put a link to his excellent textbook. If you have access to it, please do check it out. If you’re like a student and you have this book in a library, then please get it. If not, then tell your librarian, you need to get this book. It is phenomenal. Once again, this was an AES takeover episode, so please do consider coming to join us in Chicago in February, 2026. It’s on the Wednesday and Thursday. That’s the AES conference, 18th and 19th of Feb. And it’d be great to to see you there. Come and say hello. If this podcast is the reason you ended up at the AES, please do come and say hello. Now, just to wrap up for those Protruserati who are subscribers to Protrusive Guidance. Thank you so much. This episode is very much eligible for CE Credits or CPD. We are a PACE approved education provider. As you’re watching in the app, just scroll down, answer the quiz, get 80%, and our CPD Queen Mari will email you a certificate. In fact, what we do is every quarter we’d email you your personal dry folder with all the certificates that you’ve collected from the podcast episodes and our mini courses on the Protrusive Guidance platform. More than the education, it’s about the people. Now we’ve really attracted the nicest and geekiest dentist in the world. The reason I specify that is I’m trying to attract people who listen to the podcast, but who identify themselves as nice and geeky. And for those who don’t, they stay away. And that’s amazing ’cause I’m trying to build a special group of people, people who can share failures with each other, be a little bit vulnerable, and it is very much a protected space. We have to manually verify each person who applies to come on Protrusive Guidance. So if this sounds like your bag, then check out Protrusive app that’s www.protrusive.app sign up, and it’d be great to see you there. Whether you want to get the CPD or just join the community, it’d be nice to have you. 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