Protrusive Dental Podcast

We have switched roles! In this episode Jaz gets interviewed by Dr. Devang Patel on The Ultimate Dentist Podcast. The focus here is bigger picture stuff: trying to improve your clinical skills, finding your niche, dealing with imposter syndrome, burnout and the need for FOCUS! https://youtu.be/ituRPR_UNWE Check out this full episode on YouTube “Gain some self-awareness, figure out what your strengths are, and play to your strengths in your life, in your relationships, in your career, and everything!” Dr. Jaz Gulati Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 3:34 Motivation and Challenges in doing Dentistry 7:17 Niching down in Dentistry 11:55 Becoming more focused on the path you chose 16:35 Journey in implementing what you learned in clinical practice 17:38 Protrusive Dental Podcast Journey 21:51 Dealing burnout in Dentistry 25:26 Future Plans 29:41 Criteria on CPD Courses 31:33 Lesson learned on the journey 36:50 Golden tips for the new dentists 42:16 Improving your Dentistry Want to expand your horizon with TMD and Splints? Check out SplintCourse for a comprehensive online course. If you enjoyed this episode, do check out Adhesive Full Mouth Rehabs in 11 Appointments with Dr. Devang Patel Click below for full episode transcript: Opening Snippet: /Jaz/ But you can't own the patient's problem. /Dev/ Yes! /Jaz/ You still have to care as a clinician, be a caring clinician, but you cannot take that problem home with you. So, if I learned that sooner, I think live in a better place. [Erika from Team Protrusive]Hi guys! This is Erika from Team Protrusive. Jaz is sick with man flu and Ishaan has chickenpox. Please enjoy this episode from the Ultimate Dentist Podcast with our friend, Dr. Devang Patel. And we will be back next week for a protrusive episode. Enjoy! [Dev] Main EpisodeHi, everyone! So today we have famous Jaz Gulati with us. He is actually my mentor. When it comes to doing podcasting, and learning other skills. I’ve learned a lot from his SplintCourse. And I would like Jaz to elaborate on that as well. But Jaz, there are very few people who doesn’t know you, could you please just introduce yourself as to who you are, what you do, and you know how you divide your time? [Jaz]I’m a guy who’s wearing his scrubs in his conservatory holding a Thano’s mug. That’s who I am. Dev, thanks so much! My name is Jaz Gulati. I’m a general dentist. And I guess what I’m about is learning, sharing, and having a good time making people fall in love with dentistry all over again, and having a good time. And that’s essentially my mission statement. [Dev]Okay! So Jaz, as we discussed, when I started this journey, I thought you were the first person, I contacted you. Because your podcast is really inspiring. This podcast, I want it to be for people who are graduate or who are, whatever time in their journey. They want to now up their skill. And then they’re looking forward to emulate or model someone else’s success. And what I’m trying to do is I’m trying to capture those people’s journey. So, someone can look at and listen to the podcast and say, ‘Okay! you know, what, Jaz did this.’ And in general, if you do that, if you put in that hard work, you do tend to reach that goal. But my aim is not to reach that goal in that time. Probably you reach your goal in 20 years time. I would really like to get some tips from you. So the journey is shorter for the newer dentists who are listening to this podcast, and they pick up on things and you know, they learn faster. So how does that sound? [Jaz]Dev, it’s such a great idea! Because essentially, you’re journaling everyone’s experience, and you’re going to fast track everyone. So you know how they say, stand on the shoulders of giants. Essentially, that’s what you’re doing. What you’re going to be doing with this podcast, and I can’t wait to see it watch and grow is helping people to be the best version of themselves in the quickest time as possible. And quite often when I’ve been recording episodes, in the past, and the topic might be something clinical, but those 5-10 minutes we spend on the journey. That’s always I feel well received. And people love to hear stories of others experiences and journeys, and that’s what you’re gonna extrapolate. So it’s very exciting to what you’re doing. [Dev]Yes. Because whenever I want to learn as well, something I see what that other person is doing. And I’m not that intelligent to invent a new wheel. I’m just going to follow if someone’s created one, why should I invent another one, that person’s gone through the hardship. And if you get those golden nuggets, golden points, so I probably reduce that hardship as Warren Buffett says, ‘Learn from other people’s mistakes.’ You will grow faster, rather than learning from your own mistakes. That’s a very expensive way to learn. So, to start with, why did you decide to do dentistry Jaz? What was your motivation behind starting doing dentistry? [Jaz]Mine’s a very clear one. Like, for me, some people like, “Ah, I don’t know, I was Googling and this happened.” For me, it’s like, I was 14 and I wake up, look in the mirror. And I used to have this upper left one because, you know, with dentistry, we can talk about it upper left one, which was literally so proclaimed this one rogue tooth, right. It was hideous. It really put me in a down mood. It was like a subject to bullying. I hated it! I was desperate for braces. So, that fateful day came, I had braces and very quickly the teeth align, right? I felt the change in myself. I felt it, internalize myself. I became so much more confident. I became the guy who you see in here now. I think that was such a great thing to me. So, I wanted to bottle that feeling up and give it to others. And then just the way that I was inspired, I guess, or the way my shackles are broken by getting a beautiful smile that was proud of. I wanted to be involved in that. And that’s exactly the path that led me to being here today. [Dev]And so once you get into your, undergraduate years, what sort of difficulties did you find? What sort of challenges you find during your university days? [Jaz]The usual stuff Dev. In dental school, I guess when you look back now, it’s obvious. But when you’re there in the moment, you don’t know any different. It’s like, one in like every day, there’s only such a few patients you can see. And then of those 50% of them will just not turn up they’ll dna, right? And so, it’s a very slow and frustrated learning experience. Some of those things that we learned are like, three hour lectures and waste management. And three hours is the total time you get to occlusion the whole five year as well. So like, it’s learning about shit that you don’t want to learn about. And if you’re podcasting be explicit or not, but it’s learning- [Jaz]You’re just learning about, but you kind of have to do, you kind of know it is you kind of have to. So that was, I think, frustrating. But to be fair, at the time, when you’re there, you’ve got all these new friends and you’re going through this journey together that community spirit. I didn’t realize at that time. I look back, I said, ‘Wow! dental school is so inefficient.’ But when you’re there, it seemed like a good time and a lovely undergraduate time. It was good, fun. Fun is definitely a word I’d use or the memories. And you think of the all the non-clinical staff or the holidays, the elective in Vietnam, all those fun things. So I guess overall, I had a great experience, very social experience. But when you look back at it, you think ‘Bloody hell, that was an inefficient way to learn.’ [Dev]Yes. I always tell dentists who are an undergraduate that you know what, ‘Enjoy! Savor these years.’ Sort of have an experience of different things, because you will never be in that kind of environment again. Because as we know, when you come out, when you work in a real world, there’s lots of fears and lots of insecurities you have. Litigations and everything’s quite high up in dentists mind, and the university days are the time where, you can work freely. [Jaz]That’s true, Dev! I just wanted to add to that, actually those tutors that we have when you were a student at dental school, they are the same tutors who do like big courses and stuff. And they’re international educators and whatnot. And then they’re at your clinic, they just sat there in the office, writing your paper over. Just knock on the door sometimes, and have a chat and ask a good questions. And you’re gonna get that knowledge for free. So put yourself out there. If you show an interest, you’ll be amazed how these educators start showing an interest in your development. So I think there’s nothing wrong with actually showing an interest to that person as well. [Dev]Again, I’m paying the price of not learning as much in my undergraduate because I’m now kind of relearning everything back again. But it’s fun, because you can put into practice straight away. That’s the beauty of working in a real environment. So, let’s say when you finish your undergraduate, your BDS. Many people have different paths. So you have oral maxillofacial path, or going restorative, working in sort of general practice. How did you decide what path you wanted? Were you clear about it? Or did you sort of hesitated, what happened then? [Jaz]Initially, I was very clear Dev because my mission, I decided that I didn’t want to be an orthodontist anymore. Because on those ortho clinics, I don’t have a clue what was going on. I wasn’t inspired by the tutors I had in ortho. I was inspired by the restorative guys, and then also some more dental treatment that happened to me. In my undergraduate years, you wouldn’t believe this. The ortho that I saw highly praised that got my teeth fixed up was also the result of my lower incisors. All of my lower incisors becoming non-vital, having huge periapical infections. My lower central incisors being cracked and having being extracted. And now I’ve got three extractions, one of which is a Zirconia resin-bonded bridge. And so, I’ve been through it all. I went through all that in my undergrad, then I was like, ‘Oh! I want to be an endodontist.’ And then I was like, ‘Oh! I want to be a restorative dentist.’ So you know what? It was as different touch points. So, I wanted to be a restorative registrar. Something very appealing about being shit-high Endo. Really awesome at prostho. Really good at perio, like that was like the dream, right? You want to be a specialist in everything. And then when I did my DCT post in restorative, I’m so glad I did those posts, because it made me realize that okay, I don’t see myself having a future here. I feel as though it’s got the same drawbacks as being as an undergraduate, like it’s very slow paced. Innovation, unfortunately, doesn’t happen in these hospitals. I’m sorry to say. It happens in private practice. And then I realized that, I don’t want to pursue this five years Registrar training. I rather learn through short courses, mentors, one or two-year programs. And try and be good at all those disciplines and be the best GDP I can be. That’s how my soul journey evolved from being very set in my ways about, I want to be a restorative registrar to then accepting that you know what, this isn’t for me. [Dev]Yeah, I remember my undergraduate, if I’m posted on ortho department, I wanted to become orthodontist. If I’m in endo department, I wanted to become endodontist. If I’m in surgery, I wanted to become oral surgeon. It’s difficult when you come out. What would you like to do? So- [Jaz]And Dev, no one wants to be a GDP anymore. [Dev]Yes! [Jaz]You ask all these young dentists, they want to be a prosthodontist or a periodontist. They want to be a bloody public health specialist. Who wants to be a GDP- [Dev]I’m GDP, you are GDP, right? I consider myself a GDP. I’m not a special. I’m not- [Jaz]You’re a super GDP, Dev. You’re something else! You’re doing Khoury replacement one day then you’re doing like random other things. You’re a super GDP. You’re like a Lincoln Harris level, you like super GDP- [Dev]It’s good because then it gives me flexibility. If you’re doing just one thing, which is you know, there are two different thought process some people will say, you just need to do one thing to get good at it. But my thought process, if you’re doing everything is like good general dental practitioners, then you can plan cases like no one else can plan. Because endodontist will only see canals and you know, the teeth restore. Prosthodontist will you know implantologist will see things different. Orthodontist will see things differently. But if you’re doing all the disciplines, and I certainly encourage everyone to start with that. And then obviously, find your passion and then funnel in and try and release- [Jaz]Niche down! [Dev]Then exactly niche down but start with becoming a good general dental practitioner, because that will help planning your treatment plans. [Jaz]Dev, I had a dentist shadow me the other day, right? No, dental student, you won’t believe it, I had a fourth year student shadow me the other day. And he placed an implant. He’s really into implants. He’s from Egypt. He’s a dentistry student in Egypt, came shadow me. Hilarious! I won’t go into, maybe have time at the end. Well, I’ll tell you the story of how he actually fell in dental school. That was actually hilarious. But I’m like, ‘Dude, slow down!’ You only learn occlusion yet. So I think there’s, it’s good to do everything. But there’s a time and place for everything. So where do you think we should be, just finishing as an undergrad, where is that sort of standard? [Dev]I feel the standard after someone’s undergraduate finishing the graduation? Well, unfortunately, I teach as you know, postgraduate students who are in the standard is not as good, unfortunately. At least the people I’ve seen, I’m not generalizing, but the dentist, I’ve seen the standard is not good. And there is definitely room for improvement in doing general quality dentistry. Of course, if you just want to do oral surgery, then that’s fine. But if you want to do restorative, then you need to learn everything. To start with, and then obviously, as you said, niche down. So how was your first few years in foundation year or whatever you did restorative course? How was that? And how did you become more focused in what you’re doing right now? [Jaz]So the first paycheck I had, October 2013. I went on Gumtree, and I bought a secondhand camera, lens, flash with my first paycheck, to the extent that I was emailing this guy to buy his secondhand and macro lens. And for some reason, because I was polite, and I email, he thought I was a girl. And then he was flirting with me by email. And then, I had to pretend to be a girl to get the best price possible by email. So then I took my sister to meet this guy, like 20 miles away. And I made my sister go out and give them money and bring the lens back. So, the lesson here is, I knew I was listening, I was listening, I was listening, every bloody lecture, I went to about career progression. The first thing they said was buy a camera. So, it’s all good and well having knowledge. But I want to implement. So first paycheck, blew it all on the camera, basically, and a few little things. And then I started taking photos and photos and photos and photos. Like hundreds of photos. I had loads of batteries then. No stock of it. And they were all rubbish. So I’d go back now they’re all rubbish photos. But if I didn’t go through that rubbish period, I’m quite proud of my photos now. Very consistent, my quad photography is solid. I don’t have any issue with occlusals. And that is such an important thing now when I look back at it in terms of my development. So, first thing to do is I was very focused, take loads of photos, try and improve myself incrementally. Go on loads of courses, to the extent that it was a bit crazy how many courses I was going on. Because my philosophy was, first five years out, learn everything, and anything. Go to every free course, every section free course, every 50 pound course, the occasional more expensive course. And I was like a sponge, absorbing it all. And that helped me to then eventually decide where I wanted to go. [Dev]Yeah, I think that is really important. Because when you come out, you can even do 50 pounds section 63 courses, which is really good, by the way. I mean, I teach in Section 63 courses and I don’t teach anything different because people are paying less money. You know, so- [Jaz]Yes, exactly! [Dev]I don’t see any teacher who are teaching less because they are just delivering in a different way different platform. If you ask them question, they will always give the same answer kind of. So in the beginning, yes, I agree. Because you don’t have much you know, whichever course you go to, you are going to learn. Right now our level is such that now, if we go in someone, another course occlusion course let’s say, someone who is newly graduated will take more in because they will have more to learn than us. I mean for me when I go to course now I’m just looking for that small nugget. I’m looking for that small tip which can sort of improve my quality of dentistry. [Jaz]And the entire course will be worth that one small tip, right? You’ll find that it’s just one tip you gain and it’s worth it. Whereas when you’re newer, you have so much to learn. And then sometimes, because you have so much to learn, it can daze you, it can be a little bit too much. And then maybe unison, you know, you might not grasp it the first time around, but that fourth time you finally get it. And there’s no shame in that. Right? [Dev]And so you went on these courses, what I’ve found is that, when I do course, when I teach someone, they all love courses, obviously. And my aim is to make them implement that in their own practice. And that’s the whole goal, when I do that courses. How did you implement? Because the success of the course you’re doing is not almost on the tutor, it’s on you on implementing it. So did you find any difficulty? Like, you know, most of the time people like, ‘I don’t have this material. I don’t have this instrument. I don’t have patience.’ How was your journey in implementing what you learned in your clinical practice? [Jaz]Such a great question. And nowadays, if you listen to the podcasts where I talk about now, I talked about this as it’s just a big thing about knowledge is useless without implementation, right. So all these courses, they’re rubbish, unless you can apply it. So nowadays my mantra is, if you have a crown lengthening case, a patient who’s shown interest, then go on the crown lengthening course and then the next day, apply it. That’s my thinking now. [Dev]Yeah! [Jaz]But, I think like everyone, when I was new, man, I was going on everything in anything. It was all about breadth and not depth, which is the opposite. Now it’s about depth and not so much breadth. And so, I went through all where I’d go on a laser course, I didn’t really have a laser or anything, or just give an example. I go in a microscope thing, and I wouldn’t have a microscope to use. And all the things samples you can think of. Like I go on like a fiber reinforced bridges course, guess what, I didn’t have any fibers. You pick up a few things. But yeah, I was poor implementation. And so I wasted lots of money, lots of time, wasted on those courses, because I didn’t implement it. Now, because I was in my first few years, I don’t regret it because it was networking. It was a day out. It was still learning about bonding principles, seeing what’s out there. But definitely, I think a key lesson that we’re sharing here is implementation over everything. [Dev]Yeah. And again. So that’s the reason what I do is I would have my course running six months earlier than the hands on course. So people would start the course six months before, so that they can find that patient by the time they do the hands on course. And I think that’s the key for implementation because I’ve done in past so many courses. And I’m sure you have done splint courses where if patients, your students don’t have patient for splint, they forget, you know that obviously, your course is brilliant, and it’s online so they can go back. And that’s what I tried to replicate as well. But you know, that hands-on course, when you do that implementation is the key. Now coming back to a different side. Now, you know, you’ve done really well clinically. Now you’re giving back almost a lot more. And how did your Protrusive Podcast journey started? I know you described it a lot of times you started with the group, but if you could for my audience, go through it one more time. How did your journey started? [Jaz]Okay, the journey started when I was in Singapore. So surely where I left off before, I did the whole DF one DCT one, DCT two. Then I decided, ‘Oh my goodness!, I don’t want to be a restorative restaurant after all, because it’s not for me.’ And then I was, Liike what do I do? Do I enter the rat race now? Do I get a mortgage? And that’s it right? You know, I’m stuck now.’ Or what me and my wife decided to do at the time was let’s move to Singapore. Let’s experience a new country. Let’s go traveling the world. Let’s work as a dentist in Singapore. So I did that. My wife got homesick. So a year and a half later, we came back to the UK to see family and stuff goes she’s very homely and whatnot. I bloody love the Singapore. I want to stay there forever. So anyway, I came back and then rumors started spreading amongst UK dentists. ‘Oh, this is guy. He went to Singapore. He lived the good life, cool Jaz.’ And he’ll tell you how much dentists will earn in Singapore. What the language barriers are? What exams you need? How to find a bloody job? Everything, right? And so everyone and their dog had my phone number, right? So, every day from London to Oxford as I was driving there and then driving back, thank goodness I had this long commute. I was on the phone to a new dentist. There’s like a queue of dentists I’d call basically to just guide them through the same story. So, I thought to myself bloody I was knackered I was like, if there was a way to record my voice and record this message to everyone and just send them like a WhatsApp message or something, would that be great? A podcast? So, Episode One was expert dentists in Singapore. And then it was like okay, this is this is fun. Episode Two was like dentists in USA because I had my friend who has met in USA and then Episode Four for was Australia. And then it was me, I was like, ‘Actually, you know what, I’m not so passionate about dentists abroad. My real passion is clinical dentistry geeking out.’ And I got over my imposter syndrome. And started to just geek out and talk about all the things I love with amazing guests like yourself. You’re three parts on the format rehab and three episodes. I know you get a lot of love for it. You must do. Because people come to me and again one day, Dev you won’t believe this, Hameed, messaged me he said he learned more from those three episodes than he did from the entire Dawson curriculum. Entire Dawson curriculum. [Dev]I tell you why because you have the ability to make things tangible. Because I listen to your podcasts and I learn more than some of the books I read or some of the courses event because you have the ability to make it tangible. You don’t like wishy washy. Tell me what it is. And I think that works really well. Because us as a dentist we like step 1-2-3 kind of. We’re not into gray stuff. It’s better to have black and white. And you’re very good in making your podcast tangible to the level that you keep saying tangible a lot of times. [Jaz]I do. It’s become a mantra and I’m making dentistry tangible. I think it’s a great thing because so much of dentistry, A) is confusing, but then so much of it is actually simple, but it’s presented in a confusing way. So I get on great guests like yourself who made it tangible over three episodes. That was if you haven’t listened guys, listen to Dev’s three parts on full mouth rehab, a decent full mouth rehab in three episodes. Like we cover it in three hours, you’ll gain so much from this free resource. And you have to join Dev’s groups on format reconstruction for GDPs. I’ve got my principal actually, John. I’m sitting in the conservative recording with you. John’s doing a virtual console in my living room right now. And he knows you. ‘Oh, yeah, that episode was awesome whatnot.’ And he really loved it. He made it really tangible. So everyone knows about you, so- [Dev]Perfect! And as I said, I think I feel I know, it’s because of you Jaz. And it’s not back and forth. But really I’m there, right, I’m the same person, but it’s somebody it needs someone to strike that information out of you. So with this journey, have you had any struggles? I mean, what are the benefits you found out in your podcasting journey and the group, you know, created really an environment? What are all your struggles? Because doing a good clinical dentistry, spending a lot of time clinically and then spending a lot of time on your group on your podcast. Burnout is a big thing in dentistry. And you know, I truly believe I remove burnout. And I can only speak by myself. I deal with burnout by learning more, learning new things. Because I feel that people burnout many times is because they’re just in a rut, as you said used to in and out. But how have you been first of all in that situation? And you felt, you know, a little bit burned out? And how did you deal with that? [Jaz]Yeah! I have been in that situation before, two or three times in my short career so far, I guess, where I’ve really felt it because there’s so much going on at the time, I was getting married, and I was a DCT person so so much going on there. Just a month ago, I was like, Oh my god! I got my first ever full day occlusion teaching. I know you’re so experienced to doing it but for me is my first full day of content creation for that. And that was coming up to a live audience, I was getting this massive impostor syndrome. And then two days after was a full night of the live event and whatnot. And that really had to be worked up. And I think in both those times where I felt overworked. The way I got over it is, I used to believe that passion is the antidote to burnout. But I know that can be dangerous. And I want to just say that, you know, I still have experienced it. But it’s been short lived. It was 24 hours. And what got me over it was my wife and my son and a support network and cuddles and just knowing and having some mindfulness and realizing that, okay, you know what? That’s done. Now, let’s take a breather, switching off, and then reigniting and going again, basically. So it’s important to have a little bit of downtime. And I guess I’m in a situation now where, like, I have so many unread emails, which is not like me at all. I have so many unread emails, unread messages. I try my best, but I’ve accepted that I can’t be everywhere all the time. And family first, my health first. And then I always try and make time for all the lovely dentists who have something to share and I want to share something with them. So it’s all about compartmentalizing your time. And you can’t make yourself available to everyone all the time and realizing that, that’s okay! It’s okay. So I think a big part of me having the energy and the mental capacity to continue to do what I do is realizing that it’s okay to not have to completely destroy your mind and body to be able to achieve everything you know, you’ve got to look after yourself. So I think if you look after yourself, then you’ll be able to then serve others. [Dev]So how do you look after yourself? Do you have like hobbies? Outside dentistry which sort of breaks that stress level down? Obviously, spending time with family is quite important. [Jaz]Yeah! For me, it’s Cricket. I’m a huge cricket fan. IPL just finished, I watch a final on Sunday with my dad. So I used to play a lot more but shoulder injuries, I play less and I can’t wait until my son Ishaan starts playing cricket and supporting him in that. And then as cheesy it sounds, I’ve always been like so broody. And when my son came along, it was the best thing ever. So I’m a really passionate father. So when I’m with Ishaan, I’m with him. I’m not like multitasking everything. I’m 100% present with him. And like I did this mean, watch this, like online parenting course, believe it or not, right. And it’s amazing. The advice that this little lady Amy McCready. Like she she gave this advice that all you need to do is give your child 10 minutes of undivided attention per day. That’s it. Bullshit! Okay. 10 minutes is not enough. I think. When I give my son 10 minutes, no, this is the beginning. I usually do. It doesn’t work. Okay, so I tried that is that no, I don’t want to do that. And be just as a word. So when I’m with my son, I’m with him. And that gets me through as well. So cricket, and family and just, you know, watching my son grow up and teaching him things, which is such a beautiful thing apart. [Dev]So what are your future plans? And now you are where you are? Do you have any future grand plans? How are you imagining yourself in 10 years down the line? 15-20 years down the line? If you have sort of planned it that way? [Jaz]Yeah, I think in my journey, where I am now is I’m loving being a GDP. I’m getting a lot of TMD referrals naturally. And I haven’t really marketed myself to the public as TMD because then you really get overwhelmed. So I’m getting a lot of word of mouth, staff and referrals for dentists. I’m enjoying doing that. But I have podcasts about this for like, do you really want to limit your practice TMD? I don’t know. I like doing a full mouth reconstruction as well when TMD is made may or may not be involved. I like doing my Invisalign. I like doing my general dentistry. I like seeing children. I like doing my general dentistry. So, I’m at a crossroads where I think okay, do I increase the TMD stuff? Or do I keep it on the DL and treat the cases as they come along. But definitely the growth area for me and think I’m learning more about is airway. Learn more about airway, myofunctional therapies, and whatnot, to be more holistic. And I’m just enjoying learning and growing in that. And with a podcast, I’m just having such a great time there. There’s so many great dentists to interview and you’ll love the same with this as well with where you’re going with ultimate dentists. There’s so much fun to be had, and people resonate with energy. People can really pick something up and that really drives me. So continue to podcast, learn more about airway, which is such a fascinating area, and continue to enjoy the dentistry. But I think the thing I want to improve on myself is make more time for important things in life. And for me the thing with all the things that I do, the thing that I’ve let down is exercise, actually. So I used to really into gym and stuff. So the thing I need to really allow myself to do is get back into fitness and body health. As well as you know, all the fun things I do with family, the part that’s been neglected and just being out and open it is my health in some ways. [Dev]You know, this is funny, because in the sense that I have also done that, you know, grind. And all it came down during I was away on a course this weekend and all it came down to health. Because if you don’t have your health, you cannot work and you know, 100 miles an hour speed. So you know, it’s it you do need you need your health besides you if you want to play a long term game, because for short term everyone can- Because you’re young, you know you have energy. But if you want to do this long term. So are we going to see more of your courses on splints and how are you planning to spend more time on teaching? Or are you still concentrating more on developing clinical practice referral base and everything? [Jaz]I think a bit of both. I love teaching when I did my PG cert and dental education in 2013 as a DF1. Because I decided at that time, nine years ago, I decided that I want to have a profound impact in education in some way. I just decided and it’s just funny how it came to be and I’m hoping to make a dent in the next 5-10 years. But it’s a part I really enjoy. So when I did my first full, you know, nine to five full day of teaching the energy and the bars like you know, I wasn’t exhausted, I was buzzing at the end, question and stuff, sharing, learning. So, it’s definitely something that excites me so much and you’ve got to do what makes you happy do what excites you. So, I do seeing that hopefully, if people were to listen, learn, I’d love to navigate but I think it’s also growing my clinical practice. Look, I have a situation where I can do bigger case and stuff. But I want the five and ten year follow-ups. There’s no shortcut for that. That time, you have to do your time and see your recalls and stuff and then learn. Because, you know, failure teaches you so much. And the little failures I’ve had have taught me so much always. So, I also want to be at one place for a long time to learn, learn, learn in my own. And so there’s a combination of sharing some of them on basic things. But as I advanced in myself, if I can share that through a podcast or whatever with others and learn as well, by getting a really clever people on, then there’s so much fun to be had in that regard. [Dev]I agree 100%. So when you are, let’s say selecting any CPD courses, now, what are your criterias? What are you looking for, to do yourself? [Jaz]Right! So, I think there’s a trap that some dentists fall into, whereby they go on one composite course. And then six months later, they go on a different composite course. And then a year later, they see ‘Oh, this educator looks really fun and whatnot’, and they go on their composite course. For me is that once you’ve done a composite course, just implement, just implement, implement, implement, take photos, send it back to that mentor, educator, see how you can improve. I’m not saying that just learn from one person only. But don’t fall in the trap of just as you’d like composite that you’ll go on every single composite educator, right? Have a different, have some more strings to your bow, right? So, have a different learning pathway of learning different things, not just one thing from various different educators. When it comes to me picking now, I know that I’ve done enough composite and I’m very much implying it. I’m not, my posterior composites aren’t amazing. They can be improved, for sure. But I feel as I’m placed that okay, my patients are happy. I’m getting the occlusion, right. Yes, they could look a bit prettier. But that’s right. Because now I’m looking at okay, where are the gaps in my knowledge? But my patient population needs. So, I’ve got very elderly population. I’m doing far more crowns than I’m doing composite. So, that’s why I’ve really in the last three years, I’ve really gone deep into vertical crowns. I love doing vertical crowns. Okay, I think there’s so much beauty in that. And so now for next course for example, next course I’m booked on 15 in July is a Perio-Prostho 1 with Dr. Bilal Asha. He’s doing playing with the gingival levels with something I’m already doing with crown lengthening and vertical crowns. But I want to get a deeper knowledge I’m gonna learn from him. So it’s about what’s going to serve my population base? What are things that I haven’t been on a course on before? And how can I marry those two together? [Dev]Okay! Your journey has been amazing. And it’s an inspiration. And just to some sort of things up, if you have to do something different. Let’s say you rewind, 10-15 years back 2013, let’s say, if you had to do you know, now you’re back, knowing what you know, now, if would you do anything differently than what you’ve done now? [Jaz]That’s a really tough question. Because I’m a big believer in like, you know, like you said, as well- [Dev]Join some. [Jaz]You can only, yeah, you can only join the dots when you look back, right? You can only join them when you look back. And you look forward. Yeah. So, everything that happened is a blessing in the way that, okay, I am in a practice, which is 15 minutes walk from home. And it’s like lifestyle design, right. I design my life in a way that, okay, you know, my son’s nursery is behind my practice. My wife works, the next street along with my own my as a community dentist. So, I am really proud in the way that I’ve done a life design to be in a situation now. I’m also working shift pattern 8022208, which really helps in getting all the other things done. So I’m happy with that. And all the things led to coming out there. So, I can’t really say I change anything, but I guess a lesson that I could pass on is, I used to, like, I used to take out a tooth on someone, and then in before going to sleep that night. I think, ‘Oh man, what if that patient is in pain right now?’ Or I’d maybe would take an impression that wasn’t very good. And before going sleep, I be like, ‘Oh man, that air bubble in that impression.’ Or whatever, right? Bringing those issues that you know worrying seals, nothing except the peace of today, home with you. And then about when you’re bad sleep, it’s not a good place to be in your mind. It’s good that I care. It’s good to care. You should care. Care enough that you really show it. But at same time don’t care. So it’s you’ve got to find that balance, right? It’s not, you know, you can’t own the patient’s problem. Yes, you still have to care as a clinician, be a caring clinician, but you cannot take that problem home with you. So if I learned that sooner, I think I’m in a better place. [Dev]And it gets worse as you do. I mean, again, when I did my first two Khoury plates. As I worried if patients come back with a hematoma where the bleeding or you know, you worry a lot and again, when you do more complex cases, the stakes are higher. They’re more risk. [Jaz]But that’s because you care, you’re caring practitioner. You want everything to go well. You care for your patient. You care. You got to draw the line somewhere that okay, you can’t then, think about it and dwell over it for too long. [Dev]You know what? But it also comes with experience. So you’ve done enough and you know what, yes, I know this. And also it comes with patient education. So, now for me, if I’m worried about it, I’ll tell the patient. So then I know that okay, you know, patient knows, because many time you’re worrying because you think that patient might be in a situation where they don’t know what to do. So if I’m worried about, you know, hematoma or any problem, I’ll say, ‘Look, this is Friday, I’m doing a surgery.’ We can disclose, take my mobile and all my patient has my mobile, and I only have one number. [Jaz]You’re brave man! You’re a brave man, Dev. [Dev]Do you know what? In this country, we can do it. I just want, I want this. Yeah, I don’t want to elaborate. But here, it’s fine patient usually don’t contact you. Unless there is a problem. And I do push them to contact me. You know, I said, ‘I don’t wait until your review appointment and tell me that, oh, you had I don’t know, exposure of bone grafting or something like that, because there is usually no pain. So obviously, if you see any problem, call me, text me better than emailing me because I don’t go on email all the time. So just call and text.’ So if I don’t receive any text or call, I can sleep peacefully, because I know that, you know, things are fine. So I tell patient about dry socket. So if I take the tooth out, I tell them that, you know, it was a difficult extraction. Because, you know, whatever reason, there is a likelihood that you can get dry socket it. They might be a smoker. Having said that I don’t see that any smoker because I point blankly refuse to say, look, you know, you need to stop smoking. Before we go on to the implant or surgery journey. One of the way I found is just one patient, that this can happen. So the patient know. Obviously, they might freak out a little bit, but at least they know that this is one of the consequences. [Jaz]Yeah, if you’ve preempted something and said that, okay, if you get this kind of thing, then yeah. Call me if it’s this than other then don’t call me. Yeah. [Dev]Well, yes. So I mean, my nurses are trained to pick up the phone when they call next day. And tell patients, whatever patient says the first thing they said, ‘That’s normal.’ And then they panic, and they call me later. So, but usually, the first sentence is that’s normal unless it’s obviously there is nothing something abnormal. Because they have seen as well patients, how things goes, because when you do big surgeries, patients swell up. And even though I tell patient how big the swelling will be, they don’t generally, be able to visualize. I’ve started taking photos of the patients. I’ve asked them to send me photos in five days time. And then I show it to with their permission to other patients. So then they see. Because in the beginning, I was- [Jaz]That’s a good one. [Dev]Yeah. Because in the beginning, I was worried about scanning patients, but now it’s all about education. You just educate patient, and, you know- [Jaz]And setting expectations. [Dev]Yeah, the stress is less. So going back to your journey, let’s say if someone’s just finished undergraduate. They’re now dentists, they’re doing, you know, doing foundation training, or whatever they call it right now in the general practice. The whole point of this podcast is to speed up their journey. Can you tell us some golden tips, nuggets, which you want to pass on to, to make them more focused? Because I feel when you are focused, you can achieve things very quickly. More focused, and if you have any pointers as to, you know, do step one, step two, make it tangible in that sense, in your own words, how can we help them? [Jaz]Sure the things that come to our mind straightaway is an I’ll named the people who taught me all these things. Okay. So, James Goolnik top guy in London, got a great campaign about kicking sugar out, fantastic dentist. He taught me to buy this book called StrengthsFinder 2.0. And I did the book, this book, I did the quiz, and it gave me my top five strengths. So that builds self awareness. And there’s a whole theory that okay, you know, build on your weaknesses. But actually, what that book argues is that you will go much further in life, if you actually just focus fully and go all in on your strengths, you will actually make a much better trajectory. So gain some self awareness, figure out what your strengths are, and play to your strengths in your life, in your relationships and your career and everything. Number one. Number two is what Koray Feran taught me in a DF1 lecture many years ago, I’m a big fan of Koray Feran. And he said, ‘The secret to success or the hallmark of a great restorative dentist is the Trinity.’ So he thinks, okay, it’s magnification, illumination and photography. So get your loops, get good lighting, and take lots of photos. And then Lincoln Harris, told me, ‘Take photos, every patient, every time.’ And if you take a perfect photos, every patient every time, you’ll get you know good really fast taken photos. And then you get over in the beginning we take photos is like a big deal. Like training the nurses, buying the bloody retractors, not knowing which retractors to get it’s a big deal. It’s a big friction at the beginning. The sooner you can get over that friction. Get those reps in are picking up the camera. Getting used to holding one hand, taking the occlusal photo by itself, that really accelerates you. And the final thing when I say Dev to really, really get everyone up to speed clinically, as quick as possible is if you want to, if you want to grow as a dentist, take photos, if you really want to grow as a dentist, show your photos to other people. That’s when it strikes a fear of you know, fear of God into. And that’s when your work magically improves. And that’s where things beautiful things happen. Even if your works not so great the beginning just by sharing and getting over yourself. And then taking more and more photos and sharing. You can some people’s Instagram profiles are prolific tempos, scroll all the way down to 2014 or something. Look at their photos then, and they weren’t as good as they were now. But they’ve been taking photos and sharing them sinc e day one. And that’s the secret to growth. [Dev]And again, I like your idea of creating a group of the mess ups, you know, the failures, because what happens is when you are new graduate, when you see those Instagram photos, you think, ‘Oh, this is the dentist, this is it.’ You know this person, I mean, they have learned it, I mean, I have messed up many times, I still mess up. And but those are the photos not being uploaded on Instagram. And it gives you that illusion of perfect dentistry. But you know, you learn and I think social media is helping a lot of dentists. But also you need to be bit careful, looking at personal, how they portray themselves. And that’s why I really like your idea of creating that group where you post your mistakes, because you know, that’s the way to learn. And if you haven’t taken, I will tell you initially, when I started taking photos, I would not take photos on my bad book because I was so depressed, that you know, this is not a photo. But now- [Jaz]You can’t bring yourself to click. [Dev]Yeah, and my notes like you didn’t take the photo. Even my patient one time I fitted a implant crown. And I told him like, look, I want to change his crown. He was like, ‘I’m fine with it. You know, I’m going for a wedding tomorrow or something.’ As he come back, and we’ll change it. And when he came back, he’s like, Yeah, I noticed that you didn’t take photos of my teeth, like I’ve taken photos throughout the journey is like, let’s change the crown. I know you’re not happy with it, I think yes, I’m not happy with it. [Jaz]I love how your patient picked up on that. [Dev]Patients do pick up because I take photos, and I show them every time. So I’d always take for the pre-med treatment and post treatment because they need to be part of that journey. [Jaz]So important. [Dev]And again, going back photographs that I’ve sort of seen in all the successful dentist. One thing which is in common is they all take photos. They’re prolific at taking photos. If they’re not taking someone else’s taking for them. So some of the people, they have nurses who take the photos for them by the time patient comes in. But there is photos, like you know that and whenever I teach any dentists, I tell them, like forget about the loops, anything, get the camera first. Because until once you communicate with patient, and patient said yes to the treatment, you’re not going to be able to that five point magnification loops on anything, right? So you need to communicate with patient and many times I see cracks on photos better than in the mouth, you know, because you have, the amalgam cracks and everything. So yes, it does really help. So, coming to a conclusion, do you have anything that you would like to share for dentists who again want to model you, they’re looking up to you? And they say, okay, you know, how can I improve my dentistry in such a speed? How can it be focused? Do you have any tips for them apart from what you already shared really golden nuggets? Do you have anything? For as before we come to conclusion. [Jaz]I could be boring. And I say find a mentor. Because like you know, we’ve had that already. And it’s so true. Now I’ll let your other guests only get on very excited to hear all the other guests say that one because it’s an obvious one, right? Find a mentor on one eye. It’s so so important. I’m going to go a little bit left field. And I’m going to say that you’re going to have good days and bad days. And it’s okay. And surround yourself with good people at home. [Dev]Yeah. [Jaz]Family, friends. And I’ve said this so many times in the last month or so on the podcast, but it’s just my favorite thing right now. Yeah, life is not about the destination. It’s not even about the journey. It’s about the company. So you know, you’re the average, when it comes to dentistry, you’re the average of the five dentists who spend the most time with, you’re the average of those, right? When it comes to your personal life. That’s what I need. When I’m experiencing burnout or near burnout, I really need those cuddles, I need that understanding. I need that TLC. So, you know, find yourself good people in your life and in your profession. And they will be your guiding light. There’ll be your north star happiness is what you should focus on as a metric. And if you focus on that as a metric, then you know it will just guide every decision you make. [Dev]Well thank you very much, Jaz. Before I let you go, could you share us how can people find you? You know If they want to reach out to you, what are the ways they can find you? [Jaz]Yeah, of course, best place would be probably Instagram @jazzygulati or the Protrusive Dental Instagram page, you can check out Protrusive Dental podcast, the first thing you should check out because obviously you clicked on to Dev’s podcast you’d like to have already you know, Dev, if you haven’t listened to the Devs three parts on full mouth rehab, join his group, it’s epic. It’s so much free value being shared. There’s also if you’re then interested in learning further, he’s got so many great programs for you to do. But just start your journey with that. And then from the podcast, you were able to hopefully pick up a few nuggets from there as well. [Dev]Yeah, as I said, your SplintCourse is amazing! The amount of value you’re giving is amazing. I’ve done it. And I know, I’m not just saying by some of one of the course delegate of the online- [Jaz]I appreciate that man. The whole point of SplintCourse was helping dentists, like it’s a bold thing about TMD. I don’t want anyone to limit their practice TMD. But I started initially, my mindset was let me make a course to teach dentists how to think beyond the soft splint. But then I couldn’t do that. So if it was just that, if it was just splints only, I had enough content four years ago to launch a course. Because I’d done loads on splints by then. But it’s because I also wanted dentists to make a diagnosis to be diagnosis led to understand a little bit about the literature behind bruxism, literature behind TMD current thinking whatnot. What the etiology is management strategy is what makes good conservative care? That took me many more years to get it out. And so essentially, if you’re looking to learn about TMD, you got it. But really, it’s designed for that dentists who at the moment is just getting soft by God. And they want to see another way, another option. Whether they want to protect their beautiful veneers or they want to just find centralization easier. Or protect their dentistry from these horrible pathological bruxist that are out there. There’s other strings drawbar basically physiotherapy, etc. [Dev]But also there is no good splint book. So you know, you have collated all the information onto one plan. And that’s really important because- [Jaz]Man, I would love to write something honestly that you raise a good point. I would love to write something one day, man, but time is all the essence. [Dev]Yeah, no, I understand. And you know, I’m sure you will. At some point, we will see a book coming out to you. So again, thank you very much Jaz. That was Jaz Gulati. Thank you very much! And please, please follow Jaz and listen to his podcast I listen too. [Jaz]Dev, thanks so much! I wish you all the best guys. So to hit subscribe on the podcast, you have to hit subscribe so that you get the notifications. Hit subscribe. Listen to Dev. He’s on something. He’s on something really beautiful here. So support Dev, and we support people who are lifting you up or helping you like Dev. Dev’s Outro: Thank you very much Jaz. Thank you!

Sub-Gingival dentistry: the dark, scary, bloody world you don’t see as much on Instagram. Straight talking Dr Lincoln Harris will help you choose the right retraction cord protocols to reduce your stress during subgingival caries removal and crown/onlay preparations. https://youtu.be/RyOIO61wfpE Check out this full episode on YouTube Join us to see Lincoln Harris LIVE in London for a full-day keynote lecture: From Class 1 Composites to Complicated crown preps.  Protrusive Dental Pearl: When inverting/tucking in the rubber dam, instruct your DA to blow air continuously at your flat plastic instrument as it works around the sulcus. This will effectively and efficiently tuck/invert the rubberdam for a better seal (and sexier photos!) Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 3:33 Protrusive pearl regarding inverting/tucking the rubber dam 6:40 Deep Subgingival Caries cases 11:44 Deep Subgingival Caries Protocol 22:44 Which Retraction Cords to Use 25:10 Retraction cord protocol on Silicone Impression 30:50 Retraction cord protocol on Digital Scanners  31:48 Teflon as Retractor 35:53 Isolation of Class V restorations 42:02 Place of rubberdam on class V restorations Check out Ripe Global, one of the biggest groups in Dentistry with 80,000+ members! As a bonus, check this one-page summary of this episode Head over to protrusive.link under the Infographics Tab for the other one-page infographics summary of the past episodes If you enjoyed this episode, then do check out this 5 Lessons from Dr. Lincoln Harris and also this Rubber Dam Isolation by Dr. Harmeet Grewal Click below for full episode transcript: Jaz's Introduction: Hello Protruserati. I'm Jaz Gulati and welcome back to this episode on such a huge topic. We are finally talking about the DEEP DARK WORLD of SUB GINGIVAL DENTISTRY. Jaz’s Introduction:This is the real world of dentistry that you don’t see on Instagram as much. It’s bloody. It’s fiddly and it just gets a little more complicated when it’s sub gingival. Every now and then I ask you guys for a recommendation for a topic to cover on the podcast. And so many times you guys have requested SUB GINGIVAL DENTISTRY and RETRACTION CORD. Which cord shall use when? Shall I always use double cord? Single cord? Shall I use PTFE? Should I soak both cords or soak one cord? Is it okay to sometimes remove the gingiva? Sometimes, can I remove the papilla to allow my matrix to access the restorative margin? All these things we’re going to cover today with Dr. Lincoln Harris. Now as a Protruserati you probably already know who Lincoln Harris is, but just in case you don’t, you should totally check out Episode 54. Dr. Lincoln Harris is one of my heroes and one of my mentors. I’ve seen him twice once in Sydney, once in Singapore live. These are live lectures. His energy, his engagement. He is well known all over the world. He’s got one of the biggest groups in dentistry of 80,000 members of Ripe Global’s. I’ll put the link in the show notes. This is a movement that he started. He encouraged dentists to share full protocol photos and now it’s evolved into ripe global. Which is making dental education accessible to all the world and in a brilliant way with remote dentistry. And we talked about that a few episodes before, but essentially today, I’m going to steal him and his expertise to talk about this very sought after topic of sub gingival dentistry. Lincoln Harris is the definition of a super GDP. He’s just annoyingly brilliant at everything with all facets dentistry. His communication powers that he shares. His trim planning advice he shares is the best that I’ve ever come across. It helped me a lot in my career so far. If you’re in Europe or anywhere near London, then I would invite you to come and join us to see Lincoln Harris live in London for a full day keynote lecture. From class one composites to complicated crown preps. We’ve got Lincoln Harris over all the way from Australia to talk about all these things to young dentists, I’m just gonna be very blunt when I say this, I paid thousands when I saw a Linc in Singapore, I paid thousands when I saw him for a two day lecture, just pure theory lecture in Sydney. And I got every pennies worth, I made tenfold back just from his communication gems alone. And Lincoln is now coming from Australia, to Europe to London to lecture specifically for young dentists because he wants to give back. This lecture is going to be a bargain. Because what he wants to do is make dentistry accessible just like he’s doing with Ripe Global. So if you’re in London on first of October, that’s a Saturday, at the Guy’s Hospital Campus, then do join us for this live event. It’s very rare that he’s in England lecturing by the way, so must see lecture. He’s a very engaging lecturer. He’s a brilliant educator, his energy is brilliant. So if you haven’t ever seen Lincoln Harris, for sure, come and join us the events called De-stress Dental and the URL for it is destress.dental. So if you check out destress.dental in your browser, check out the date. And if it all works for you, come along! Come along see Lincoln Harris. It’s going to be a sold out event and we’re excited to host Lincoln Harris. The early bird rate expires on the 14th of September and it’s just 149 pounds if you’re more than five years qualified, if you’re less than five is qualified it’s 99 pounds. And if you’re a dental student, DM me. I can sort you out with something even more special than that. The Protrusive Dental Pearl:Today’s Protrusive Dental Pearl, Imma keep it really quick because I want to jump straight to the main interview, which is full of so many gems with Lincoln Harris. So the Pearl is when using rubber dam and you’re trying to INVERT that RUBBER DAM, you’re trying to tuck it into the sulcus, so you don’t want the rubber dam coming out. You want to TUCK IN nicely around the gingiva. It leads to prettier photos but also actually improves your seal as well. So how do you do that effectively and efficiently? Well, I’ve always instructed my nurse to hold the three in one and my nurse is instructed to blow air or my DA is instructed to blow air as I’m using my flat plastic instrument around the sulcus. So if I am on the buccal he or she is blowing air at the buccal where my flat plastic is, and I’m just tucking that rubber dam in. And as I’m going around the mesial, she’s following with the air as I’m going around the palatal and distal. So, where all times where my instrument is the air should follow. This makes it stupidly easy to invert you’re dam if you do without there, it’s frustrating, it’s difficult. So, that’s my top tip when inverting rubber dam and for those of you who are watching on YouTube, you just saw a video of me doing that. Now let’s join the one you’re waiting for Lincoln Harris to learn more about how to make these STRESSFUL SITUATIONS just a little bit MORE BEARABLE. Main Episode:Lincoln Harris once again for the third time back on Protrusive Dental Podcast as always, you know we love having you on. So, thanks so much for for making time for these really important topics. Linc, today we’re talking about a real pain area because you’re so good at covering these. I’ve seen so many of your infographics. You introduced me to ViscoStat Clear, and we’ll come on to that later, obviously. So, sub gingival dentistry, the dirty dentistry that you don’t see on Instagram, that’s what we’re talking about. For those few people once again, every time you have to do this, in who may not have heard of you, maybe it’s the first ever time they visit the Protrusive. And they’ve clicked this episode. And like, who’s this Australian guy? Please just introduce yourself and what you represent. [Lincoln]Hi, Jaz. It’s a great pleasure to be here. So thank you for having me back again. Always entertaining for me to join you on these podcasts. I’m a general dentist, I have a practice full of general patients who have problems who, you know, that my patients don’t have nice gums, they turn up with perio. They bleed. They carries a sub gingival. They have all of the problems that regular patients have. And but beyond that, obviously I run helped found the largest cloud, and only actually, cloud delivered procedural training company in the world. So I do some lecturing as well. But our complete focus is on helping people get the best education in the world, as long as they have internet. [Jaz]Guys, that was a very humble intro from Linc, because I’m the first one to always say. And so many of my peers out there, listen to you, following you, Linc. You’re one of the best educators there are, your cases. You created this movement of full protocol learning, which I think you know, when we look back, I do feel from my exposure anyway, that you are the real pioneer in convincing us that, ‘Hey, before and afters aren’t really that valuable to a community of dentists, that’s all about sequential photographs.’ And you’ve really taken that to the next level. So, we owe you a lot as a refreshment. I know we talked about that a lot in the sort of last episode we’ve done. So in this episode, we’re gonna dive right in, right? We’re talking about those deep sub gingival cases where you’re sweating, you’re changing matrices all the time, you’re constantly battling that internal voice in your head, ‘How do I get this dry? How do I isolate this and you’re just, it’s full of stress?’ So let’s take a more particular scenario, which I think be more helpful to our listeners. Deep sub gingival caries, let’s say a lower second pre molar, deep sub gingival caries, and you’re deciding to treat this direct so you can do a composite, DO restoration. What works best in your hands to isolate those kinds of cases? [Lincoln]Well, that’s actually the wrong question. The question is how do you treat them, because it’s not just the isolation. So there’s two types of deep, direct restorations. The one is where you know it’s going to be deep, and you can plan accordingly. And the other one is where you don’t know that it’s going to be deep. And you get caught by surprise that two different scenarios. And the reason why I outlined them is that if we go back to extractions, for a moment, when you are very experienced, you can look at the radiograph and go, that will be a difficult extraction, or that will be an easy one. This one looks easy, but it’s going to take me 45 minutes, even though I’m a very experienced dentist. But the problem is that when you’re inexperienced dentist when you most need the help of being able to tell that it’s difficult, you can’t tell. When I was for the first however many years of my practice, maybe 10, I would just get caught by surprise because I couldn’t tell the difference. So if we go back to the deep restoration, once you have all of the skills to deal with this in a cool, calm and collected way, probably you’re not going to get caught by surprise, you know, which is easy, and which is difficult. And I’m going to just lay out now that I have been through the full process of how you deal with these deep and difficult restorations. And what I can say now is that if you can recognize them ahead of time, and it’s in any way possible, either do the surgery yourself or send it to a perio and get it turned into a sub gingival restoration. Because after many years of proving that I can treat a deep sub gingival restoration. I’ve now worked out what happens is it takes a long time, I can’t charge any more for it. Whereas, if I do Crown Lengthening I get to charge for the surgery, I turn a very difficult situation into an easy one. And so that would be my first thing is that I’ve been through the full cycle from every patient must have perio surgery, otherwise, you’re a biological width criminal too. I can solve everything with restorative which is true, I can too. Now it doesn’t make sense to work that hard for the same pay. So that would be my first thing. If you can get it done or charged for the Crown Lengthening so it’s a very simple procedure. I mean Crown Lengthening is easier than dealing with it- [Jaz]I mean on the note Crown Lengthening, one but one people who may argue against Crown Lengthening would be that you lose the papilla. And therefore some guys are proponents of it. I actually am a fan of the gingivectomy using a thermal cut bur as well, get rid of the papilla and then now you have access. Your matrix can get in, your wedge can get in, those kinds of sub gingival cases. In your experience, where do you lie in sort of crown lengthening, getting rid of the papilla and that causing issues further down the line? [Lincoln]So I have done a lot of perio surgery for soft tissue grafting. And in many of those surgeries, you lose the papilla. This part of the procedure. Papillas are extremely important in anterior for aesthetics. Papillas in the posterior, the posterior aesthetics is only important to dentists who take buccal photos with a mirror. Like even a direct photo, you can’t see the papilla. So it’s not like you get more plaque because you do or don’t have a papilla. I mean, you can get more volume of plaque, but you can’t get. The presence or absence of plaque is not determined by the papillas to turn by whether you clean or not, it’s easier to claim when there’s no papilla. So I say to the papilla loving folk, you’re wrong. Papilla-philes, Papillas at the front, worth the effort. Papillas at the back, you know, when they’re gone, it’s easier for everyone. So you don’t need, like, I don’t know, I mean, the cases were one of the big benefits with when I’ve done perio surgery is that when you raise the flap, you actually pretty much like if you do a dissection of the middle, you’re gonna lose some of the papilla. And then often, if you have to do a bit of bone removal, you definitely go from having a and now Papilla is a funny thing because if a papilla is actually like the col. So, the top of a papilla has no effective keratinized epithelium, the way the rest of your tissue does. So actually the cases where I’ve got rid of the papilla, so it’s just epithelium, you know, and you widen out the space between the tooth. You need to actually have a bit of weight to get a proper epithelium developing. It’s easy to clean so papillas don’t care. [Jaz]There you have it, papilla-philes. I can’t believe you weasel that term in. [Lincoln]Yep, anterior, I’m a papilla-phile. Posteriorly, papillla-phobic. They’re a pain in the backside, get rid of them. Okay, so, I mean, now let’s get back to the direct restoration where you haven’t recognized or you don’t have the skills or you’re afraid to do the surgery. Or you don’t want to refer it to the periodontist because he, I don’t know, hasn’t bought you enough dinners or something? Okay, so these are all, you know, perfectly logical, evidence based reasons. There are so many variations- [Jaz]I know it’s a bit of an unfair question. [Lincoln]The very first thing is prep without mercy. And what I mean by this is often when people start prepping a deep cavity, they start going, ‘Oh, it’s deep.’ And then they start slowing down as if the speed that they prep the tooth that will make any difference to how deep or large the cavity is, it’s like when you go, ‘Oh, this cavity might go to the pulp.’ And then they start like, ‘Ooh.’ Okay, I mean, this is one of the great crimes that gets inflicted on us. Is this idea that pulp exposures are our fault, okay? I mean, yes, we can avoid them in certain circumstances. But sometimes, we can’t. And so if you can’t, you can’t, it’s not like we put the caries there. So when you’re doing sub gingival, prep without mercy, now you might go, ‘But what about the gingiva? I might make it bleed.’ Pretend there is no gingiva when you are prepping the carries. What about the bone? Pretend there is no bone just you must get the caries out. And so just do whatever now from once you have the caries out. And so this prep without mercy thing, because people are often going, ‘I’m trying not to hit the gum, because I’ll make it bleed.’ You can stop the bleeding, just prep the tooth. In fact, prep the gingiva as well, that’s often better. So, then you got to make a decision. And at that point is where it starts to be many options. So, now you use a thermacut bur. For people who don’t have a thermacut bur, you can use any fine bur, I use my either my flame tungsten carbide polishing bur, which is for, you know, removing the overhang on anterior composites. So use that, turn the water it’s like a 24 bladed tungsten carbide finishing. So, I use that I turn the water off. It’s very hard to cut tooth with it. Like you literally have to sit on the tooth for ages. But the more important thing when you’re cutting tissue is that, if you use a coarse diamond, it does how much trauma to the tissue, you can’t stop the bleeding. And so to stop the bleeding, you have to use some sort of fine bur that cuts the tissue with cauterizing. Yeah, well no, it doesn’t need to be cauterizing it needs to not be traumatic. And if you use a coarse diamond, it’s putting all these like little tiny lacerations through the tissue and so to stop at bleeding is more difficult. I also use the standard superfine diamond that I use for finishing my crown preps that’s also a great bur for cutting the tissue. And so, if you finish and you look at it and there’s just a mess, then I will cut the tissue away with a gingivectomy. If it’s not too much of a mess, then you know sometimes I will, that’s one step is so one step is you go bam! You cut all the tissue away. You pack some cotton wool soaked in ViscoStat™ Clear in there and you leave it for a few minutes and like if you wait five minutes, it’ll have stopped bleeding. You have to pack that cotton wool- [Jaz]It will go black or they’ll stop bleeding absolutely? [Lincoln]Yeah, I mean it mostly goes black. Not always but mostly. And it’s just the clotting blood. And then you decide from there so often, the big trick with the gingivectomy is that most people don’t do enough. That’s number one, because they’re afraid. The difficulty with almost anything is like BASE jumping. If you’re going to base jump, you have to jump with commitment. Otherwise, you’re going to hit the cliff just below where you jumped off and you will die. And so dentistry is the same that if you don’t commit to the procedure fully, then it won’t work. So people go, ‘Oh, well, I tried the gingivectomy and I still couldn’t get the wedge in.’ And that’s because they didn’t commit. So often, you actually have to take that gingiva right out to the buccal and to the palatal. Because they have these big high bits of tissue that sit there and you won’t be able to place a wedge or a rubber dam. So that’s one option, and then you decide will I be able to place a wedge and a matrix. Now, the second big trick besides cut the tissue. I will say and this is a misconception, if you cut the tissue, it is easier to stop bleeding than if you don’t. So if you have inflamed gingiva, and you don’t cut it, it just bleeds and it bleeds because the surface of the tissue is inflamed. And so all the blood vessels are very ready for inflammation. So if you like poke a cord into the papilla that is inflamed, it will bleed and bleed and bleed and it’s very difficult to stop. Whereas if you cut the tissue back and you when you cut it, you want to at least cut it back to fresh, healthy tissue that it will bleed but that is controllable bleeding and much more controllable. And so this is a big misconception, then you have to go, ‘Can I get a matrix in?’ If you can get a matrix in, then great, put a rubber dam on put a matrix and so on. But sometimes what happens is you go, ‘Ah I don’t know if I get a matrix in there.’ And then you start packing Teflon. And you can get the Teflon beautifully sitting there. Or you put a wedge in and the wedge sits beautifully against the tooth, everything’s lovely. But then you try and put the matrix and the matrix gets a big kink and goes into the cavity. And you’re going to end up with this massive, like, I don’t know, weird looking composite that has a big dip that goes into the cavity. And then it comes back to the contact point. [Jaz]Plaque trap. [Lincoln]Yes. And so this was probably the second, like massive mindset change for me. Often, particularly you have rubber dam on, you pack that Teflon down there to retract the rubber dam down to the base of wherever you did the gingivectomy and to seal the blood. And the Teflon creates this perfect little matrix. And then as soon as you start sticking wedges and things in there, you can’t get a decent contact at large. And so quite often, either the wedge or the Teflon becomes my small matrix for that first little part of the cavity. So the first couple millimeters- [Jaz]Kind of like a deep margin elevation with the Teflon, right? [Lincoln]That’s right! Yeah, like do what you have to do. But sometimes the Teflon gives you the best, like you pack it down there and the flat plastic instrument using the packet is kind of smoothing that inside edge and then it pushes down. And then the rubber dam pops it back against the tooth. So the other option is sometimes you have the rubber dam on and everything’s lovely. And then the moment you put a cord or wedge or a matrix, then everything goes terrible. And so in cases like that, I actually use no matrix at all for that first little bit. So you do your like bonding, and then I will use flowable and basically just freehand build up two millimeters or so of follow up. Now, this is where you start wishing you’re done surgery because then you have to cut the wedding of the rubber dam and smooth that first bit of margin elevation because you haven’t used any matrix at all. So you have to use like some sort of polishing there. That you can fit down in that area to smooth it against the tooth so that you get rid of the overhang because you haven’t used a margin. And then you have to reapply the rubber dam and put a wedge in and so on. So, there is no way to do this. That is easy. So, I think that the number one realization is if it’s a deep margin, you’re not going to do it in 20 minutes, like everything else unless you’re going to do a terrible job. It’s going to take a while and don’t panic. Just do each step one by one, slowly and calmly. I mean, once you have a matrix and a wedge in then the rest is easy. It’s like 90% of the difficulty is getting to the matrix and wedge with no blood and no extra dice. So, I mean, that’s- [Jaz]I think the key lesson you’ve shared there, and you did a couple of ways that is, be purposeful. Be purposeful, in your preparation, be purposeful, in your gingival removal, whatever you’re doing, do it purposefully. I think that’s a key lesson to reemphasize that. [Lincoln]Yeah, look at depths of the cavity won’t change if you prep slowly. So, just prep fast. And if it’s sub gingival, it’s sub gingival, you know, you’re going to cut up the tissue. And then if you are going to cut the tissue, cut it away and you go but it will hurt and you go yes, yes, it will hurt. I used to sleep but- [Jaz]It doesn’t hurt you. [Lincoln]It doesn’t. I feel nothing. Okay, I know that sounds like a joke. But what I realized, and actually the big breakthrough for me, was we worried because we get beat up about being dentists, okay. We’re all so insecure about being dentists, because we get told that we charge too much, and we cause pain, and we’re awful people, okay. And we get like smashed with this. And so we’re like, super trying so hard and so desperately, ‘Oh, no! we don’t charge too much. And, we’re lovely people and we don’t cause you any pain.’ And so the big breakthrough for me in dentistry was when I realized I am a surgeon. I cause pain, just accept it. I don’t cause pain when I do the treatment. But afterwards, yes, I’m going to. And in the scheme of surgeries, that people get the pain that we cause postoperatively it’s hardly worth talking about. So it takes tremendous effort to do pain-free dentistry, because the patients are awake, they’re not asleep. But postoperatively dental pain doesn’t even rate on the post surgical pains. If anyone here has had a foot surgery done, they will know what proper pain is. That’s like three months with your foot elevated, it hurts for six to nine months afterwards. And we’re here worried about them. You know, like at five millimeter gingivectomy that will hurt for maximum four or five days like so I no longer- [Jaz]That really puts into perspective. I think I love that, that is so true. And I think over the years, I’ve become a little bit more not not numb. I don’t wanna say numb because it’s harsh. I care about my patients, but you have to accept that, you know, the patient will get dry socket, or there will be post operative discomfort as part of the healing process. And to just like you said [Lincoln]Pain, say pain. Oh, come on. [Jaz]Okay, pain. There you are. [Lincoln]Pain. We get pain afterwards. I get on board with this. It’s like soft tissue. Soft tissue grafts- [Jaz]Like therapy. [Lincoln]Yeah, it’s just like a soft tissue graft. Okay? Like the patient goes, ‘Will it hurt? Yes.’ Don’t negotiate on this. It’s like, ‘Oh, yes. But do you know? Like, will it hurt? Yes, but you’ll get over it.’ Okay, like literally, I’ve never had a patient go after a soft tissue graft, I’m talking about where I harvest the tissue off their palate. And it’s not a sub epithelial. So it leaves an open wound, which I cover with dressing. But I’ve never had a patient say a year later, that was the most horrific thing, I would never do it again. Okay, after a couple of months, they’ve forgotten. So the problem is, the patient will be afraid of anything that you are afraid of. So the big problem is not the patient’s fear. It’s actually the dentist fear. If you’re afraid of a procedure, then you won’t do it properly. [Jaz]Yeah, and they totally sense that. Amazing! So we covered that really well. The next thing was it’s such a common question, Linc, and we see all the time on the group, on Ripe Global, is knowing which cords to use. Not I mean, like which brands, the common question I get from young dentist I’m gonna pass on to you is, ‘Do I always need to use two cords?’ Like so you’re doing a crown preparation. And so that decision making process into ‘Okay, when to cord, when not to cord?’ And then if you are cording? Do you always have to use two and then do you always remove that last one they put in? Or is it okay to keep him in? Let’s talk about the sequencing and the troubleshooting and decision making. When it comes to cords. I think that’d be extremely valuable. [Lincoln]So it would depend on are you taking a silicone impression or scanning because they’re different. So that’s the first thing. [Jaz]Let’s go with both, let’s talk in them in imps first and then scan- [Lincoln]Let’s start with the impression because most people will still do that. But within a year or two most people will be scanning and once you go scanning you never go back. But the big advantage of scanning so I was late convert to scanning but now I’d never go back. The big, there’s two big advantages. The occlusal records with scanning are far superior than anything you can do with bite registration. Like the first time I did a full arch of ceramics with prime scan. And like 10 units designed, milled but if I pop them in bang 10 occlusal dots perfect. I’ve never had that from a lab ever in my entire life. It always takes adjustment or a secondary bite record. And then the second one is you can tell if your scan is bad while you’re doing it. Whereas an impression you have to wait three and a half minutes. Pull all the retraction cords out and then you basically want to go outside and drown yourself. So when you find out that but the distal of the second molar has a drag for the third time and you have spent 45 minutes taking impressions. The pain, okay. So, impressions, your dental school is correct. Everyone does the right procedure at dental school. They graduate or Satan comes and sits on their shoulder and says, ‘I think you only need one cord or you need no cords.’ Usually Satan comes in the form of temptation comes in the form of you know, some experienced dentist saying, ‘Well, that’s not necessary coming here, young man, young lady, I’ll tell you the correct way to do this.’ So, and then you spend longer taking your impressions because you take the first impression, and then it’s rubbish. And then you take the second impression, and it’s rubbish. And then you take the third impression you go, ‘Look, I got an impression without using two cords. Whoo!’ Okay, so impressions, two cords, you put a skinny cord in. For me, it’s Ultrapak 000, not because it’s the best thing on the market. It’s just because it’s what I have used for many years, and I’m reluctant to change. It is a braided cord so it doesn’t tear apart so much. Someone has told me recently there are better cord, so I might have to change my ways. So that one, if the tissue is not bleeding, I don’t soak it in anything. If it’s patient with a bloodbath, I soak it in ViscoStat™ Clear. And then I pack that cord that will basically stop the bleeding. And it stops the exudate you know the or crevicular fluid. But it doesn’t give you lateral retraction. Now, cord is not meant to retract tissues vertically. So you’re not trying to get a deep sulcus you’re trying to get a fat sulcus. So then the second cord, which in my case will be a Ultrapak 0 because I don’t like to use too many things. And I’m not usually going to dip this one in ViscoStat™ Clear. Unless once again, it’s still a bloodbath, which preferably it’s not by this point, but if it is, then I will pack. You just dip it in, and then you got to wipe off the excess with gauze. Otherwise, you have too much excess and it’s going everywhere. And it tastes awful. [Jaz]Ah, the patient’s always complained about the taste. [Lincoln]Yeah, maybe you should stop slapping it on their tongue, Jaz. So- [Jaz]I think there’s something to be learned here for me. Yes. [Lincoln]Advanced techniques. Don’t slop the ViscoStat™ Clear on a patient’s tongue. I mean, yes, they do. I mean, you get those patients who like to be helpful. So you’re doing a very delicate procedure. And I think, you know, I think the best way to help you would be to get my tongue and stick it right in the middle of your bone graft and flick it all about. So certainly, that is a universal patient problem, fat cord. So when you use the Second Cord, which is a fat one. You want to first of all, for neatness and photographic excellence, always start on the same part of every tooth. So always start on the mesial of the tooth. And then you pack always to the buccal, and then you go distal, and then you go lingual or palatal, and then you go back to the mesial. And then you cut the tail. And that way, all your tails will be on the same side of every single tooth. And so when you go to remove them, if it’s like five or 10 in a row, it’s easier to grab the tails. And when you take a photo, it looks nice. Now, the secret, of course, is you have to wait five minutes, if you want your cord to work. This is where everyone goes wrong. And when you pack that second cord, you don’t want to pack it below the tissue. Only packing it equigingival because you’re using it to push the tissue laterally. You’re not trying to get a deep sulcus that’s so important- [Jaz]I want to add Linc actually, when I made that mistake before of putting the zero in too deep, what tend to happen? And I think you’ve demonstrated this before again, in your cases of how to avoid this is that the tissues then sort of sulk in, right and it has the effect of you want. Collapse, that’s a good word. [Lincoln]Yeah, it collapses on top. And if you are placing your second cord, it’s really deep sulcus, you sometimes can’t help that as you’re packing it. The tissue collapses over the top and you actually have to then if you’ve got a long enough piece, continue around the tooth a second time, or cut another piece and go around the tooth a second time you have three cords. But you have the second cord cannot have any tissue over the top or the third cord. So there are some times where I’ve had to go around the tooth you know two times. And on the distal of a lower second molar where you’ve got really thick tissue. Or an upper second molars, sometimes you need even three like you do what you have to. Or sometimes have to get a piece of cotton out of your cotton roll and stuff that in to get enough lateral retraction. So it doesn’t matter how many bits of cord you do, but you must not have tissue collapsing over the top and then you have to wait five minutes because if you don’t wait five minutes, the tissue is not retracted. So if you place the second cord and then one minute later pull it out the tissue immediately collapses and you lose everything. And then if it was bleeding, it immediately starts bleeding. And why do you need two cords because when you place one, it always starts bleeding when you pull it out. Unless you’re one of those dentists where every single patient who had perio surgery and soft tissue grafting and stuff, and that’s just not realistic for most general dentists. And the reason that the width of the sulcus is so important is because silicone has a certain surface tension. And so if that gap between the tooth and the tissue is too narrow, the silicone actually can’t flow in there. So it exceeds, the viscosity is not low enough, even the Light Body silicone is not low enough to flow into such a tiny gap. Or if it does, it will be like this tiny fin of silicone and it will tear off as you pull in and push it out. So if you have a big fat gap, you know, that’s half a millimeter wide or a millimeter wide, the silicone will just fall in there and it won’t get bubbles, and it’s easy. So that’s- [Jaz]Do you use electrocautery for when the tissue start to collapse over? Do you have an electrocautery unit? Do you recommend using it as an adjunct to your cording? [Lincoln]So, if you have one and you’re good at using it, then sure use it, I don’t have one. Oh, I do have one it’s in storage somewhere. It’s like, I don’t know, I just never got in the routine because I didn’t need it very often. And then when I did, I couldn’t find it. So it’s currently with the amalgam carrier. [Jaz]So real world. [Lincoln]I mean, it’s the same with lasers. Lasers are great. If you have a laser use a laser, I don’t have a laser and and when I teach because most people don’t have lasers, I don’t want to teach a procedure that most people can’t do. What I do know is that I have to reiterate five minutes of waiting will seem a very long time. If you don’t set a timer, you won’t wait. And so if you don’t wait five minutes, your second cord does nothing you most will not use it. Now, if we go to scanners, often with scanners, you don’t need a two cord technique, but you may need to go to an even bigger cord than a zero. So with a scanner, if you have one big fat cord, and you can get it down and it retracts the tissue laterally. Particularly if you’re only doing a small number of teeth, then that gives you a clear margin. And that’s all you need. Because with a scanner, you don’t need very much or almost no vertical depth to your sulcus at all. You just need a clear edge. So basically, as long as that big fat retraction cord is very slightly below, then you’re going to get a good impression, whereas- [Jaz]A good scan. [Lincoln]Well, yeah, sorry, good scan. So, now I’m only moving into trying that technique. Now with both of them though. That is when I’m using doing a standard prep like a prep with some type of margin. So chamfer shoulder something like this. The moment I’m moving to vertical preps, now I’m moving to Teflon because with vertical preps you can first of all you can prep on top of Teflon. Whereas you can’t prep on top of cord because if you prep on top of cord, even with a safe ended bur, the cord will helicopter and frightened the life out of you. You know it’s like you know, nice relaxing afternoon, warm sun trickling through the windows, leaving dappled light on the floor and mixing. And you have a piece of cord helicoptering on your high speed bur frightening everyone so. So Teflon, you can prep on top of and you can prep even with a diamond bur but it will erode it away. But with safe in the burs, I will pack Teflon sometimes. Sometimes I had a case the other day where I actually purposefully, it was a perio case and there’s just a few little areas where it wasn’t healing. And in a case like that, I will actually purposely prep without Teflon as close to the bone as I can and cause as much damage to the surrounding tissues as I can and prep the surface of the tooth. So it’s perfectly clean and the tissue heals very, very well. It’s like the ultimate periodontal therapy so well as good a periodontal therapy as you get without flipping the entire arch. So- [Jaz]But in that case, Linc, like you’re probably doing a long term, temporization provisional. And then when you come to actually scanning at that point, you’re gonna go back to your PTFE at that point? [Lincoln]Depends. So Teflon is the cord of choice. First of all, if you haven’t used Teflon, go and read on Instagram, I’ve got a little infographic on how not to get incredibly sad when you try and use Teflon for the first time. Because the first time you use Teflon, it will just keep coming out. It’s not an easy thing to use. So we’re I’ve prepped down to to the gingiva. And I’ve created a giant mess and whatever and I’ve let it heal. When I come back the next time it will depend on how the tissues looking. Teflon is very aggressive. It’s a very, very aggressive retractor. So it retracts far more deeply and aggressively than cord does. Because to get it to actually stay on the sulcus you have to pack it really, really hard. And so it would depend on how much retraction I want as to whether I’m going to use Teflon at the second visit or not. I mean, if you have theoretically, if you’ve had beautiful temporaries in there for a while, then you shouldn’t need any cord that’s the original BOPT technique or any little fine cord. This is where you get into and I think it’s very important for people to know that you don’t always just like choose the method and you get it right. Like sometimes you’re getting halfway through you go, this is not working and then you do something else. So mostly I’m using Teflon when I want to do a single stage, vertical prep, take the scan on the same day. And I’m going to place a thin cord that’s usually either a thin cord that’s been treated and then put Teflon over the top. Or I’m going to place just prep and then place Teflon and then place a thick cord to retract the sulcus and do the scan then. And scanners love Teflon, because the color contrast between the white Teflon and the edge of the tooth is so profound. They just pick it up really, really, really, really well. So this is like there’s the standard method and then there’s the ‘This is not working. I have to try something else method.’ [Jaz]Well, yeah. Oh, you mentioned it in Instagram, the Teflon frustration posts. I’ve got it up now. That got so much love on Insta because it’s such a pain. I said it look, I said pain point for dentists all over the world. So I think that was awesome. So guys, if you haven’t seen it, I’ll pop it up on the screen now. So you can see that and follow the link in the show notes, to find that post and all other post by Lincoln. And Lincoln is actually Lincoln and Pasquale Venuti. When I went see them in Sydney some years ago, who taught me about reconsidering how I cord, or how I isolate for class fives. I went through the stupid phase of using rubber dam and the yen, the breakers and as Pasquale described at that event, it was like a circus. And then I switched to Teflon, in the sulcus and under magnification, I noticed how much drier I was able to keep my field. And so, I, my bias for class fives is Teflon. Now, how about you? Is that something that you’re still doing? Or have you changed? Or have you found a different way to isolate the sulcus of class five restorations? [Lincoln]There are many things in dentistry where you do them first to prove that you can and then once you’ve proven that you can do them. Now you’re well able to choose whether it’s a good idea or not. So I went through a stage of rubber daming everything. So I proven that I can do it and now I can not rubber dam where I think it’s inappropriate. And there’s a number of times when rubber dam is inappropriate, and one of them is the class five, mostly particularly at the front of the mouth. My isolation technique of choice will be an OptraGate to hold all the lips and cheeks out of the way. And then if it’s a deep class five, in particular, I’m going to place Teflon and then I’m going to often do a gingivectomy down to the Teflon. So I can find the margin because often, when you have a deep class five that’s slightly sub gingival, then the tissue gets inflamed and it gets even bigger still. And also that inflamed tissue, you can never stop at bleeding. So you want to place the Teflon, cut the tissue away if you need to. And then scrub with this ViscoStat™ Clear Or put some cotton on there that soaked in ViscoStat™ Clear and leave it. Where people have the massive stress is they panic. So they cut the tissue and then it’s bleeding. And they go, ‘Oh, my goodness it’s bleeding? How will I ever do this filling I’ll never be able to do the filling. Oh my goodness!’ And so what you need to do is go first of all, I’m going to retract the tissue. Do not think about anything else, except that one part of the procedure. I’m going to retract the tissue, and I’m going to retract it properly. And that’s it. So then get your Teflon and retract the tissue. Now you’re going to go I need good access to the cavity. Do I have that? If not cut the tissue and don’t think about the bleeding and all the other things because you deal with that later. What happens is once you start thinking about okay, right now I need to do retraction. But what if I start bleeding? Okay, now you’re thinking about two parts of the procedure simultaneously, and then you go, but if I retract, and then I can’t see the cavity, I won’t be able to restore it. And then it might start bleeding. Now you’re thinking about three parts of the procedure. And then you go, and then how will I shape it? Now you’re thinking about four parts of the procedure, and you’re not even done one. And so what’s happening is that you are using up your entire mental capacity, and you haven’t even started doing something. And so now it’s really tiring because you’re thinking about four things simultaneously. And people cannot multitask. The idea that you can multitask is wrong it is not physically possible to multitask. What you actually do when you think about more than one thing at a time is you switch. So a fighter pilot, they can’t multitask. But fighter pilots are chosen because they have a very low switching cost, that energy that they burn to switch between three different tasks is very, very low. And they’re physiologically chosen, because they can do that. Now as dentists we’re not chosen, we don’t go through a fighter pilot selection test, which like a fighter pilot selection test is a heavy like a little video game that they have to pay whilst recognizing colors and doing math equations simultaneously. So that’s how the selection criteria, we don’t get that in dentistry. So, if you continually change and think about four different things, you are draining your brain’s energy massively. You’re fatiguing yourself. The second thing that happened is that if anything goes wrong in the procedure or anything is not quite right, you are already maxed out. You have no reserve left to deal with this. And that’s when you’re just staring at the tooth. And you pick up an instrument and you put it down, you pick up another instrument, you put it down, and you’re actually doing nothing effective. It’s because you’ve actually, you’re like a computer that has maxed out their memory, it’s now crashed. And so it’s common for dentists to crash and that’s when they just go, ‘I don’t care anymore, just do anything.’ Okay, because they literally have given up because they have no capacity left. So only do one thing at a time. So, place the retraction, get it perfect. Like imagine you’re not allowed a second chance. So, if you don’t get it perfect the first go, you’re not allowed to go back ever. Okay, and a crocodile eats you. So like, cool down- [Jaz]Only in Australia, does that happen? [Lincoln]I’m trying to think of something dangerous in the UK. [Jaz]There’s no such thing even when you compare it to Australia, it’s just there’s everything’s tame. It might you know, it’s everything’s- [Lincoln]You turn up to Wimbledon, and you’re wearing the wrong clothes for high society. Okay, that dangerous? [Jaz]Yeah, that sounds more like it. [Lincoln]You’re dressed in a tux and everyone else is wearing cool whites. Oh! That level of danger. And then if the tissues in the way, cut the tissue, only focus on that like gingivectomy’s very simple procedure. You get a tungsten carbide bur, bat bur any sort of bur actually just not a coarse bur. And then trim the tissue out. Turn the water off so that you get sort of a cautery effect. And then you go okay, now I need to stop the bleeding and then pack some cotton to ViscoStat™ Clear. And that’s it, don’t do anything else and wait five minutes and do nothing else until it stopped bleeding. Okay, now, you can focus on the cavity. So like, this is why dentistry gets stressful because when it’s a procedure that’s like multi-stages. So you know, it’s first you’re doing a DO composite, okay, single procedure. Now you’re doing a DO composite, plus, dealing with sub gingival restoration and gingivectomy and bleeding gums. Now you’re doing actually like three procedures. And if you try and think about all three at once, you’ll just crash. So you only do each step one at a time. This is when dentistry stops being stressful when you do one thing at a time. [Jaz]I think that’s going to resonate so well. With everyone listening certainly it reminds me of errors I’ve made. And I think everyone listening is just nodding their head. And I think that was, you know, you’ve been on point today with your humor, Linc. I’ve enjoyed it a lot. So the lesson there was guys with class fives one thing at a time. And yeah, Teflon is something that you’re still a fan of as well. And it works well for class fives. And certainly you made it clear that rubber dam isn’t really well suited for Class Five, right? [Lincoln]Yeah, I mean, it depends. Rubber dam is well suited for easy Class Five. So if it’s an easy Class Five use rubber dam. If it’s a deep one, or it’s sub gingival, then I can do it. But the thing is, you’re going to place a Brinker, you’ve got to retract the tissue, there’s always a risk that your Brinker will slide off the tooth right at the most crucial part. And then it rubber dams don’t necessarily give you good water seal. And so quite often, the water is wicking up underneath rubberdam. And so then you have to place Teflon anyway. And so at that point, it’s silly. I mean, another example of this is, we have to do bonded restorations. But if you look at most deep margin elevation books in the world, the deep margin elevation bid, which is the most crucial part of the entire restoration is done without rubber dam, because it’s impossible. So like, you know- [Jaz]So true. [Lincoln]And also keep in mind that there are significant differences between how clinics run. So like my experience in many parts of Europe, particularly Eastern Europe is that people don’t use the same amount of dental assistant capacity as countries get more expensive. And as time and money get more expensive. So you know, in London, your rent is very expensive. And so it’s not the cost of having staff is less of a concern and is more just a mindset of you know, you have one assistant or maybe even two so that you can work really fast. And so if you’re working with one really, really good assistant, they can help you or two, particularly if you’re working with two. You can have one assistant that’s entirely devoted to isolation and controlling moisture. And then you can have another one who’s doing all the other stuff. And so this makes a big difference. Whereas if you’re in a small, you know, like I have some colleagues who are amazing dentists, but they work often alone. Like they have one assistant who also does reception, and sterilizing. And so that assistant is off a lot and these dentists have to use rubber dam for everything because it’s like their dental assistant. So there is a huge variation in you know, culture and the business practices of how practices run and that actually has an impact on the way that you isolate as well. [Jaz]I didn’t even consider that actually. Very good point. Now Linc, I just want to say a wrap up this episode with an announcement that you’re coming to London to speak to dentists. I mentioned the previous episode as well. And the the main title of your event is brilliant guys, you have to listen to this right. It’s very much in tune what we spoke about today. And as you can see, Linc is such a real world dentist like he’s a world class dentist. But what I love about Linc is he’s real world, he treats real world patients. He understands our struggles, they’re real. So the topic is DE-STRESSING DENTISTRY, from class one composites to complicated crown preps. And I think that what I love is when he wrote this up, he said, ‘According to the University of Instagram, all patients one mouthful of veneers, and tiny little super gingival classroom composites.’ And obviously, I was tongue in cheek, but it’s such a great theme. Just give us a flavor about the other kind of things that you’re talking about on that day. [Lincoln]I basically just want to talk about the most common procedures that causes stress, which is our everyday procedures. But when they’re difficult and class two composites or composites in general, or crown preps that are deep, badly broken down with patients that are difficult to get down, and they’ve got a big tongue, and that gagging. That is because I’m a multidisciplinary dentist, I can tell you that a deep class two composite can be more difficult than a sinus lift. So, not more difficult than a really difficult sinus lift, because there are some really difficult ones. But on average, the only reason that we think sinus lifts are more difficult than class two composite is usually we’ve done about 10,000 class two’s, and we’ve done about, you know, either zero or a very small number of sinus lifts. And so actually, the most common procedures that we do in dentistry are the most difficult. And the only reason that’s not recognized is due to the massive repetitions that and the fact that we get taught them early in life. But I still have difficulty so the things that we’ll be talking about is the actual techniques of it. But even more importantly, is the psychology of how you maintain a clear head and don’t fatigue. And you will have heard me mentioned some of that, but this is most crashes in aviation, which is the equivalent of when you do a procedure, and it just goes out of control. And you end up, you finish the procedure, you don’t feel good about it. Because you know, it wasn’t a controlled procedure and so you’re not sure if it’s going to be greater. Mostly that occurs, not because you don’t have the skill or the knowledge, or the ability, it’s because what’s called human factors, which is the stress and the mental fatigue got to you. And under stress, this is well researched, your ability reduces by 85%. So if you can only just do a procedure, when you’re relaxed, you actually cannot mentally do it when you’re stressed. And so it’s not just about how do we make the procedures more of a straightforward protocol. But how do we mentally and psychologically do a procedure and prepare ourselves for procedures so that we don’t end up in that massive mental fatigue state where everything just goes out of control, and you finish the day and you want to quit the profession. So those two things very important that latter part of it is not studied or talked about, but it is talked about very much in paramedics, in fire brigades, in aviation, in anything where people die. They study human factors, which is how you deal with things under stress. So we’ll talk about that, and how to deal with that. And I think that bit is almost as important as the clinical part, maybe even more so. [Jaz]You’re so right. It’s stuff that’s not talked about enough. And that’s why I’ve always you know, enjoy going to your live lectures, online stuff, because you talk about the real nitty gritty things. And also, you know, you draw these comparisons with other industries. Aviation is a common one that you that you talked about as well, and howwhat we can learn. I know, you talked about ophthalmologists about last episode about how they have so much training and you made that comparison, you’re full of a lot of wisdom, and I can’t wait for you to share it in London with us. So guys, I’ll put everything in the show notes. Linc, thank you for talking about retraction cords. I know for a fact I guarantee it. This episode will get a lot of engagement because something as basic as retraction cords, as we talked about a few times ago, actually, the basic things are the things that really, really, really are the most helpful when we’re creating content to help people. So I think that’s going to go down really well. As always, I thank you for your time despite the time differences. [Lincoln]Well, it’s always always fun talking to you Jaz. You are a man full of energy and it’s very exciting. But the thing about basics is just because something is basic doesn’t mean it’s easy. This is great mistake. So the basics of dentistry are frequently very difficult thing. So it’s like simple. It’s simple, but that doesn’t mean easy. So we’ll talk about the basics, but it’s going to be mostly the hard basics, the ones that ruin our day. So look forward to it- [Jaz]It is essential for all dentists I think but if you’re new in your career, I think this will save you a lot of heartache, heartbreak, stressful moments to sort of get into the mindset of how to fulfill the rest of your career. Working in a reduced stress way. So de-stressing from class one composites to tricky crown prep sub gingival dentistry. A lot of what we talked about today. So I know links working really hard to put on really good content for that as you expect from Linc. So Linc, we look forward to seeing you here, mate. [Lincoln]Well, I look forward to coming and you know, then you can take me to a good British pub afterwards. [Jaz]Of course! Brilliant. Thanks so much! Jaz’s Outro:Well, there we have it guys. Lincoln Harris on sub gingival dentistry. I hope you gained so much value from that I know I did. Yet again, I’m gonna go ahead and get an infographic made and a summary of this podcast because there’s so many little gems in there and don’t want to miss anything. So I will email you that if you’re not already on my email list, go to protrusive.co.uk forward/emails. And once again, Lincoln is coming to London this is a big deal guys, right. He doesn’t often make this trip and he’s lecturing live for the full day from class one composite to complicated crown preps. Come and join us! Saturday 1st of October that destress.dental, D-E-S-T-R-E-S-S dot dental. That’s the URL. Book on now and definitely do it for 14 to September to get that early bird rate. Anyway, I’ll catch you in the next episode. And of course if you haven’t listened to Episode 54, go back and listen to that one because it’s more of Linc and I know you would have liked that. So I’ll catch you in the next one guys and I hope to see many of you in London on the first of October.

When is Botox an appropriate option for the management of Temporomandibular Disorders? Knowing this will help you make better referrals, or even consider Botox as a management strategy. Dr. Sheila Li guides us on the use of Botox/Toxins for TMD pain management. We discuss indications, protocols and regulatory requirements (which surprised me!) – as well as learning if these patients will now require Botox indefinitely…? https://youtu.be/QJyxF0EGwsM Check out this full episode on YouTube Protrusive Dental Pearl: How do you routinely check the masseters and the temporalis at your new patient examination? As a restorative dentist, the most important thing I want to know (and what will influence the occlusal risk for my patient) is the size of the masseters. Start palpating and feeling for the size of the masseters to understand how much force these patients can generate! If you want to learn more, join the Facebook Group: Protrusive Dental Community because I’ll be doing a little blog post on that about the significance of masseter size on Occlusal risk. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 2:50 Checking Masseters and Temporalis 13:34 Dr. Sheila’s journey in managing TMD pain patients 16:13 Ideal case selection for Botox regarding TMD 21:15 Botox as a standalone vs Botox as an adjunct to splint therapy 24:26 Patient communication about the frequency of Botox treatment 26:39 Place of Botox for myofascial pain patients 30:01 Additional indemnity for GDPs in doing Botox 33:31 Functional Perspective of Botox 34:47 Success rates in using Botox for TMD pain management 39:53 Experience of having Botox 41:55 Long-term side effects of Botox Learn more about Botox with Dr. Sheila Li on her functional toxin course just for dentists to treat functional elements!  Want to level up occlusal appliance therapy and TMD management? Check out SplintCourse for a comprehensive online course. If you enjoyed this episode, do check out TMD Full Exam with ‘The TMJ Doc’ Dr. Priya Mistry  Click below for full episode transcript: Jaz's Introduction: Hello, Protruserati! I'm Jaz Gulati and welcome back to the podcast that makes dentistry tangible. Today, we're covering a favorite topic of mine. Now, if you're new to the podcast and don't know me yet, it was a topic that confused me so much at dental school that I was drawn towards once I qualified from dental school. Jaz’s Introduction:So, that things like occlusion, orthodontics and temporomandibular disorders. Today, I’ve got none other than, Dr. Sheila Li on the show, who really is the best person to discuss the USE OF BOTOX OR TOXIN for the management of TMD. I’ve actually wanted to get into this field. But for those who watch the videos on YouTube, does this look like the face of someone who is interested in facial aesthetics? I really didn’t want to learn lips and eyebrows to get to the really important stuff like the masseters. But, Sheila is great at both of those things. And teachers dentists like me who are more interested in the functional aspects like TMD and gummy smiles. So, by the end of this episode, you will know which diagnoses, symptoms or patient features lend themselves to Botox. Now, this is really important because on the dental groups, I see Botox suggested in the word bandied all the time, all over saying, ‘Yeah refer for Botox or you can treat this Botox.’ But really, not all TMD lend themselves to the management of Botox. Now, BOTOX CAN HELP for TEMPOROMANDIBULAR PAIN, but you’re not going to treat clicking and locking joints with Botox. You have to get your diagnosis right. We also discuss what regulatory requirements there are for dentists who only want to do Botox for the TMJ pain. And the answer might pleasantly surprise you. And finally, we DISCUSS THE PROTOCOL. How many visits? How often? Is it something you have to do for the rest of your life? Where does occlusal appliance therapy come into it? Don’t worry! Me and Sheila have got you covered. The Protrusive Dental Pearl:The Protrusive Dental Pearl for this episode is related to the MUSCLES OF MASTICATION. Do you routinely check the masseters and temporalis at your new patient examination? If so, what are you actually checking for? As a restorative dentist, the most important thing I want to know that will influence which materials I use, and the occlusal risk for my patients is the SIZE of the MASSETER. You see, large masseters and temporalis muscles, and the history of destruction and mechanical failure are features that I take very seriously when treatment planning. On the flipside, someone with very weak muscles usually poses a much less of a parafunctional risk. And I’m more likely not to worry about lengthening their incisors, for example. So, if you want to learn more, join the Facebook group, Protrusive Dental Community, because I’ll be doing a little blog post on there about the significance of masseter, temporalis, their size, and share some photos of patients with meaty masseters. And how, in those individuals, is correlated with a higher occlusal risk and more destruction of their teeth. Main EpisodeNow, let’s join the main interview with Dr. Sheila Li. Sheila and you and my old friend. How are you? Welcome to the podcast. [Sheila]Hi, Jaz! I’m really, really well. Thank you so much for having me. It’s really exciting to be here. And I’m really glad that I’m doing this with you today. [Jaz]Sheila, I see all the BSPD, all the events and stuff, this was like nine years ago. We qualified roughly similar time. And then, you know, we went our different ways in our careers. And it’s amazing to see what you’ve achieved in the space you’re in and facial aesthetics. And I love what you’re doing. So, for those who haven’t heard of you, Sheila, tell us about what you do at the moment? But then I might just take it back a few pegs and tell us about your journey into facial aesthetics. But specifically, for today’s podcast, what I really want to know from you Sheila is, why is it that you, as someone who is doing wonderful things in the field of facial aesthetics, you decided that, ‘You know what, I actually want to now also use this to manage people in pain.’ Because I imagine that it can be easy when you go into facial aesthetics to be like, ‘Oh you know what, I’m happy to make people look pretty, but then I don’t want to touch this stuff because pain is complex, pain is difficult.’ You know, you’re in a difficult niche if you’re helping these people out, right? It’s so rewarding, but I want to hear it from you, how you got into that. Was it an accident? Or was this planned? [Sheila]Oh! What a great question. So, as you may know, dentistry wasn’t my first degree. But even before I graduated, I knew that I wanted to be the very best dentist I could be. I was also inspired by my best friend. She was a doctor training to do getting her BDS so that she could go and do max Vax. She was actually the one who trained me in aesthetic medicine. And following on from this, I focused a lot of my energy on investing in courses, and increasing my injectable case numbers early on in my dental degree. So, quite quickly, after I graduated, I absolutely loved that I was able to offer aesthetics alongside dentistry as a complete sort of option for my patients. But, I really lacked confidence in my abilities. And I wanted to do aesthetic medicine, as well as dentistry because of the joy that I knew I could bring to my patients in improving their confidence, right? You mentioned the sort of wrinkle treatments and the facial treatments that I do. That helps improve their confidence. Because we know as dentists, we can improve their confidence with their smile. It’s one of the most important features of the face. It was early on in my career and I had so many dentists and so many colleagues telling me that I needed to concentrate on my dentistry. That I should get good at basic dentistry before branching out to do anything else. And that actually, I should be doing both things at once. And I was like, ‘Why? Why can’t I do both?’ Who says, I can’t do both? I do really, really well, you know, so I wanted to challenge that. And that’s what I did. I spent the first few years of my career investing everything that I had and then reinvesting everything that I made in my training. [Jaz]Can I just pause you Sheila? For those who don’t know, like, I’ve seen some of your work, you’re supposed to, like ‘For dentists, By dentists’, you know. For those who don’t know, Sheila is actually a really competent, really good restorative dentist. So, it’s hats off to you for then deciding that, “Okay, I’m gonna go further into special surgeries.” But, you know, it’s not like you were a below-average dentist. We focus on photos that you are very competent restorative dentist. [Sheila]I am, I really am. And, you know, because pretty much I invested everything that I had. All of my time, all of my energy, both in facial aesthetics and dentistry, I did it both. And I demonstrated that. It is possible to do both really well. You just have to be able to provide that treatment to the highest standard, both in facial aesthetics and in dentistry. It’s absolutely possible and it can be done. But it takes time, it takes commitment; it takes an investment, and it takes energy. And all of this is so much easier when you have someone in your corner supporting you and guiding you. And that’s one of the lessons that I’ve learned. I’ve learned that the hard way, and it took me years. But, you know, when someone’s able to show you how they’ve done something, it just takes so much time off of your plate. And that’s the reason. For the last eight years, I’ve taught and I’ve worked in seven different places, every single week. I’ve learned from lots of clinicians. Sometimes I worked, I didn’t earn anything. I went in just to shadow people and work as a nurse for clinicians. And that really allowed me- Yeah! [Jaz]That’s the way it should be. [Sheila]Yeah, absolutely. It’s the best way to learn, actually; it’s the best way to kind of get experience from much more experienced clinicians. And that’s how I significantly improved my skills, personally. Both from cosmetic dentistry and facial aesthetics. [Jaz]Just sidetracking a little bit, Sheila, on that. Because you’re mentioning all the things that you did extra, that you know, where you weren’t being remunerated at the time for it, that was to gain experience. I wonder if this has also affected you. A common issue I find with our colleagues is that they want to up their game in a certain discipline of dentistry. And then the stumbling block they approach is that they now need to ask their principal for certain equipment, X, Y, Z, whatever. And then they’re like, ‘Well, no, not really, because it’s not gonna work as part of their business plan.’ And then that’s it! They know that the journey ends for that associate or whatever. So, did you have to go through the struggles of, you know what? I have to buy my own toxin. I have to buy my own facial aesthetic stuff. I have to buy my own, like, you know, clamps, whatever, you name it. Do you also have to have that struggle? [Sheila]I did. I bought my own soflex discs, because there were certain ones that I wanted to use. And they were too expensive. You know, I bought certain instruments for composites that, again, they were far too expensive. And actually, we were worried about things scratching. But you do these things. Because actually, it’s too short-sighted to see that it should be an investment for the principal. And actually, it’s really, really nice if they will buy those things for you. But if they don’t, they shouldn’t be the things that stop me from doing it. You’ve invested your time, your effort, your energy into going into these courses, and you need these tools. And without them you can’t do that. So, it isn’t a case of going on the course and then forgetting. But also what I find really important is, that post course support, which you do really, really well, Jaz. Like having that person, a cold your liberal accountable, be there and support you and say, you know, perhaps you probably should take that next step. Are you seeing enough cases? Because one part of it lies in the fact that you cannot, you know, not having the instruments or not paying for the more expensive composites. The other lies in the fact that, too many associates expect their principals to find all the patients for them. And it doesn’t rely on anesthetics. And sometimes you do have to do a little bit of the way that you approach your communication skills with your patients. It’s not just the clinical skills. It’s the soft skills that we have to work on the way that we talk to our patients. Our communication and how we talk and approach treatments and treatment planning for the patients, as well. You know, your principal can get a patient through the door, but the rest is then up to you as the treating clinician. So, it’s all of those things and all of those things, they come together beautifully, to be able to allow you to practice dentistry to a really high standard. Once you’ve done enough of the learning and the practicing. It’s just doing and seeing cases- [Jaz]And seeing the cases consistently enough to actually build your skills. And you made a good point there that you know, what people expect their principles, get the patients. Let’s say you want to go into facial aesthetics, for example, and no one in your practice has ever before offered this. So, you have to expect that already in the marketing of your practice, the marketing or website, there’s zero stuff on this, right? So, you now, as the associate perhaps, or the Brit, or the principal has acquired a practice or whatever, have to do some extra work to market to the world, and to change the way that a practice communicate so well that, Hey, we’d love to help you with this problem, right? [Sheila]Yeah, absolutely! And this is what I tell my mentees all the time. Lots of dentists will tell you. They’ve been on a course and it means, this doesn’t necessarily lie just in facial aesthetic. They may have gone on, for example, a laser gun contouring course, or whatever it is that they’ve done, you know. And they haven’t put to use what they’ve been taught. And they’ve learned because they can’t find the patients. And they expect the principals to find patients, and a lot of principles are not even familiar with the field. So, you have to also do a lot of the work here. You know, social media is such a massive factor within all of these. Patients are using social media as a way to inspiration, as it were. And a lot of patients come from social media, hate social media. It’s not enjoyable; it’s spoilsport. You have to do it! You absolutely have to do it. You have to do it, because it’s also social proof. Patients want to see that you exist. That you’re real, that they can relate to you. And actually you’re just yourself. And it’s not hard work first and foremost, and actually- [Jaz]Show your human side. [Sheila]Yes, absolutely! Show your human side. And then you attract similar patients that are like you as well. Which are the easiest patients to treat, by the way, because you can have normal conversations with them. So, there is a lot of legwork to be done, and there were associates that will be or the dentists that will be successful. And they are the ones that kind of take the initiative, and they go, and they do that. And so, I did do that, as I said. But by doing all of those, I was able to improve my skills significantly and the confidence that I gained. And it’s that confidence that you know, when you tell your patients that you can get that this is what your treatment plan for them, and you can deliver on those results. You know, that’s when you’re able to do it. [Jaz]They can smell it. [Sheila]Yeah! And you’re not talking them out of treatment, because that’s often what we do. We learn a skill and then we start talking about treatment, because we’re not too sure about whether we can actually deliver on that. And that’s what happens. I think, I believe in dentistry as well. So, you know, it’s something you have to invest in. And for me specifically with facial aesthetics, something I had to invest in outside of dentistry, and then, you know, work away from the dental practice so that I could then bring it back into dentistry. But, you know, don’t get me wrong. I absolutely love dentistry, and I love facial aesthetics. But I did come to a bit of a crossroad after I became a parent and maintaining that momentum that I had and the successes. I built pre-motherhood was completely doable. But after my children came along, oh my god, it took its toll. And I had to make a really difficult choice. And I chose to step away from more traditional dentistry and that’s sort of, you know, that’s how I’ve come to do facial aesthetics. [Jaz]Niching is a beautiful thing to do in dentistry. It is such a wonderful thing. And, you know, mom is the hardest job in the world. So, hats off to all the moms out there. Working hard and achieving their dreams and aspirations and stuff and doing that kind of stuff. Why is it that you went into also helping your patients with myalgia and myofascial TMD or TMD of muscular origin? Wouldn’t have been really easy to just take a back seat and say, ‘You know what, I like all the aesthetics stuff.’ [Sheila]Yeah. [Jaz]What actually inspired you to think actually, I want to help people in pain as well? [Sheila]So, you know, you’re right. I still consider myself to be a dentist and I’m still part of the dental team. Yes, I do the more facial aesthetics, cosmetic side. I get to make patients look great. But, I also get to work alongside my dental team to improve the functional muscular elements within the mouth as we’re going to discuss managing TMD and providing an alternative option to treating a TMD pain, and migraines, managing bruxism, all of those things. And the joy that you get when you really get your patient out of pain. One of the things that we can potentially do right to make patients feel better. When you take a patient out of pain, and we know with TMD patients, often if they’re lucky enough to see the right person, if they’ve gone through a couple of phases of different types of splints, different types of treatments, they’ve done, you know, by time if they’ve come to you and they’ve done all that they’re already really difficult. They don’t even believe in the whole system as it is. But when you actually get the diagnosis correct, you can treat them and get them out of pain. It’s a feeling that you can’t replace by doing cosmetics. You can’t get that from anywhere else. I actually realized that, there’s not enough dentists doing this as part of the armamentarium that we’re offering patients. And I believe that dentists can do this. And they are able to do this really, really well. Because, you know, we inject local anesthetics everyday. It’s no different. It’s just learning the anatomy and understanding what your goals and what your aims are. So, I do believe that dentists should be the people that the conditions are off officially stated. But, particularly functional. There’s no reason why we every single dentist can’t. And that’s my goal. That’s my reason for sort of branching now more towards training and mentoring only dentists, especially to deliver this part of functional facial aesthetics, using neutralizing toxins to do that really, really well. And supporting them to do that case planning and holding them sort of accountable. But doing it as part of an overall care plan for the patient, not in isolation, not by itself. As part of the full plan. [Jaz]I agree that there are some dentists out there, like myself, who have zero interest in facial aesthetics. However, I have a lot of interest in functional restorative and managing TMD, which is a lot of what I do. And therefore, when I attended one of your webinars, you talked about two really great uses of Botox or Toxin, or watch aluminum toxin if you want to call it. For the restorative dentist who, just like me, is interested in managing TMD was for Botox and also for the gummy smiles. And that was really great. I want to ask you specifically to focus more on the masseters and temporalis. Botox today mostly master slave, if you focus on one topic. [Sheila]Yeah. [Jaz]What is your ideal case selection? So, you know, that the patients come in for a consultation with you regarding the TMD. What are the signs that a patient will tell you that, ‘Okay, I’m gonna get a good result here with Botox,’ what are the signs that are suggesting that perhaps this isn’t the right case for Botox? This gonna help the dentist listening to know A) if they don’t already provide his current treatment. At what point can Botox help their patient? But, also whether they feel as if, ‘Oh, actually I see these patients every week, and I could potentially help these patients.’ So please let us know about case selection. [Sheila]So, your patient’s symptoms, and what you can assess and see and feel with the patient will lead you to your diagnosis. And we know that TMD is one of the most common causes of chronic facial pain for the patient when it’s not related to, you know, the dentition itself. And we know that the etiology is multifactorial, and we don’t know why exactly, some patients experience this pain and others don’t. And why some of these patients actually just get to have TMD. But generally, TMD is classified into two different groups. We’ve got the articular and the muscular origin. And often both of these are present together. And it’s the muscular origin that we need to treat when it comes to Botox. So, that diagnosis is really important. So, patients will obviously usually present with facial pain. And this is often the reason why any patient will come seeking treatment, particularly from a dentist as well. And pain, particularly in the masseter and maybe the temporalis muscle, so they may complain of things like headache, or morning headache or headache at the end of the day, are the most common symptoms that I see. And that patients will complain as well. And often what you’ll find is when you’re doing your extra oral exam, when you’re palpating the masseter, they might say, Oh, there’s a bit uncomfortable, or actually I do get jaw pain. What I find is it’s usually pain on palpation, they’ll already complain a pain. They can pinpoint where the pain is for you. And then when you palpate the masseter, it will usually be uncomfortable for them. There’ll be have some pain on opening and this may spread beyond the area as well. They also may have headaches. They may complain of headaches, and they may have pain around the ear area. This could be close to the TMJ or within the TMJ joint itself. This is where I push and refer over because TMJ joint pain is more arthralgia and Botox here will not do anything. But of course, you may get the patient’s pain off anterior to the to the ear. In this case, we’re still looking at the superior portion of the masseter because it originates on the zygoma, which literally runs in line with your ear there. And treating the masseter for these patients will help improve significantly their discomfort and pain in the area. We also know, as I mentioned already, that in a lot of cases there’s a combination. So, as long as we can identify a muscular component, then absolutely, I would approach with Botox alongside prescribing a splint for the patient. I also find what’s really useful is there’s a screening tool, 3Q/TMD. It’s really useful at identifying the myalgia patients, which essentially looks at pain in temples, the jaw and the face. But it is really useful for dentists who don’t manage TMD and bruxism to aid their decision to obviously refer to colleagues who do. And so, when patients do have pain in any of the muscular areas, usually the masseter, the biggest muscle of mastication. So, that’s usually where it starts. If they have some additional headache pain, then I may treat them there, but often it’s the masseter first before anything else. And I find Botox to be a really useful adjunct to splint therapy, obviously, in conservative management, as it gives the patient a little break. And it does significantly improve their pain. We know patients aren’t religious in wearing their splints. I’d love them to be, but they’re not. Their compliance tends to be poor, especially when it starts to get a little bit better as well, right? So, they’re wearing and it gets a little better, and when it’s not wearing, it gets bad again. [Jaz]I’ve got videos after video consultations or video testimonials on my patients saying, ‘Oh, it feels great.’ And I see them six months later. ‘Oh, I felt so great. I stopped wearing it. And then the pain came again. And I wore it again.’ I got that on video from multiple patients. So, patients do get a little bit cocky. They get a bit complacent. And so yes, that’s another avenue to go by, which is really fascinating, actually. The thing I want to really emphasize here, and it’s a great point you made, is that, ‘Guys, when we’re referring on for patients who you think may be a good candidate for Botox. If someone’s main issue is clicking, locking, and very precise pain, exactly where the condyle-disc assembly is. That’s an intracapsular patient, okay? That’s not the kind that’s going to benefit from Botox. There are other things we need to do for that patient. The kind who is like diffuse pain all over. They’re kind of point everywhere. I’m in pain everywhere. That’s more the one that lends themselves to having Botox. So, that’s the main sort of takeaway there. Now, you mentioned about being an adjunct to splint therapy and whatnot. In which order do you go like, do you just post because we are allowed to disagree. I think the best episodes are when my guests and I disagree, it’s completely cool. But where do you see that in the hierarchy? I get a lot of patients who come to me and they say, ‘Should I have Botox first?’ Then I screen them. Okay. Yeah, it’s not intracapsular. It’s muscular. Can they benefit from Botox? Yes. But then we have that discussion: ‘Do you have an appliance? No, you don’t. Okay, well, maybe we should consider that as well or maybe even first.’ But because they’re coming to seek you, as the facial aesthetic practitioner, and they already value. And if they’ve sat in your chair, they’ve already done a bit of research, they value that this is going to help them. And therefore, that’s a huge part in them getting help from it. So, do you ever give Botox as a standalone, and then maybe just encourage the splint? How does it work for you? [Sheila]So, first of all, it depends where I’m based. So obviously, if I’m working in dental practice, for me, it can be done alongside the two. If they’re in severe acute pain, then I may make them an NTI immediately, because that will help. And I know that I can inject them with Botox, and within two to three days time it will already started to work. If they’re in my chair, because they’ve come to see me, I will always do the Botox first, because I know in two to three days, it will work. But the next thing that the patient needs to do is either see a member of the team for the full assessment, and I’m prescribing with a splint. We know that, of course, we’ve got to take the impressions and that’s going to get sent off to the lab. So, it’s gonna take time. It’s gonna take up to two weeks. And as busy as we are at the moment, so it can take longer for that to come back. In the meantime, they’re still going to be in pain. So, the Botox can start getting to work whilst you start doing your splint stuff. So, if I’m fortunate enough to be in a dental practice, it’s both they will see me and they will see either a member of a team straight after or send them out to the dentist, and have that. If they’ve already had the splint made, then they can still see me afterwards. Because remember, the toxin also helps to reduce that daytime clenching as well, because they’re not going to be wearing this splint during the daytime. So, that’s where it can be used. And if they see me, I’m putting it in straight away because I know that it will start to work into three days time. And actually, they can then go and get their impressions and the next stage of their plan. But absolutely, it’s done as an adjunct. The only time where I will not talk about a splint is if they’re coming in for cosmetic reasons where we’re trying to slim down their jaw. My primary aim is to preserve and protect the teeth. And if they have TMD, if they have bruxism, we know that this can lead to tooth wear, tooth fracture and worsening the pain later on as well, and maybe potentially causing a joint problem. So, it’s always prevention. And Botox alone is only temporary. Maybe patients can afford to have it forever, but most cannot. So, the splint is what’s going to ride them through it and how to protect them. So, we need to be sensible about this. We can’t just be saying, ‘Right, Botox is the answer for everything’, because it isn’t. [Jaz]And since you mentioned, let’s say we have a patient, I made a splint on them. I said, ‘You know what, you got huge masseters, as well as a splint.’ I want you to see Sheila, the patient that comes to you, you’re gonna do your thing and get their Botox, hopefully smaller and working in not such a hypertrophic way, maybe temporalis as well. Now, what do you say to that patient in terms of frequency of Botox need for the immediate sort of year ahead? And also lifetime? What is the kind of discussion that you have? [Sheila]So, that’s, again, a really, really good question and important question for patients because you have to manage the patient’s expectations. And my plan for patients is they need to be seeing me for the next year. If they don’t intend to do that, I just don’t start the treatment because it’s not effective. There’s no point in having one or two treatments, because they’re unlikely to see the long-term benefits. So, it’s three treatments exactly three months apart. No break. Maybe a fourth treatment at month nine. Sometimes, depending on how hypertrophic they are, how much pain they’re in, and how much reduction or atrophy we get from the first treatment, that will determine whether they need a fourth treatment, or whether we space that sort of three appointments in a year or four appointments. After this point, if they follow the plan, there will be a significant reduction in the masseter bulk. And then, maintenance is once every six to nine months, because all you’re doing is stopping. It’s not taking them six to nine months to get to that level. They’ve taken the time patient presents. They’re around in their mid 30s, right? Work is getting more intense, lifestyles changing; maybe they’re starting a family. Things are getting more sort of a psychosocial element of TMD that we’re treating. So then, once we’ve reduced the master bulk to where we want it to be, the maintenance is every six to nine months or once a year. And if that is the case, and they’re wanting to do even less than that, they absolutely need to be using their splints. So, that’s what I said. And they also need to know, it’s so important that the patient needs to know that it doesn’t kick in for at least a few days. And there may be some balancing that we may need to do around about two to six weeks. Also, depending on the bulk of their muscles and level of pain, I may do an additional dose at six weeks the first time we do it. Because we know that the muscle starts to recover from the Botox at six weeks. And if I think I don’t even want it to quit, I’m gonna go in and literally just whack another dose in there. That’s what I do. But we know that Botox is safe and it’s effective. And so, we can do that, but we don’t make a habit of doing that. Because we don’t want you to become resistant to the Botox, because then that’s a nightmare, and we’re not going to be able to treat them. [Jaz]Brilliant! I think that’s a good common question you probably get in terms of frequency. And I didn’t know that, you know, they can taper down to about up to an annual that’s really good to know. What about those patients? This is something that, you know, I’m very much coming to you as the expert here. I have some patients who have got myofascial pain, myalgia, but they don’t really have the hypertrophy element. You know, you don’t always need to have hypertrophy for them to have facial pain. Their muscles are in the normal ranges. Would that patient still benefit from having Botox that you feel their muscles, they’re not particularly large, but they got a clear diagnosis of myofascial pain, maybe got referral patterns, their teeth, and whatnot. So, we’re kind of sure about a diagnosis, do you think there’s a place in treating that patient? Is that patient more difficult to treat? [Sheila]There is definitely still a place to treat them because again, it’s that spasm of the muscle that now you’re referring to and it’s the overuse. Maybe it’s early on. So, what normally happens is, at the beginning, when they’re starting to overuse the masseter and the muscle spasms, they’re getting that pain, but they’re not necessarily getting the hypertrophy. It’s that repeated clenching that then grows the muscle, kind of like being in a gym. It hurts more in the beginning when you’re first lifting weights. But as you progress, it’s not as painful, but the muscles are really, really tight, aren’t they? So, it’s exactly the same way. You will know when you can palpate the masseter and you can feel it. And I encourage you to do this if you have masseter pain. And you can almost feel the knot, you know, that sort of same sensation after we’ve had a hard day at work and we’ve got really bad shoulder pain. We go and see a sports rehab and they literally dig in; they find a knot and they just really reduce it. You don’t necessarily have to have bulky muscles. But if you find that knot to that spasm, you can still- [Jaz]Sometimes as a maxfax surgeon described it as once. [Sheila]Yes! You can feel it. You literally can roll over with your phone. And, you know, because as soon as you press in, they almost like just sort of move right into your finger. And if they’re so comfortable, and they’re like ‘Oh, that feels so good.’ Okay, I know that if I can specifically just put a little bit of Botox here, allow them to rest and relax. Now the alternative to this is that they go see a physiotherapist where we can get some stretches from relaxing. They can do some jaw exercises. So yes, we can still put Botox. It still has a role that has an improvement. But the dosing that I would use in these patients will be less. And actually, they wouldn’t be as a bigger long-term plan. They would be more about education. Potentially getting them to see physiotherapy, getting them to massage and jaw exercise themselves. And actually, putting them down the route of some therapy, because then that’s going to protect them and hopefully help prevent that need for heartburn. That needs a long-term sustained treatment plan. And this is where we may just do a spot treatment of Botox to help relax and give them a little bit of a break and reducing that muscle spasm. So yeah, it’s still effective. But it’s not the only answer here. There are other things that we can do. And actually, the patient has rested their jaw, as well. Gave them a little bit of ice to rest their jaw, do some jaw exercises. You probably find that actually fine. Because it goes away, doesn’t it? [Jaz]It does! And most patients need a team approach. You know, they need the education, the appliance, the whole conservative care therapy. Physiotherapy helps greatly. For some people, there’s a posture element. They need the chiro. So, that’s when it gets more and more complex. And when we get chronic pain, pain that’s been there for more than three to six months, yet chronicity. And those patients become much more challenging. So, at that point, yes, they may then be seeing multiple people. But that’s sometimes, what’s needed. When it’s early on, we want to get in there and treat them and help them prevent from entering the realm of chronic pain. I want to ask you next, with general dentists who then decide to do facial aesthetics. I can see that, ‘Okay, you need to get some additional indemnity.’ I want you to tell me about what’s involved in that. And is that true that it’s an additional indemnity to get? But also, imagine I do some training with yourself. For example, I learned how to place Botox into a masseter and do some lip repositioning. Would I get specific indemnity that covers me for just the functional elements? Does that exist? Because I can see that as being a really helpful thing if it exists. [Sheila]Let’s talk about that first. Let’s talk about general facial aesthetics. Yes, you will need completely separate insurance to do facial aesthetics, if that’s what you’re doing. But for dentists, who are just interested in treating the functional problems and treating the disease, diagnosing TMD and sort of hyperactive lip muscle repositioning. You know, as dentists, we’re able to assess a diagnosis, and if we are appropriately trained, we can treat them so there is no regulatory requirement. Dentists just need to be appropriately trained and indemnified. That’s the GDC expectation. Your dental indemnity will ensure you treat TMD, bruxism and gummy smiles. Because they do anyways, if you want to do some Crown Lengthening, you’d be able to go back to your dental indemnity. It’s the same here; we’re not cosmetically treating these patients, in a sense. We are diagnosing the condition and treating it as a disease. And so, you’re absolutely fine. You don’t actually need separate insurance. You just need to let your indemnity know that you’re adding these treatments to your plan. There shouldn’t be any issues because you’re doing it from a dental perspective. You’re not doing it as a Botox- [Jaz]If I throw a curveball your way though Shiela, I’m gonna throw a curveball. So, I made something that I didn’t know that actually was amazing. So, if I want to do Botox, it’s I’m treating it purely for functional reasons. That’s dentistry. So, that’s how I manage my TMD anyway. But then, what you shouldn’t do if you’re that dentist now, is start to see these patients for whom you haven’t made a diagnosis of myalgia and myofascial pain, but they just have big masseters and now you’re treating large masseters for a cosmetic reason. That’s where it’s a blurred line and you shouldn’t probably cross that. I imagine, right? [Sheila]No, you shouldn’t. In which case you do need cosmetic indemnity for that, and actually still, you can just have that added on to your insurance more than likely. Just speak to your insurance company, and they will indemnify you, but you have to be specific about what you’re treating. And absolutely, you have to make, if it’s a diagnosis, that’s what you’re treating. You can’t be treating for cosmetic reasons if there is, that’s a real blurred line, so you’re right. Yes, you do need to get advice and speak to them and they will show you. Generally, the major indemnity companies will insure you for simple Botox treatments anyways. [Jaz]Okay, brilliant! It’s another common question that I know people want to know. [Sheila]I want you to just jump back on that, though. The thing that we need to be careful as dentists as well is that a lot of dentists are unfamiliar with advertising prescription medicines. So, Botox is a prescription-only medicine. We cannot advertise or market prescription-only medicines. We cannot use the name, we cannot advertise it. And I do find that many dentists fall short of this, first of all, because we call it Botox. That’s a drug and on their websites. They will use words like Botox treatments for TMD and even on their windows- [Jaz]Botox is the brand name, right? [Sheila]Yeah. [Jaz]So, even this podcast episode, we should rename it botulinum toxin and not Botox, right? [Sheila]Yeah, we should. But we can’t even say botulinum toxin, because again, it’s all prescription medicine. So, you can talk about bruxism and TMD, but you can’t talk about Botox. And it’s important that we understand that it’s a prescription medicine, so we can’t just advertise these services on our websites and things. It’s really important. [Jaz]So, how does one do it? Like, I know people do wrinkle relaxing when it comes to- [Sheila]Can’t do that. They can’t. [Jaz]Really? I didn’t know that. I see that all the time. Okay, wow! So, how do you do it for functional and facial aesthetics but functional? [Sheila]So, for a functional perspective, we just talked about TMD. How we can manage TMD as a dentist. How we can, you know, what’s really important is the assessment, the consultation and the treatment plan and being looked after. And you can talk about the different types of options that can be used. But it’s all surrounding the consultation with regards to things like anti-wrinkle, unless you’re offering other anti-wrinkle treatments that aren’t prescription medicine. If basically you’re trying to get around using the word Botox, you can’t do that. You just can’t. Just because lots of people do it doesn’t mean it’s right. You’re not allowed to do that and actually- [Jaz]Wrinkle relaxing, is that a big no, no as well? Because I’m thinking of all my friends practices who have that on their front door? [Sheila]Nope, because that’s obviously Botox, and you can’t, on social media posts as well. You can’t hashtag Botox, hashtag Botox injections, or anything like that. You cannot use any of those terms whatsoever. You just have to talk about the toxin and you just have to talk about the consultation. [Jaz]Just for the legal purposes, those listening. This is an educational episode. This is not for patients. This is a discussion between two professionals about the use of this toxin. Now, what percentage is an interesting one? My success rates in managing TMD, let’s talk about that actually, they’re not 100%. No one can ever expect that from a pain-oriented condition. I would say that, in my general population of patients, ie my own general patients who I see. I pick up the signs of TMD. But not necessarily the symptoms. I pick up the signs. I’ve got an extremely high success rate of them coming back and saying, ‘Whoa, I feel better.’ And I’m like, ‘Whoa! like I never knew I was doing so bad. And my headaches. My migraines I had 15 years ago.’ I got videos after videos. But those patients who seek me out, who’ve been suffering with signs, come first. Then the symptoms come. So, now they’ve gone beyond the signs, they’ve had the symptoms, and they’ve been suffering for months. See multiple specialist and now they come see me. My success rates will be much lower. They’re in the 78% percent, which is pretty much like, it isn’t literature. So, what has been your success and any trends that you’ve noticed in terms of Botox, or this toxin, that I won’t say it any more toxic, unhealthy? [Sheila]Okay. So, you know, when it comes to success, what’s really important is getting the diagnosis, right, isn’t it? If that’s the most important thing. And of course, in my patients, who where myalgia is the muscular component of TMD, they experience the best transformative results, because they’re usually the ones who tell me that I’ve changed their lives and had the biggest impact on their lives. And that’s fantastic! And that’s where you’re going to get the best results. Where there is also a joint sort of alder component, then patients can expect a significant reduction in pain, but not a complete improvement in their symptoms. But it’s understanding that these may coexist and understanding actually, that you’re managing the pain. You’re not claiming to try and cure them of pain and make them pain free. And therefore, managing their expectations. This is a reason why, I would say, that when it comes to muscular components, even if it’s in addition to a larger, all I’m ever saying to the patient is that, this will help to improve your symptoms and reduce your pain, you may start to have longer periods where you’re painful. You may not have headaches and wake up with jaw pain. But it’s unlikely that this will completely correct all the pain altogether; then my success rate is just there every single time. Because I’m acknowledging the fact that my goal isn’t to completely cure them of their pain and make them pain free. Therefore, I’m never promising that I’m always just promising an improvement and that’s the key and that’s the reality. Now, talking about the difficult patients who have gone see multiple people and you know, they’re not just getting, because I get the referrals as well. Because as I do more and more of this, I’m getting more referrals from the trickier patients. So these patients, you’ll know they’ll come in, and the pain is generalized. It’s not just on their face, it’s on their neck, they’re suffering from migraines, because, of course, we’ve used toxin- [Jaz]They’ll also have depression, fibromyalgia, all the other things. It’s very complex, chronic pain patients. [Sheila]Yes, absolutely! And that’s it. And in those patients, again, you may be able to improve their symptoms. But because they’re suffering from all other problems, they’re taking painkillers, left, right and center. There on, you know, muscle relaxants, antidepressants in those patients, much less success rate. And, but I already expect this, and I know this, and I always say to them, ‘Look, we can try Botox, because you’ve tried everything else.’ And it might work. It may not work; it may not give you the results that you want. But it may be enough to just pull you back from the edge because some there aren’t, they’re really on the edge. [Jaz]But the important thing is that you’ve made the diagnosis, and then you’ve made the link. Okay, this is one way additionally to manage this diagnosis that you have. And that’s what you know, keeps your confidence going. ‘Okay, it’s still worth giving a go.’ It’s not like ‘Oh, you tried everything and try.’ It’s because they’ve actually got a diagnosis of myalgia based on your examination and history. [Sheila]Yeah. And what I would say as well, sometimes as well, because they might come in and like say, ‘Look, I tried Botox, it didn’t work.’ And often, if there is a true muscular component, this is likely due to the Botox, but not being injected well, at the right depth. But often it’s injected far too superficially, if the muscles is really bulky or is really thick, it needs to be injected deep, almost on the bone, you know, hit the bone slightly pullback and inject. And so, if it’s failed in the past, that won’t be my reason for me to discount treating them. I will say, ‘Look, let’s give it a try.’ Maybe it’s because it was injected in the right place. Maybe they didn’t inject the right muscle. Maybe they didn’t use as big a dose. I actually often find that we’re not using a high enough dose to treat when it comes to TMD and when it comes to pain. For cosmetic reasons completely different, but when it comes to TMD and pain, I find that they need a much, much higher dose. And where a high dose comes in, a bigger increase of side effects and adverse events happens. And that’s why dentists tend to pull back slightly and under treat. But patients in pain, they want a result. They’re paying a lot for it. They definitely want results. So, yeah, it may be that you just need to try again. We need to make sure we’re getting the right muscle and we’re injecting high enough. But not so high that we’re causing a complication as well. [Jaz]Have you had Botox in your masseters? If you don’t mind me asking? [Sheila]I have. Look. It’s coming back. It needs more. [Jaz]I know you mentioned that in the webinar, actually. [Sheila]I’m a clencher. I’m a clencher. [Jaz]Yes, you said I remember. Now, when you’ve had it, can you just speak from your first hand experience? What does it feel like to have it the day after, in terms of eating. What difference does one feel? [Sheila]So, immediately after, it feels tight and sore, because actually it’s a stress. Your reaction to having any injection is to clench and make it even worse. So, the trauma of having the Botox itself, it feels a little bit bruised, a little bit sore, a little bit uncomfortable. But kind of very similar to a really deep intense sports massage. You feel a bit battered afterwards. But as it starts to kick in, you feel a sense of weakness in the muscle. Now, there is an absolute reduction in the ability to bite very, very hard, chewy things. So, I found around about day five to seven, chewing a steak felt really, really different to what it would normally feel like. And it’s really great that I’ve had this because I can actually relate to this and explain to the patient, ‘Look, around about five to maybe even 10 days, you might feel an intense weakness in your jaw.’ That’s the goal, you’re supposed to feel that, because I’m just retraining your muscles to use your jaw muscles, the way they’re supposed to be used. Not in this hyperactive way that you have been using them. So, you will feel some weakness. You’ll feel like it’s loose. That’s probably the best way to describe it. But you will get used to it. When you take two weeks and you’ll forget about it. Takes two weeks to adjust to that new sensation. And you can tell when it starts to kick in because you’ll wake up or you’ll start to feel the tension again. Usually, I’ve had it injected in my masseters. You’ll start to feel, for me, the tension headaches, and the tightness in my jaw when I feel like I’m starting to need it again. [Jaz]Have you ever injected Botox into someone with a beard like mine? [Sheila]Yeah, I wouldn’t expect you to shave. We would just make sure it’s really nice and clean. And what’s really important is, that you need to feel the muscles but yeah, it’s fine. You don’t have to shave that all. [Jaz]Fine. Good, good, good. [Sheila]You have to clean it really well. [Jaz]Yes. I have very hypertrophic masseter muscles. So, you never know, I might. You know, I’ve tried virtually most splints. I teach about it and talk about it. And so, if I ever go down to Serbia bit, that’d be nice to experience it, right? So, on that note then, it’s the final question, actually, it just leads me nicely, okay. If I have it, do you expect any side effects, and then also, any side effects long-term? [Sheila]So the biggest, long-term side effect is the atrophy of the muscle, which we’re actually trying to achieve. So, it’s the point of Botox injections. Now, on a man who has a beautiful square jawline, because of their huge masseters, it’s one of the things that we have to counsel them and explain to them, ‘Look, you’re going to lose your excessive jawline, unfortunately.’ [Jaz]Thank you. [Sheila]But you know, I want to get you out of pain. And I also want to make sure that you’re not going to have lots of restorations in the future. So, you know, it’s your jawline versus your teeth. And I’m always going to choose your teeth over your jawline. So, you do have to explain that to the patient, because, of course, we’re creating atrophy of the muscles. So, you’re going to get that reduction. You’re going to get the facial shape changes. Now, in a man, that’s not desirable. In a woman, that is desirable. But when a woman, what they need to be warned about is, if they’ve got any looseness and laxity in their skin, they’re going to end up with worse than an older woman. They may exacerbate their gels, which isn’t great for women. They don’t love that. They really get annoyed if you haven’t pre-warned them about that. [Jaz]So it’s like a turkey neck but the angle of the mandible. [Sheila]Yeah, sort of more along the jaw line, so it hangs a little bit more. And that doesn’t happen to everybody. It’s more likely in patients with lacks loose skin tissue, older patients with skin tissues. And that’s the long-term effects. If you’re repeatedly over treating, and of course, you’re going to get beyond this, we’re going to get excessive atrophy of the muscle and then really weak patients are not gonna be able to chew. That’s not what we never get to that point because we always buy nine months in, we’re reassessing. And then, actually, that’s why we’re increasing our duration of treatment time to six to nine months. The sort of short term side effects that you can get if you don’t place the Botox in the right place, or if you inject it too superficially, or you inject far too much volume or in the wrong places. Things like a asymmetry in their smile. That’s not ideal. The patients get really annoyed and you can’t correct it. The only thing you can do is go out and take the other side out. Or you reassure them by telling them that it’s going to get better in six weeks time and smile restriction as well. If you’ve gone too forwards with the injections or you’ve injected too superficially, you’ll get some restrictions. Sometimes they have to accept that if they’re in severe pain. I say to them, ‘Look, I have to use a big dose. We have to accept that you may get some smile restriction, not asymmetry.’ The restriction is something they feel, not necessarily something they see. They will feel that they can’t smile as wide. But usually to other people, it’s not something that’s noticeable. So, for the first time, we may just accept it. The second time, we may modify and reduce the dose depending on how much atrophy they’ve got. But it’s something that I can send patients for. And inevitably, not everybody gets a small restriction because there’s a muscle resource and not every single patient has resource. But in some patients where you want to inject the full depth and muscle, really deep, but more superficial as well. Then they will, to a certain degree, have a restriction. There’s more, that’s something you have to warn. Also, a small number of patients, I believe it’s one in 300, may get a headache following the Botox treatments, and it’s quite a severe headache. You have to warn them about that in the last a couple of days. It seems to be only the first time that they have the toxin injection. We think it’s due to the relaxation, or maybe the trauma from the actual injections themselves. But it’s quite severe, and you have to warn them about that. Other than that, all the other things really, really- [Jaz]So it’s like toxin in the masseter but then they get a headache not necessarily toxin in the temporalis, right? Toxin in the masseter. [Sheila]In a masseter, yes. As a side effect to that. [Jaz]What about bone resorption? Is that something that worries you long-term chronic use? [Sheila]So, bone resorption, we’re thinking about more to do with the fact that the patient is not able to know the reason for bone resorption. It’s really difficult for the evidence when we’re looking at this because if we think about the bone resorption, that’s happening anyway, that’s an aging process, every single patient will get bone resorption. So, that’s my first argument. The second one is, that it’s more linked to the fact that they’re not utilizing and not having teeth in the back of them. So, that’s going to exacerbate bone resorption from a perspective of masseter treatment. For me, it doesn’t make any sense that they would get bone resorption with overall long-term use because you’re not completely taken away that in their ability to chew and bite. You’re just reducing that force. So for me, it’s not a risk and bone resorption happens anyway, as we age. It’s a natural part of the aging process. [Jaz]Okay, brilliant. No, I think it’d be covered a lot of ground there. Sheila, if anyone wants to learn from you how to do these things or into facial aesthetics or functional. How did you go about doing that? Because I know I’ve been attended a couple of webinars and stuff. Tell the world of dentists listening right now, how they can reach out to you and learn because you’re such an inspiring teacher. You’re so passionate about this. You’ve done the whole restorative dentistry now. You’ve niched into it. Tell us where can learn more from you? [Sheila]Thanks, Jaz! So, I do have a functional toxin course just for dentists to treat functional elements. Reach out to me, head over to my website, mediject.co.uk, and you can fill in a form. But I also have a quick guide to what we’ve discussed today as well. So, quick guide to TMD management with Botox. So, if anyone is listening, you want a quick guide on the steps for assessment diagnosis, what to say to the patient, the treatment options, including the risks and benefits, head over to the website and just send me a form and title it ‘Protrusive Podcast’ and I can send you that 10 point guide just to help you treatment plan. I’ll also include the little screening tool as well, for those of you who don’t actually do any treatments for TMD specifically, but you want to be more knowledgeable and refer onwards. That is a really, really useful tool that I find. It’s great to add into sort of like your medical history for or your new patient assessment. It’s really great for that. So yeah. [Jaz]It’s great that someone on the dental forum for Dan’s Biden has actually commented saying, posted it, ‘Look, I’m actually not interested in facial aesthetics. I want to learn functional.’ And then people are like, ‘Well, actually, with these other institutions, you have to do like four levels first, before you can do the functional bit.’ But it’s great that you recognize the value and importance of general dentists who are treating functional issues day in day out to add this to their armamentarium is a good thing. And I respect you a lot for teaching this. That’s amazing! [Sheila]Thank you, Jaz. Yes, and there is a need for it. And it can be done really well. It’s really straightforward. And once you understand how Botox works, where the anatomy lies, and what to do. And of course, you know, having somebody to support you. You mentioned, you make sure that you are doing things properly, will mean that you will get predictable results. And actually, again, as I said, learning how you need to be able to prescribe and to be able to make splints as well as part of this is one of the most important things. [Jaz]All work with someone closely who does this things, if you don’t want to do it, right? [Sheila]Yes, if you don’t want to do it. Yes, absolutely! But assessment and diagnosis are crucial and you will learn all of that and I will teach you that and I’ll guide you through that whole process. [Jaz]Amazing guys. Head on over to, is it MEDIJECT? [Sheila]MEDIJECT, M-E-D-I, ject, J-E-C-T.co.uk. [Jaz]Amazing! Fill in the form. Tell Sheila in her subject, Jaz says hi or something Protrusive. And then get this download and start a conversation Sheila. Keep in touch when the time is right for you. You should totally learn about these functional things and you never know you might go to facial aesthetics. For those listening to this podcast, probably you clicked on because, ‘Oh, someone talked about masseters let’s listen.’ [Jaz]Sheila, thank you so much for giving up your time. I really appreciate it. I know you’re such a busy clinician, busy mom. It’s great to have you. We’re going to be seeing you on our monthly grind on the sixth of July. So, our monthly SplintCourse live webinar. We’re gonna do is specifically for the group of dentists who have done or are doing splint course. And they know a little bit extra than the average dentist about TMD. So, we’re niching down a little bit, and we will cover some themes from today, but then some more specific ones. And it’d be great for you to share some cases on that evening as well. [Sheila]Yes, I will do. I can’t wait! I’m really looking forward to that. Thank you Jaz for having me. Jaz’s Outro:Thank you, Sheila. Well, there we have it, guys. Thanks for listening all the way to the end. If you want to reach out to Sheila, then go to the show notes on the website. Or if you scroll down on your native player sometimes, for example, on Google podcasts, you scroll down, you see all this sort of text, all the links, my YouTube video, etc. But if you’re on a platform where you can’t see the show notes, then I always advise going to the main website. You can even download and see all the transcripts for all the episodes. So, for this one, it will be protrusive.co.uk. That will take you to the notes for this episode, and the transcript at the bottom and a link to reach out to Sheila. And if you’re a dentist who’s already using Botox to help their patients with myofascial pain, and TMJ issues. And perhaps you’re looking to level up when it comes to occlusal appliances, especially if you’re not already harnessing the power of things like B splints and how to provide them safely without worrying about AOBs. Then check out my flagship online course, www.splintcourse.com to guide you through that set of appliances, diagnosis and everything in between. Thanks again for listening all the way to the end and next time you see dentists arguing about which cases are suited for Botox and which ones aren’t. Send them a link to this podcast. Thank you again!

Being ‘Mum’ is the hardest (and most rewarding) job in the world. What are the unique challenges of Parenthood for Dentists? I’m thrilled to be sharing this non-clinical episode with you about work-life ‘balance’, especially if you’re thinking of starting a family one day (or just want to reminisce about real-world challenges facing young Dentists that are parents). Even if you’re not a parent, I think it will help you in your career and personal life. Dr. Hardeep Basi and I also discuss why Women in Dentistry sometimes do not get the recognition they deserve. https://youtu.be/FRP3vUQQdQI Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: Dr. Hardeep’s Journey 6:33 The ‘complaint’ that changed Dr. Hardeep’s perspective in  life 13:01 Motherhood affecting career progression 19:34 Parenthood and Dentistry 28:14 Female (Mothers) Support Group (Lead Her) 33:57 Work-Life Quality 38:20 Worrying about the Future 52:51  Check out the Support Group LEAD HER that Dr. Hardeep established to support females especially mothers in having the work-life quality they deserved! If you enjoyed this episode, you will also like Being Unstoppable with Ferhan Ahmed Click below for full episode transcript: Opening Snippet: There are so so many challenges. I could spend an entire day talking about this and I made a list of about 25 unique challenges to particularly mothers in dentistry and things that I've experienced. Jaz’s Introduction:Hello, Protruserati. I’m Jaz Gulati and welcome back to the Protrusive Dental Podcast. This is an interference cast which is a non clinical interruption. For those who are listening, I don’t know if I sound different. For those who are watching, you’ll notice this crack on ceiling and my room looks very different. And where’s my background gone? Hi, I’m recording in my sister’s old bedroom in my parents place because Hardeep, our guest today who is a just a fantastic person. She’s a shining light in dentistry, she’s blossoming into this amazing voice for females in dentistry. And I brought her on to talk about parenthood in dentistry. It was so difficult to plan this date that it actually worked out that I’m recording not in my usual studio. So do excuse the acoustics and the video if it’s a bit different. For those of you that know me parenthood is something that’s really important to me in my life. And I’m so happy to be sharing this episode with you guys. Even if you’re not a parent, and you never want to be a parent, I think there’s so much you can gain about our discussions at work life balance, like Hardeep maybe changed my thinking about it not being balance. It’s about work-life quality. So we discussed that towards the end. We talk about family planning and how especially for females and mothers to be, this could really change your career trajectory. And we kind of touched a little bit on why, perhaps, in dentistry, women in dentistry sometimes not get the spotlight they truly deserve especially when you look at the lecture circuit, there are many more male dentists on the lecture circuit despite there being more females in dentistry up and coming than males. So motherhood may have something to do with that. The challenges, unique challenges like being mum is the most difficult job ever. I remember Lakshmi. Lakshmi kind of got the I know you’re listening to this. You’re one of the loyal Protruserati and you came to our live splint course day and we just talked about being mum and being a practice owner and how it poses such unique challenges. Now one thing I discussed in this episode with Hardeep is I have been like the broodiness guy ever, for the longest time, like it was a dream come true when I became a father. So this was an episode I was really looking forward to recording. And I think dentistry does pose some unique challenges. And some of the challenges that Hardeep talks about, like wow, her being three months into becoming a mother and having to go back to work to see a patient while her child who’s breastfed was being getting express milk upstairs by a nurse because this is the reality of women in dentistry. And I’ve seen that in the practice of our work where the dentists will come back from maternity leave to see, squeeze this private patient in for orthodontics. Like you know, if you’re in the middle of orthodontics, and you need to go on maternity leave, that becomes a little bit messy. So we tackle these really real world themes. And as a parent as a father in dentistry, with all the things I do clinical and non clinical. It’s a real challenge I do and I know Hardeep tries not to bring her work home with her. I feel as though me and probably you listening and watching to this and the Protruserati, you probably take your work home with you, you’re doing ClinCheck, you’re doing treatment plan that is, you’re doing courses, online courses, webinars, etc. So it becomes really challenging to find that, probably I say work-life balance, but work-life quality, because that’s the main change in thinking that we explore in this episode. So I really hope you gain so much from this journey that me and Hardeep explore as well the unique challenges that parenthood poses to us as dentists. And so listen, and I’ll catch you in the outro. Main Interview: [Jaz]Hardeep Basi, welcome to the Protrusive Dental Podcast. How are you? [Hardeep]I’m very well, thanks, Jaz. I’m excited. I’m excited to be here. [Jaz]I’m super excited. And, you know, I don’t know if you believe me or not, but I’m being deadly serious here. I have never been this pumped and exciting. I was telling my wife as well for an episode of Protrusive before even though I do so much clinical, this specific nonclinical episode, which is very close to my heart. I’m going to talk all about that today. Parenthood is such a beautiful, beautiful topic. And I remember sharing an Instagram story. Not too long ago. It was actually in March and then that’s just a testament to how a busy lady you are Hardeep, you’re so difficult to tie down. I’m so glad I finally got you on this Friday morning. I’m actually recording right now in my sister’s old bedroom in my parents place. You see a nice little crack in the Loft ceiling here. You see all this red and pink decor. It’s not me, it’s not my usual place. So I’m making an exception for you to make this happen because this is long overdue. Anyway, back to the story. I shared a story on Instagram, saying, Hey, I’m recording on Hardeep and someone message, who, whose name I now forget because it’s so long ago. And he said, wow Hardeep, I was in hospital placement when she did MaxFax something. Did you do MaxFax? [Hardeep]Yes, I did. That’s right. [Jaz]So he message me, he said ‘She was one of the sweetest people I ever met. She was very popular with the nurses. She wants to bring in food.’ I don’t know that you’re, Is that something you’re famous for? [Hardeep]Oh, yeah. Well, I used to bring in like sort of leftover dinner from the night before. I used to bring it on my mom’s curries and not feel guilty about eating them in the staff room? No, but I did share with others. Yes, yes. [Jaz]Amazing. Well, you had this reputation. And he said that he was really looking forward to this episode. So sorry, buddy. It was in March, and I’m not gonna go through my Instagram all the way to March. So thanks so much. And for that. And so you know, I’m really pumped for this. And just to give everyone a bit of context, Hardeep, I know, because her dad is the person whose practice I did my first ever work experience that when I was like 15, or 16. And then your brother and I were worried or at school, and I used to see him through dental school events as well. So and then I met Simran as well. So a real true family of dentistry. But for those who haven’t got the complete picture here, just tell us a little about yourself, Hardeep, what you do at the moment? And I always want to extrapolate the journey. Everyone’s journey, how has your journey been? You’re now in in Scotland, you’re a mother of one, tie into your personal life. But just tell us a bit about your professional journey. [Hardeep]Yeah, sure. First of all, thank you. Good morning to everyone and Jaz, what a gracious introduction. And I’m so, so delighted and honored to be invited onto your incredible podcast platform. You know, the fact that we’re here today, after arranging I think, somewhat three times is a huge achievement in itself. And so it’s all about getting the timing right. So Hartaaj started to nursery and I’m now able to fully focus on enjoying and having fun in this conversation with you. And yes, you know, you’re well connected to the, to our family, you know, I think for me, the journey has been, you know, people would think that I’ve come from a family of dentists, it’s been quite smooth and quite easy. And it’s quite the contrary, you know, obviously, I came into dentistry before I came into parenthood. So I’m coming into dentistry for me, it was a challenge in itself. And Jaz, you know, of my dad, he’s incredibly inspiring. He’s a humble gentleman, is a great educator, a mentor and a supportive [Jaz]Very much it’s very truly he is [Hardeep]Yes, so many colleagues in the profession. And I’m very, very lucky to have had parents who encouraged me to go down any path that I wanted to, and they would always insist that being a girl, I should never limit my dreams. And I’m always eternally grateful for that. And growing up, my dad devoted a significant amount of time to building the family dental practice, which was incidentally just down the road from our home. And I really enjoyed going to the dentist as a young girl and it wasn’t far for a start, you know, it’s swivel around on the chair in the surgery or at reception watching and listening and learning all the time. And, you know, built rapport and relationships with all the staff and the patients are like, and you know, on the odd occasion, I would sit the reception desk and cover it. And what really strike me though, while I was there was that I was inspired by how many female dentists are working in the practice, who had children as well. And taking all that into context with working alongside my dad and looking at what the dynamics of the practice were that he was building an inclusive practice of males and females, I set my sights on following in his footsteps and studying to be a dentist. And the journey to becoming a dentist in itself was challenging. And during my school years, I suffered a lot with bullying and harassment actually, and debilitating migraine attacks, which would incapacitate me for weeks. But this didn’t stop me, I kept focused on my education. And I achieved the grades that I needed to to get into dentistry. And I graduated in 2012, at the age of 24. And you know, being a young woman from humble beginnings in Hounslow to living independently that far from my family was really tough initially. But you know, I got my head down, and I graduated with distinction and finals. And I had a few academic prizes at graduation. And the reason I share that with you is because I worked so diligently and I was so focused on my career aspirations as a young, independent woman, that my desire to put that energy, effort and time and hard work was almost ingrained in my DNA. And don’t get me wrong. I did. I pursued hobbies at university. I was socializing with my peers and I was that girl who went out on a social night and I would still make that 9am lecture the following day. But yeah, in my mind, [Jaz]I can vouch for that from our meetings at BDSA. [Hardeep]And yeah, that stage in my life, I’d set my, I’d imagine this was my lifelong career, you know, clinical dentistry. And you know, university was a great place. You know, I when I met you at the conferences and things, you know, we made amazing friendships. And while I was at uni, I met Manreek, who was studying medicine at Edinburgh. And so, you know, university time was really the opportunity where, you know, I had a few part time jobs, I was studying really hard. And I was playing hard as well. So that’s when the juggling act sort of began. And then to explain a little bit more about my journey. When I left university, I entered the realm of clinical practice, I was still an energetic, ambitious, mature, although my siblings, my big two might disagree there. But my focus was channeled on attending courses, conferences, volunteering, networking, and just continuing to learn as much as I possibly could. And I’m glad I did that, then because looking back now as a mom, it’s quite different to be able to seek those opportunities and have those networking opportunities and be out and about. And after completing my VT year training in Edinburgh, I returned to London where I spent two years doing core trading posts at King’s College London and Queen Mary where I did oral surgery and maxfax in general duties. And, you know, I look back at that time in life. And I’m always grateful for the inspiring consultants, the peers from whom I learnt so so much from in those early years. And during those years, I sat my MFTs exams. And I was maintaining a long distance relationship with Manreek, but we made it work and then we married in 2015. And I settled into married life and I moved to Scotland. And, you know, obviously a new town, no friends, [Jaz]That’s why you’ve got this Scottish twang. Now I can definitely hear it. I mean, at record, you sound very different to the Hardeep I once knew. [Hardeep]You know, when I first started university, I was like, Girl from London with the Posh English accent. And then now I’m like, you know, so hybrid, there’s a wee bit of a twang. Yeah, you’re right. Jaz, there’s a wee bit of an accent comes through. But yeah, it was difficult, you know, because I was new town, no friends or finding a new job. And but you know, I had incredible support from my in laws, my family that I settled in with up here. And life was different, but it was so so pleasant Jaz. And I landed a job in general dental practice, which was fortunately, in comparison to my SHO jobs. The commute was only 15 minutes. And this was ideal, you know, for me. And yeah, clinical practice was going really, really well. And I was building my self esteem and confidence until one day I got a patient complaint. And I don’t know about you Jaz. Have you had a complaint? [Jaz]I mean, I’ve had my fair share of near misses, but hasn’t been so bad. So are you happy to share just a little bit of about how that affected you? What happened? [Hardeep]Yes, absolutely. I think it’s really important to be open and sort of transparent about these because, there is a stigma attached about talking about things that don’t go so well in clinical practice, you know, and I’m more than happy to share that, you know, the mental trauma of going through that tough time. You know, it took a real negative emotional, mental, physical impact on me. And it was actually a turning point in my clinical career where it made me question whether I really wanted to continue with clinical dentistry. And I know to some that might sound really irrational, but it was a thought that crossed my mind. And, you know, [Jaz]I don’t think so Hardeep, I don’t think so at all. I don’t think that’s irrational at all. Like even all the near misses I have, even like the restorative failures that I get that don’t lead to any complaints and the patient’s very understanding, right, and I bring the patient in and fix it even just the other day, I was a bit ambitious with the Zirconia Resin bonded bridge, and I wasn’t happy with the connector with but I still fit it. And then the pontic snapped off. And so, you know, that still has a potential to give me a sleepless night. And then I still, you know, despite how passionate I am, I still have those thoughts like, oh, man, I hate these failures. Is this really what I want to do? So everyone gets those thoughts, especially when they experienced failure, or I guess heightened even more so when you have something as stressful as a patient complaint. So I don’t think it’s irrational at all. I think it’s very much normal to have those thoughts. [Hardeep]Yeah. And Jaz the sort of difficult part of it was that I didn’t feel fully supported. Yes, we have our indemnity, but it was an experience that I know so many of us feel like we go through alone. And for me, fortunately, the complaint was resolved amicably. Right. And it wasn’t as significant but the fear of that litigation, the fact that it was going to allow it to destroy my drive and my determination and passion because of one negative interaction over all the positive patient interactions I’d had up until that point And so, you know, it was really, really tough. And then to compound on top of that I had a horrific car accident in June 2017. And without going into detail, I was so lucky that I survived because my car was written off. And, you know, I suppose up until this point, the experiences I had made me reflect on life, about, you know, up until this point, I’ve been so focused on a career, that what did I want out of life that I wanted to live fearlessly? And I wanted to live it fully in my potential, because you just never know how short it is. And, you know, Dentistry was my life. But you know, as a young married woman with that passion for the profession, but these are life events that were happening to me made me question whether it was really for me, and I was overcome with anxiety. But you know what, there was a reason for this all happening to me, and life was happening for me at this point, it was a realization, it was a time where I knew there was a deeper purpose in me, and I had a desire that I wanted to start a family. And, you know, my faith has always been a solid anchor, you know, my self belief. And I started reading around a lot of personal development, listening to podcasts, rebuilding my energy and my focus and surrounding myself with supportive positive people, so that I could really unleash that potential in me. And, you know, Jaz, things happen according to the divine timing. I really, truly believe that. And after my brother’s epic wedding festivities in India, we went to Amritsar and we went to the Golden Temple. And there I prayed so deeply for a child. And six weeks later, I found out I was pregnant. And it was just the most incredible moment in my life. And the sheer joy of becoming a mother filled my heart with so much excitement. You know, I thought, you know, getting into dentistry and [Jaz]Is that something that you always wanted to do? Were you always a broody? Because I can tell you now, like, I don’t know, or is a man allowed to be broody? Is that the right term for a man but I’ve always wanted to be a father. So for me, though, all those comments you said there about how it made you feel and stuff like when I saw those two lines on my wife’s test, like, I’ve got a photo of me, like, almost like just so emotional, and charged and happy and stuff. And it’s been the best thing that’s ever happened in my life. And I’m sure you can talk about that. But also talk about the challenges and how it affects our profession stuff. But yeah, I definitely share your sentiments. [Hardeep]Yeah, absolutely, Jaz, you know, like, I grew up in a big family, I had lots of surrounded by lots of cousins, you know. And so, having a family of my own one day was definitely an aspiration. But the timing of it, you know, it’s always something that culturally and socially conditioned, were thought to believe that things need to happen at a certain age, and you know, all that sort of stuff. But, you know, for me, I was at the age of 30. And it for me, it didn’t matter about the age, it mattered just about the stage of life that I was at, and I was ready to take on this new challenge. And, you know, I thought the journey of getting into dentistry, my career was challenging, I was in for a real treat, when it takes eight years to get into some sort of stability in the dental career. And it takes nine months to become a mother, you know, through that whole journey of pregnancy. But fast forwarding all of that, and when our baby boy arrived, it was [Jaz]Hardeep, I just gonna stop you there one more, because I just want to pick on two small aspects that was gonna so in case anyone in case you missed it, when you were listening, guys, one little thing, which you know, might be missing passing is that you said how you did so many courses early on. And then you did actually touch on the fact that actually now as a mother, you couldn’t imagine doing that. And I feel the same that I’m so glad I did so much of my education on the front end, so that now I choose quality over quantity, whereas before it was, like, get quality and lots of quantity to see what’s out there in the real world dentistry to expose myself. And as a parent, I definitely as now a learner, avid learner as an educator now as well, finding the time that’s why I do a lot of my stuff online because I can make more time for my son. So that’s a thing just worth mentioning to anyone listening that okay, if you’re a position where you’re not thinking about children, but you might like to have a family one day, then how is your career gonna kind of map out and then on a similar vein, my main question for you now is before taking the plunge into motherhood before family planning, did you and I don’t know if you’ve spoken to other mothers in dentistry, Were you nervous about how this might affect your career progression? Because one of the themes I want to, it was actually last question was asked you is we see so many people at the top of field who are male, we see so many lectures, I look at conference programs, male, male, male male, you see one female. And I feel as though a lot of the high positions in dentistry are occupied unfavorably or to bias towards male. And I feel as though perhaps this has all got something to do with it. So, how do you feel? How did you feel the time about this would affect your careers? That’s something that you thought about? [Hardeep]Yeah, I mean, absolutely, Jaz. You know, I think this advice would have been really helpful while I was at university, you know, to give people that advice at an earlier age, you know, things will happen when they happen for you And when you decide that you’d like to do things, but I think going on courses and pursuing your career aspirations, do that as early on as you can, while it’s all fresh in your knowledge, and you’re building on a good foundation from University. And I think coming out of university, I realized when I went into the real world of clinical dentistry, how much I didn’t know. And so yeah, I would absolutely advocate for doing things now, and not procrastinating on those choices. And family planning is really important as well, you know, I didn’t have those sort of conversations with people earlier on I just, for me, it was a turning point in my life where I had to go through such adversity and such challenge and then decide, actually, I was so tunnel vision focused on dentistry, but I lost sight of other things. And Hartaaj wasn’t actually, it wasn’t actually planned in that way. You know, as to right, I’m at this stage in my career, you know, now’s the right time, it was other things that made that gave me that realization. And I think for me, you know, it’s quite interesting because I was having this conversation with Manreek the other day, and he said, and I said, I think I’d been on more courses before I had Hartaaj. And he actually looked at me and said, No, I think it’s the other way around, I think you’ve been on more courses since you had him. And I thought, Well, maybe it’s to get a break from both of you then. And, you know, it’s different, there’s a lot of shifts that happen, Jaz, you know, when you become a mother, and I can talk from that perspective, you know, I have this wonderful life changing experience of becoming a mum to Hartaaj, who’s now three, even though I do introduce him as 3 going on 13. And it’s the greatest thing, but it’s also the hardest thing being a mum, because there is this, there’s this shift in your identity. And, you know, the amount of learning that happens when, you know, a child is born, but so too, is a mother or in your case, as well as a father. And so for me, the sort of key challenges that I had, when I came into motherhood. And also, you know, in keeping in line with my sort of career aspirations was that when I returned back to work, after nine months, so I took nine months of maternity leave, I was so anxious Jaz, I was stressed, I had this fear of letting go, this separation anxiety, when I would drop him to nursery, we would be bawling our eyes out, you know, that I’ve spent nine months with him, he’s been in my arms, he’s been spending a lot of time with me, there is that sort of emotional connection that you have and that attachment. And then to sort of hand him over to somebody else who effectively is a stranger, you know, you don’t know the nursery staff, you know, you know they’re there to take care of your child, but you don’t know them. They’re not like a family member. They’re not you. And I think for me, it was just all the emotions, I didn’t know what I was feeling, I didn’t know that this was normal, I and I became overwhelmed with the emotion of that sort of unhealthy attachment. So separation anxiety, is a very real emotional feeling. And for me to kind of come through that, you know, to grow through that, because, you know, it was there for a long time, you know, Hartaaj cried for every single day for 18 months before he turned a corner and actually had a smile on his face going into nursery. And, you know, for me, it was about managing, getting the help and support to help manage those feelings, that it was valid to feel that way. And it was an accepted part of being a mother or a parent, and leaving your child in the hands of someone else while you know you go to work. So, you know, it’s it’s very normal to feel that. And I think it’s really important to acknowledge it, to know that you’re not alone in feeling it and that you can get the help and support you need to manage that feeling. And so, that’s the beauty of it is that you go through that, to know that you become stronger. And then now you know it’s wonderful, dropping him off to nursery, going off to work, grabbing a coffee from the drive thru on the way and listening to a podcast, you know, just enjoying that time without feeling guilty. About that’s really what it means to me. [Jaz]You know what that reminds me of? I just thought, I have to it to mention this as a book called, you probably familiar with it. The Seven Habits of Highly Effective People by Stephen Covey. Very highly referenced, you’ve probably read it, I imagine, [Hardeep]Yes, I have read it. [Jaz]One of the first chapters talk about what it is that you channel your focus to. So we have many dentists who are very much focused on their careers, their everything in their life is about my identity is a dentist Now, if that gets taken away from them, then their life is over. That’s it. And then on the other end, you have people who are spouse centered, or children centered, so everything in their life revolves around their children. And then, you know, when they’re 18, or whatever, they felt the mess, and suddenly their life has no meaning anymore. And so what Stephen Covey argues is that we shouldn’t be centered around any of those things. We should be values centered, so I’m always having this discussion, my wife, I’m saying to Sim, Look, I know we love Ishaan, he’s the world to us. But you know, everything in our world shouldn’t revolve around just him. He’s very important part of our life, but it should be revolve around our values. And he is very much part of that. But he is not the sole thing. And there’s something that I think is worth mentioning, would you say? [Hardeep]Absolutely, Jaz couldn’t agree more. And I think, you know, the conversation about knowing what matters to you as a person first and foremost, you know, I think a lot of the time what happens is that, and coming into motherhood, before that, my responsibility was me and my career. And then he came along, and obviously, you’ve got your relationship as well. And it’s about your value system and quality of time in life, you know, how do you choose, as a family to spend time together to make that time that devoted, you know, no distraction time together, and also then be able to manage your work commitments and pursue your career aspirations? Because somebody like me, has realized that they are, you know, passionate about dentistry and specifically leadership in dentistry. And, you know, you’re absolutely right, it comes down to your why, you know, why are you doing these things? You know, what are the barriers, [Jaz]So it’s essentially to children, our children, anyone listening, who’s a parent or wanting to become a parent, we love our children. But I think the message here is, our children probably shouldn’t become our why because then you’re attaching your entire center of everything to an individual person. And you know, if you had an argument, that person when they’re a bit older, and that’s it, your whole world turned upside down. It should be very much centered around you and your values. That’s essentially the book says, Would you agree with that? [Hardeep]Absolutely. Yes, you come first, as selfish as that can sound to some people, it is absolutely necessary to set out why you’re, you know, absolutely Jaz, you know, what matters to you as a person? What do you value in your life? And of course, we value relationships, family, work. But you know, as part of all of that as well, Are you giving yourself enough time to look after you, wholeheartedly? Are you filling your cup with a lot of self care? And self care isn’t, you know, that sort of all around the sort of fluffy stuff. It’s really unraveling your thoughts, your processes, your, it’s messy, it’s hard work, you know, it’s understanding the barriers that are keeping you stuck from unleashing your full potential. So absolutely, first and foremost, you need to tap into, what it is that matters to you? What do you value in life? [Jaz]I’m gonna switch it up. I’m gonna just talk about very specifically in our niche in dentistry, what do you think are the unique challenges that we have? Very much the meat of this episode? Like, you know, fine, you know, a lawyer could be discussing with another lawyer about the unique challenges that lawyers have with being parents. So what do you think are the unique challenges that that dentists might have? As a role as a, you know, wearing the hat of a dentist, but also wearing the hat of a parent? Can you can you think of any I’ve got one to share with you, but anything that you’ve experienced as a mother especially? [Hardeep]Yeah, I think, Jaz, for me, I’ve kind of alluded on it, but coming back from maternity leave, back into dentistry as a mom with a new sort of, you know, role and responsibility. For me, it was the lack of support when I came back. And, you know, it was quite sad to just see that, you know, you’re just expected to throw yourself back into it, with no sort of additional support. And, you know, there were so many changes that happened, because, you know, I was full time before I had Hartaaj, and then I came back and I was part time, I had to obviously reconsider my working hours and my working patterns. You know, there are so so many challenges. I could spend an entire day talking about this. And I made a list of about 25 unique challenges to particularly mothers in dentistry and things that I’ve experienced. I remember [Jaz]Just go for it, real amount, just to spend a little bit of time just to go for it. Let’s hear it. [Hardeep]Yeah. You know, I remember Jaz. I had a few sort of ortho patients before I went on maternity leave, right. And I still remember, he was only three months old, and I had to go back into practice. These were private patients. I had to go back into practice while I was breastfeeding, and sort of look after these patients and that stress, you know, luckily, I had, you know, a really nice supportive team at work. You know, I remember one of the nurses holding, you know, Hartaaj upstairs in the staff room and giving him sort of express breast milk. And I’m downstairs in the clinic treating this, you know, this patient. And, yeah, that in itself was a huge challenge. Like, how did I do that? You know, taking him with me to practice. [Jaz]Oh, my goodness [Hardeep]All a lot going on. And I think it’s just so overlooked. And, you know, then you have the guilt, the feelings of guilt, you know, are you coming back to work too soon? Putting your child in nursery, what’s too early? What’s too late? You know, you’ve got to think about your working hours. Your, you know, especially in the evening, if you’ve got no childcare, how late can you work? You know, your career progression, you’ve taken a break from clinical dentistry, when you return and you’ve got this feelings of being good enough, but your clinical work, you’ve got, you know, the impostor syndrome in dentistry. [Jaz]I get those thoughts when I’ve been on like, a one week off holiday, and I come back, and I feel okay, oh, my goodness, I’m so rusty in my decision making in my precision, I can only imagine after a maternity leave, and whatnot. Absolutely. [Hardeep]It’s crazy. And, you know, a lot of people do sort of just dismiss it as when you go back, you’re just all come back to you. But it takes time Jaz, and you need people around you, you need to be able to speak to people and share these concerns and struggles with them, you know, you’re coming back to work, you’ve got broken sleep, and I’m sure you experienced that too as a father, you know, if you’re sharing that sort of responsibility, looking after your child, you’re coming back to work not fully alert. And you know, then you’ve got this sort of mad rush in the mornings dropping the children to nursery or school or what have you. And have you had breakfast, you know, have you eaten something? Have you fulfilled your basic needs? You know, it’s and then you’ve got the element of, you know, if your child is sick, you know, you’ve got to leave work, you know, what’s the contingency? What are the measures for this? that consideration [Jaz]I just want to talk about that. So my wife works in community, I’m in private practice, so she’s salaried, I’m not and therefore, if Ishaan’s sick, then it’s going to be her. And it’s always unfair. It’s always unfair on her and the trust that it has to be her. Because I’m the one who’s private and you know, why does it work like that? It just, it is just makes sense. Right? The person who’s salaried takes at least a day off, it’s just the way it works out. But you know, lots of women in private practice A) The whole maternity pay situation is something we may touch on, that’s very complex, but B) you know, if your child is sick, you know, there’s no replacement for Mum. Mum is mum. That’s why I think motherhood poses such unique challenges to tell, challenge in a good way that you know, it’s such a beautiful challenge that you embrace. But Mom is mom and motherhood is a, mother is the most difficult hat to wear as a dentist. And that just highlights some of the issues like what if your child is sick? [Hardeep]Yeah, you’re absolutely right. You know, they have this strong desire, you know, ‘when I’m sick, when I’m ill, I want Mum’, you know, that’s how I want to be around. And it’s that phase of, you know, that sort of attachment that happens and you can’t just, you know, working you’re busy NHS practice with all those sort of considerations, you know, rebooking patients and things like that, it’s tough going to get your head around. And you know, when you finish your nine to five job, you’ve then got your five to nine job, you know, your dinner, the dishes, the bedtime routines, all of that. So it’s really hard going and I think, that can’t be overlooked or underestimated by, you know, there needs to be more support for mums returning back to work. And I feel like that is one of the biggest challenges, you know, that sort of holding somebody’s hand and saying, Look, I’m here with you, I hear you, how can I help you. And that is something that I’m so passionate about, which is one of the reasons why I started which was back then the dental motherhood, and is now the ‘Lead Her’. And we’ll talk about that in a little bit but.. [Jaz]I’ll just bring that into actually, because I’ve seen so much of your stuff on Instagram and how passionate you are about this. So just tell us because you are essentially fulfilling the role that you wish you had in those stages where you felt maybe isolated that you felt you need support, you want to be that support to amplify the voice of females in dentistry, which is a beautiful thing to aim for. And also motherhood being part of that as well. So tell us a little bit more about ‘Lead Her’ What beautiful name. [Hardeep]Yeah, thank you, Jaz. So yeah, originally it was the dental motherhood. And the reason for that starting under that umbrella term was because on the back of as you say, you know, my struggles, my anxiety, returning to work, first time mom, and also passionate about dentistry and my career aspirations in that field. So I set the group up to really provide an online community a space so I created that space which was never there. And to bring together a community where we can have connection, we can have collaboration, and we can really share quite transparently and quite often honestly and anonymously if you wish, your struggles and provide that support network, which I think is so important, just to know that you have a platform to share, and to get support is so pivotal. And I think, you know, once I did the dental motherhood, and it started to gain some traction, I then decided what, you know, why am I restricting this to just dentistry? You know, there’ll be, and this also came on the back of my clinical leadership fellow post that I did that, you know, I was with medical professionals, and mothers and pharmacy fellows who were mothers, and, you know, I decided, you know, let me broaden this out, let me expand it so that more women can come in. And you know, it’s not just for mums, it’s for any female out there in any field. You know, it’s about empowering, supporting, sharing knowledge and information, because I’ve been through those tough times. And if I can be there to support in any measure or capacity, then I will do that. And it’s growing. It’s a growing community. And it’s lovely, it’s a wonderful feeling. And we have so many exciting things going on in that group. Slow and steady, because obviously, I’m trying to find that, you know, time to be able to do it. But yeah, it’s brilliant. It’s really, really amazing. [Jaz]How, how do we connect? How do we connect with that? What’s the first step like, you know, you’ve inspired someone listening today and she would like to come on and connect with you and learn more about how to empower herself as a female in dentistry or beyond, because this podcast has got more more reach now, how is the best way for them to connect? [Hardeep]So it’s through Facebook, so it’s a Facebook group called Lead Her so it’s lead dot her, and you can join the Facebook group, and there are, the community is growing, there are ideas that I’m coming up with, as time goes on, you know, we’re going to be starting a book club, which is very exciting. And that will be a great way to learn and to get to know each other. And then I have organized retreats, which are luxury retreats for women to come away from their sort of comfort zone and experience new surroundings, with new people, and, you know, epic experiences and activities. And on those retreats, there is learning there are leadership masterclasses, where I impart some of the knowledge and wisdom that I have, and tools and strategies and techniques that have really helped me to grow into being confident, feeling empowered, and feeling happier in life in being a dentist and a mom. So, you know, it’s a great community, and I would love as many to come in and join because I think there’s real value in that [Jaz]And I love your social media, Hardeep, it’s such a positive voice in dentistry. And you’re such a wonderful leader in what you’re doing in the moment. And I wish you all the best success with this So ladies, if you’re listening in particular, it for lead her is resonating with you, I think you should with every every female listening to this, you should definitely reach out, check out what they’re all the ideas that Hardeep has, and it’s only gonna grow you as a person. So thanks so much for sharing that I just want to bring you on to highlight and put a spotlight on lead her which I again, I can’t get over how awesome the name is, I can’t believe you own that. That’s amazing. Tell us about your work life balance as it is now. In the stage of life, you know,Hartaaj is three, my son also, Ishaan’s gonna be three next week. So tell us about your struggles, your goals, who would work life balance? Is it elusive? Does it exist? [Hardeep]I love this. You know, I love this topic. And I could spend a good few days talking about this and I do share quite powerful information about this on the Lead her retreats. And you know what Jaz, the word ‘balance, right, recently, I had some conversations with some colleagues about this and friends in dentistry who coincidentally are mothers but also that aren’t. And we debated the word balance, because balance is sort of defined as a stable mental, emotional and psychological state. And what we were thinking was, you know, a better word, a better term to use is quality. Quality over balance, because balance implies that everything is in a controlled state and certain state and the equilibrium, but the reality is we live in uncertain times, and adversity and things are changing all the time. So the idea of achieving balance almost seems quite unrealistic. So what we feel is that and what I feel particularly as well is looking at the quality of personal and professional life, knowing that that quality will vary from day to day, it will be different in your health and your sickness and under different circumstances. But as long as you’re giving your best, and that will be different day to day. The quality can improve and as long as you’re focused on being better, and being kind to yourself along the way. You know, for me that that’s what it stands for. And, and you know, I’ll share my perspective terms and these are just my personal thoughts they will be different to you know, my parents and friends alike. But your quality of life, work life is different for each and every one of us. And for me, it comes down to again, what we already touched on is my why and my values, you know, why do I do things the way I do? What do I enjoy doing? What lights me up? What is my purpose here, and you know, becoming a first time mom, it was a tough ride, I had no one, give me a manual, give me some advice or anything like that, you know, my mom did impart some great wisdom with me. And having raised four children herself, you know, I saw how she did it. But it is a roller coaster of emotions. And, you know, with me having experienced burnout, overwhelm, anxiety, guilt imposter, I can relate to how many of my female colleagues, and especially working moms feel because I’ve been there. But I’ve come out the other end with now a solid toolkit that I can tap into whenever I need. And we need our quality of personal and professional life to be a daily practice like that self care has to be disciplined daily practice at home and at work. And I’ll focus, you know, for the benefit this podcast, I want to focus on the positive reflections, because I’ve grown massively, just in this last year, there’s been a huge amount of self awareness. And unraveling and unpacking all the messy thoughts and things that are going on and gaining a deeper understanding of standing of my values, my needs, my aspirations to live happily, in both my career and at home. And for me, it needs to be achievable. And it needs to be about taking the time to reflect on how you want to lead in your life, you know, taking control of the choices that you can make. And for me, it’s about optimizing your mental and physical health and well being every single day both at work and at home. And it does come down to how you use your time to really focus on how you spend it, because it’s the most valuable asset we have, it keeps going. And it’s the currency, we have to get what we want out of our one life, our one conscious life. So for me that a good quality work life balance is about being happy. It’s about being healthy, it’s about leading life on your terms. And, you know, even when things get tough, they do get tough, but you have tools to help you thrive not just survive. And so for me, it’s about prioritizing, it’s about my primary focus to make it to have that sort of good quality life is personal health. And there’s no substitute for health, you know, positive healthy habits that you can do at work and I don’t know if you’ve read the book, Atomic Habits by James Clear, but you know, your habits [Jaz]Audio book are my way through at the moment. [Hardeep]Yeah, it’s a fantastic book, right. And he, you know, he talks quite about it being that, you know, these habits that we have in our personal life and our professional life need to be obviously need to be attractive, they need to be easy, and they need to be satisfying. And so for me, I prioritize things like sleep, you know, it’s a necessity, you know, worry thrives on a tired mind. So, I do some meditate, I do some meditations before bed, I do some light gentle exercises, and you know, we try and distract, take away all the electronic devices, at least an hour before bed. For me also a good quality of life and hygiene, [Jaz]Sleep hygiene [Hardeep]Sleep hygiene, exactly. And doing that sort of daily physical exercise as well, you know, making time in at home and at work to do some daily physical exercise. So I have a personal health coach who educates me on good dietary habits, you know, taking supplements, I have vitamin D sitting on my desk, discussing nutritional needs, and he has actually given me a tailored need a lot. Where, you know, he’s given me really, really, you know, a bespoke fitness plan where 5 to 10 minute bursts of physical activity such as squats, squats, and lunges between patients is enough, you know, we don’t, as working mums, I don’t have an hour that I can spend in the gym. But I have 5-10 minutes between patients that I can do some squats and lunges or 5-10 minutes at home between, you know, while the kettles boiling or whatever I’m doing to do that regular sort of physical exercise. And, you know, I think he’s also you know, at lunchtime, I always go for a walk, whatever the weather, it’s so refreshing to get away from those four walls. And, you know, I can’t emphasize that enough and I’m trying to get people at work now to come and join me on these walks because often the default is let’s go into the staff room and you know, chat about cases or patients or you know, whatnot, but actually getting outside in fresh air is great for that quality of life. And also, you know, Jaz, having time for your relationships, you know, you can get so consumed with work or home and kind of lose track of your relationships. So I schedule, Manreek and I schedule some time to go for a breakfast date or a dinner date. And we’ll do that while Hartaaj is in nursery on a Tuesday morning. So having that sort of communication and enjoy [Jaz]Even in couples, who are friends of ours who don’t have children. And then I know that, for example, a couple of friends of mine, who were both doctors, no children, and they just tell me how difficult it is to see each other, like they both are busy GPs, and then have very active lives in terms of sports and stuff. And then they have to make time for each other is difficult. And it becomes even more difficult as a parent. So you have to do life design, you have to design your life, to actually put that in the diary as a recurring event, which as lame as it sounds like you’re so so sad that in, you know, in 2022, we have to diarize time with your other half, but you do in a way, otherwise, you just leave it to chance. And then other things take priority to have that dedicated space, where you’re going to give yourself to someone else for that time and their undivided attention and to nurture that relationship is so important. [Hardeep]Absolutely. And you know what they also, you know, for example, Hartaaj gets to spend quality time with his grandparents, you know, for an afternoon a week, and sometimes more. So it’s great while you’re, you need to consolidate and build on those relationships that you have, otherwise they do challenges do come in between that. And in terms of work commitments, you know, I keep my clinical commitments, I work three days a week, I’ve now dropped to two at the moment. And while I’m currently on this Leadership Fellow, which is half my working week, and you know, my full clinic days coincide with the days that Hartaaj has full time in nursery. So you have to sort of work around your personal circumstances and you know, Manreek’s working four days a week, and then he has a Tuesday off with Hartaaj. So he’s got his day with him and his commitment with him in the afternoon. So there’s lots of things that come into play. And obviously, for me, out of my working hours, I’ve dedicate time for leadership, coaching, developing lead her organizing retreats, I’m constantly reading books on self improvement and leadership. And you know, all of it is learning, you’re gonna make mistakes along the way. And sometimes I feel like, Oh, I haven’t spent enough time with, you know, Hartaaj or I haven’t spent enough time with Manreek, even though we did have a breakfast date, whatever it was, you know, or I missed out on family dinners, you know, things like that. It does happen. But it’s all learning at the end of the day, and it all comes down to your boundaries, you know, at work and at home. You know, I try not to bring work home, I consciously decide at work, there is no such thing as procrastination, if I do my notes, and I don’t try, I don’t try to have any sort of access at home to do any clinical notes. I don’t do it, we don’t I don’t do it. I do what I can, if I have to add another 5-10 minutes on to the day, I’ll do it. Of course, sometimes, realistically, some things do need to come home, like I’m doing some Invisalign planning case planning at home, or, you know, whatever it is, but I also learned to say no to things, you know, what am I saying Yes, to all the time that I should be saying no to, and realizing that I can’t do everything, and I can’t please everybody that I’ve got a level of autonomy, and I need to make decisions, you know, it might be at home deciding No, I’m not going to do the ironing today, because, you know, I want to play with Hartaaj for a couple of hours. Or no, I’m not gonna go tonight, we’re gonna get a takeaway, because, you know, I want to, you know, spend time doing some work, you know, it’s whatever really suits you. But it’s that ability to create those boundaries. And if you don’t, it can be quite disruptive to your day to day living. And I think, you know, it’s about being organized and having some structure, but also, you know, being quite spontaneous and picking out time to just, you know, have fun and go on a little adventure outside and just, you know, switch off and not everything needs to be so regimental and routined, you know, apart from obviously, when I’m organizing to go on courses and conferences, that also requires some, you know, structure, but it’s really important Jaz, I think, to get a good quality of life, both in a personal and professional sense. You need to have support. And I think that’s, we’re very grateful that we have family close by and friends that we ask for help. And there’s no, you know, I’m so so grateful for that. And there is no, you know, as cliche as it sounds, you do become the average of the people that you spend the most amount of time around. So it’s really about deciding what kind of life you will carefully selecting the people who will help you live that life, right, both in your personal and professional circles, and learning from each other. And I think also for me, what’s really important is that I spend time with positive people because energy’s really important to me and their personality characteristics rub off on me, you know, you start to grow together. And with Hartaaj as a mom, that quality time that I focused with him, I removed distractions, I silenced notifications, I sit with him. And I asked him what you’d like to do. And I think just giving that dedicated time to build that attention, connection and love, the present is more powerful than anything, you know, we sing songs together, we read, we draw, we color, we snuggle up and watch a movie, we’ll go outside and kick the football around, whatever it is. But, you know, as they say, [Jaz]I’m very much the same, it’s all about undivided, it’s quality, you know, in your quantity is great. And we can have it when you have a week off and you spend X time together. But when that, you know, when he’s gone to nursery, I’ve come to work come home, it’s about everything has to go, it’s all about Ishaan for that one hour and to really fulfill my role as a father and I get so much enjoyment and fulfillment and energy from that base about at that point, if I’m not replying on Instagram, whatnot, is because I’m busy and with Ishaan, and there is a place to that if I’m constantly multitasking, and I’m giving some of my time to Ishaan and some my time to Instagram or whatever, it’s just not going to work. So I definitely agree with that. [Hardeep]Absolutely. And I think also, well, you mentioned, you know, disconnecting from social media, because it can be, you know, really overwhelming, you know, all these sort of messages and replies and things that you’ve got. And people do generally post and I aren’t guilty of this, I post a lot of positive good stuff, right. And I do also share struggles and, you know, mistakes along the way, because it’s an important platform for learning. But I think it’s so important to be able to decide I’m going to switch off. And also if it’s not playing with him or doing things with him, I like to have time for me, I like to be alone, you know, and have some time to really ground myself go and do things that fulfill me whatever that might be. You know, whether it’s booking a massage, or going away on a retreat with some other incredible women, you know, I think we really, really need to give ourselves that, to have a good quality of life, which I think between personal life, your home life and work life, you are in control of that quality. And, you know, I try to live in the moment, in the present [Jaz]A huge learning point from this podcast for me Hardeep is I’m removing the word balance now it’s no longer work life balance. It’s work life quality, I really as lasting sentiment, that’s such a wonderful thing that you shared. And definitely, I agree so much with that. And yeah, balance, I agree, there’s no such thing as balance, it’s impossible to achieve, I think, I think you always one or the other, and then things just bounce out. But it’s all about quality, focus on quality. So that is something that resonated very much with me. [Hardeep]And Jaz also, you know, like, I think we just really need to a lot of us worry about tomorrow, five years, and worrying about tomorrow really robs you of the joy of today. So it’s about being present, you know, it’s okay to plan for the future. But to live there, you know, live in the present moment, enjoy the precious time that we have now. Make it a value. And I think that is so so important to really understand that and I think, you know, you really can have it as a female leader in our profession if you want it if that’s what you desire. And, you know, if you choose to believe I think dentistry is a great profession for women with families and without, you know, do pleats fall as I’m performing my course they do, but the show must go on and I keep showing up, I keep learning and I keep being inspired. And then it’s my duty as well to share it and support others along the way you know, each one teach one and you know when you make it to that point when you’re there at that point in your journey, it’s your duty to look back and help the person behind you and I firmly believe that and yeah, so we need to focus on [Jaz]I definitely think you’ve helped a lot of people who listened and watched today. I’ve gained so much I think this episode is an essential like listen or watch for anyone in dentistry, whether you have a family or not, but especially if you are female I think the things you covered with lead her and things you’re doing I want this to reach every single female dentists I want everyone who’s thinking about children the future of family planning to to listen to this episode, I think we’ve covered so much ground and I’ve had a really lovely time and I knew there was a reason I was looking forward to this and you have absolutely lived up and they exceeded that expectation. Hardeep, thank you so much for making time for this and finally made it happen. And I’m gonna get one to I’m gonna put the link to your Facebook group or just instructions how to find it, you know, down below on the show notes so everyone can find that. And yeah, I mean, I really appreciate you making time for this. [Hardeep]Thank you so much Jaz. It has been an absolute privilege and an honor and you know, I’ve got while I’m on this platform, I’d like to share a little bit about the retreat that’s coming up if anyone is interested in coming and joining us. So the Lead Her retreat is in September on the date of the 23rd to the 25th of September. So it’s a Friday to a Sunday. And it’s really there for you to have quality time and space out for you away from your family in a stunning luxury resort in Scotland. And it’s a really unique opportunity to enjoy epic experiences, and connect with other amazing, amazing, wonderful women. And it will allow you to relax and recharge and learn really, really powerful leadership skills that you can employ into your personal and professional life. And if you’re interested, get in touch with me through the lead her Facebook group. Alternatively, in Jaz can share some contact information about me, I’d be happy for you to reach out by email or text. So yeah, it’s an experience. [Jaz]I’m really upset, Hardeep [Hardeep]You want to come, Jaz? [Jaz]Really? Well, no, it well, I you know, I just checked the dates. And we’re away in Turkey that week. And I really wanted Sim to go, I really wanted to Sim to because you know what, she used to work so hard. And I love everything you’re doing, I want her to be part of what you’re doing. And she recently she wants to talk about on social media. But she got, she finished her first year as a master’s in peds at Eastman she got a distinction. And she’s done really well. And I want her to mix with the positive minded females like you because sometimes he lacks that self confidence. And I think some you’re capable of doing wonderful things, and you are the injection of positivity she needs. And so September, she can’t make it. But the next retreat, I’m all well, I’m going to make sure I pack send her post first class to you to change her life. [Hardeep]Amazing Jaz or listen, you know, there’ll be plenty of these opportunities. But yes, no, you know, I would love love, love to spend time with Sim, she’s a fantastic woman. And absolutely, it’s about inspiring, empowering each other and lifting each other up. Because there is greatness within each and every one of us. And we just need to recognize our potential and be around that support network that drives you to be the best you can. So thank you so so much for giving me access to your incredible platform. And Jaz you inspire me every single day, every single day. [Jaz]Thank you. The feeling is very much mutual, Hardeep. Thanks so much. And I’m indebted to your family, your father, your brother, all these people in my life growing up in my journey of dentistry, you are important parts of it. And so so thanks for and I just want to say, Waheguru Ji Ka Khalsa, Waheguru Ji Ki Fateh. Thanks so much, Hardeeep for coming on once again. [Hardeep]My pleasure. Thank you. Jaz’s Outro:Well, there we have it guys, thank you so much for listening all the way to the end. Do reach out to Harddep on her platforms. In the show notes on protrusive.co.uk, I’ll put all the links, the brochure for her retreat and how to connect with Hardeep. If you enjoy this episode, would you consider leaving a review on your platform wherever you’re listening, whether it’s Spotify, Apple, whether on YouTube, comment below if that’s the case, a review would go a long way in making me see who’s listening who’s watching out there. As always, I really appreciate you being a true fan and listening all the way to the end. Thank you so much.

Let’s demystify what is often considered an ‘advanced’ Restorative technique: Shell crowns. My guest Dr. Basil Mizrahi is known for Comprehensive Dentistry and teaches Dentists the art of perfect provisionals- we go from A to Z of Shell Crown, how to reline them and cover all the nitty gritty details of this useful technique. https://youtu.be/6-a3XGBKZWM Check out this full episode on YouTube Protrusive Dental Pearl: Preventing Bisacryl Temporary Crowns from cracking: Hollow out the inside of the temporary crown (just enough space for the cement) and therefore create the space for the temporary cement to flow and exit, preventing cracking of the temporary crown. Check out @Dental.Story IG page “You should become familiar with acrylic before shell crowns” Dr. Basil Mizrahi Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: Preventing Bisacryl Temporary Crowns from cracking 5:35 Temporary Crowns 12:08 What is a Shell Crown? 13:59 Technician role in creating Shell Crowns 15:22 Acrylic Shells vs Bis-acryl Temporaries 20:07 ‘Relining’ an Acrylic Temporary Shell  21:20 Using Bisacryl instead of Acrylic inside a Shell 24:14 Relining Acrylic Shell with Fresh Acrylic 25:00 Use of Vaseline? 35:41 ‘Fit Checker’ for shell crowns 38:26 Anterior vs Posterior relining 39:23 Shell Crowns vs Lab Made Acrylic Crowns 40:19 Shade decisions in relining the shells 42:47 How to Remove shell crowns 44:08 Polishing after relining 45:59 Multiple Shells at increased OVD 46:49 Head over to protrusive.link for the one-page summary of this episode and for the other summarized infographics of the past episodes To learn more about it, check out Dr. Basil’s Courses and other wonderful stuff on his website! If you enjoyed this episode, be sure to check out the Adhesive Full Mouth Rehabs in 11 Appointments (Part 1) Click below for full episode transcript: Jaz's Introduction: Hello, Protruserati. I'm Jaz Gulati and welcome back to the Protrusive Dental Podcast. If you follow me on the socials, you'll have seen that I've been quite busy these last few weeks. Jaz’s Introduction:In fact, the whole of last week I was nonclinical because I took some time off for my brother-in-law’s wedding. Now this is the same brother-in-law who you saw in that famous, has become pretty famous now, the IPR video I made. So, I did this whole experiment with using different types of IPR, burs and oscillating handpiece, disks, et cetera. And that got greatly received on YouTube and all the platforms as a helpful aid. Now, if you haven’t seen that yet, just Google search for IPR Ultimate Review video. You’ll find it. It’s like number one on Google at the moment. And in that video, my guinea pig patient was my brother-in-law. And there we are. He got married. I was his dentist. I was proud. And also his wife, I whitened her teeth and they both had wonderful smiles. And it made me really happy. But I was experiencing a different type of stress. Now, usually it’s clinical stress. This was non-clinical stress. What I mean by that is this was life. The thing I was stressed about was having to do a performance on the wedding reception. And actually at that wedding reception, 700 people, in attendance and me and my wife were like hosting it and going around, make sure everyone had their seats, okay, food and drink. So it was a really big affair in there. Lots of stress. But it went well. Performance went down really good. We streamed it live on Instagram actually, so you can follow @jazzygulati. That’s my personal account. If you want to catch our little Bollywood dance. I’d also booked out a Spider-Man for the kids, so I kept Ishaan, my son busy. So it’s been a pretty eventful week and I kind of feel like I need a week off just to recover from the wedding. But hey, ho, life goes on and tomorrow I’m back to work clinically. And now it’s 11:00 PM at night, my son is asleep and I’m able to record this intro to a phenomenal episode with a quite remarkable condition. Guys, you’ll listen today to Basil Mizrahi. Dr. Basil Mizrahi is one of the most famous dentists in the world, he is known for really high-end comprehensive dentistry. He’s a wonderful educator, just a great all round clinician. So it’s an absolute honor to have him on the show, and I’m looking forward to demystifying a kind of confusing topic when you are starting out with this stuff, it’s called SHELL CROWNS. You may be wondering, okay. What is a shell crown? So if you don’t know what a shell crown is, essentially, instead of doing the crowns the usual way, ie you take a putty and then you prep the tooth, and then you fill the putty with the bisacryl, and then you put it in the mouth. By doing a shell crown, the lab have already sent you the temporary crown, and you haven’t even prepared the teeth yet. So you’re thinking, well, how are you going to fit this crown on if the technician wasn’t able to fit it on the model? The technician sends you these ultra thin shell crowns, like eggshell thin. And then once you do the prep, the shell crown will sit on your prep and it’ll be really loose, right? It’s not going to be falling off. It’s not going to be staying on because now there’s too much air inside. So what you do then is you reline it with acrylic and we’ll hear more about the protocol and how to do it, when to do it, the A to Z of shell crowns being covered today. And then essentially you have a lab made crown that was relined chairside. So there’s lots of advantages of doing this. And we’ll discuss all about the nitty gritty details of techniques and I think this episode had so many gems that just like we did for the episode with Dr. Ed McLaren on ceramics, which was really popular and the infographic we made for that was downloaded over a thousand times. So for this episode as well, we’re summarizing this entire episode because there’s a lot of details that in case you are multitasking, you might miss it, and there’s lots of like good juice in here. So we made this infographic. Now you can download as like, once you’ve listened to this episode or watch this episode, you’ll have a nice little, like a revision if you like. And all the key details are on there, so if you want to check that out, as well as any of the infographics I’ve made in the past, I made a brand new page. It’s called protrusive.link. So protrusive.link. If you visit protrusive.link on your browser, it’ll take you to this page and just scroll down a little bit. Protrusive Dental Pearl:You’ll see infographic section, and you’ll be able to access all of them from there. As for the Protrusive Dental Pearl, it’s only right that I share with you a pearl that is relevant to temporary crowns. So sometimes, and it’s happened to me loads of times and it may have happened to you, is you are seating your chairside made, you know, your bisacryl, your protemp, integrity, you know, pick your poison, you are seating your temporary crown. And then you try and place it, you feel a bit resistant. You get the patient to bite together. And then now that temporary crown has cracked. So that often happens because of impurities, porosities, it wasn’t made the right way. It had an air bubble inside. But sometimes because there’s not enough space inside for cement, so the cement, it could be too thick. And then as you seat the temporary crown, it just splits it apart and you see that temporary cement ooze out of the crack. And so that, you know, you have to do the whole thing again. So one way to prevent it, if you feel as though that it’s just too tight and there’s not enough space for the cement, and you worry that the cement’s going to split the temporary crown. And this tip is by the way, from Dr. Salman Pirmohamed’s instagram and his Instagram handle is @dentalstory. Now, Salman, he did episode 97 about facebows, so do check that out. And he’s coming on again soon for resin bonded bridges, we have recorded already. We’re going to bring it out soon in the content calendar. But the tip is to, instead of just accepting it and playing roulette and then thinking, okay, which ones are going to crack, which one’s on what you could do is the inside or the intaglio surface of that temporary crown, you can get like a coarse diamond bur something like a rugby ball shape, and on the inside just start DRILLING AND HOLLOWING out just a tiny bit hollowing out the inside of this temporary crown so that now the temporary cement has space to flow and exit. And it’s not going to build up all this pressure that’s going to break your temporary crown. So if in doubt, and if you worry, maybe it’s happened once and you’re going to make a new one and you’re thinking, okay, how do I prevent this from happening again? Then you can hollow out the temporary crown to make space for the cement. So thanks Salman for that tip, and look forward to presenting the RBB episode for everyone with yourself. Now let’s check out the main episode with Dr. Basil Mizrahi, this episode was aired live on Facebook. So there’s the odd shout out here and there. So do excuse that, but this, it’s just absolutely jam packed.I can’t wait to share it with you. I know you’ll gain so much value from this. And remember, go to protrusive.link to check out the full page summary. Main Episode:Hello everyone, and welcome to this very rare Live Protrusive Dental Podcast, it’s great to have you guys on. We’ve got none other than Dr. Basil Mizrahi, Basil, thank you so much for making time for us today. [Basil]Hey Jaz. Hi, everybody out there. Looking forward to this. [Jaz]It’ll be a really tangible, very wet fingered sort of episode. I told Basil, I promised Basil that while we are waiting, hello Cosmin. While we are waiting for people to join today, now I would tell Basil and you all a very interesting thing that you may have never considered about Sikhs who wear turbans, and something you can tell about me just by looking at me and the position of my turban. So you can see the apex of my turban, right? So it’s like an apex right here. And by Monday it’s like, the turbines really low. Cause I’m fresh, I’m full of energy, right? And then as the day goes by, as the week goes to the end, the turban gets higher and higher and higher. But it’s, I change my turban every day. But the point is I just get more exhausted and you’re more exhausted. The turban just gets loose and it rides higher. So if ever you see me and my turban’s really high, you say, ‘Jaz, just go to sleep, man. Let’s not do this anymore.’ So you can see it’s getting to that point where I might start revealing like my hairline, if I get any more tired. So interesting, fun fact to you. It is so amazing to have you on. Guys, before we hit record button, before we went live, I was just telling how I was telling Basil if I even become half the dentist he is in my career, that would be the best thing ever. And then you said something really beautiful. What did you say? [Basil]You know, be half the dentist. I’m, you want to be the full dentist you are. [Jaz]That’s so special. I love that. Well, please, tell us Basil for the few people who are, who might be there, maybe like literally they qualified yesterday, which could have happened because it’s June, right? So they qualified yesterday and they entered this big bad world of dentistry and they haven’t quite seen your amazing work and what you do. Just give us that little introduction if you don’t mind. [Basil]You’ll hear from my accent, I’m South African. So I did my dentistry in South Africa, worked for about four years, got bitten by the specialization bug. In my days, we’d never had guys like you giving all content out on social media. There weren’t courses that you could do. So, you had to go specialize. I’m talking 22 years ago. So I went over to the states, and I did my prostho and implant training there for three years in New Orleans. With a guy called, Gerard Chiche, a great guy. If any of you have ever read his book, if you haven’t, highly recommend. He was one of the forefathers of aesthetic dentistry and a lovely person. And then I had the decision, do I stay in the states or do I come to the UK? I licensed in the states, ended up coming to the UK for family decisions. My family had come over from South Africa. So about 21 years ago, I set up a squat practice in Harley Street. I just kept it cheap and cheerful. Rented a little room with a basic chair and a brown oil stain carpet and a desk. And I had a nurse who was my secretary and receptionist and all in one everything. And gradually over time, built up the practice that I have today. Still small. It’s still me. And I work with Jurgita, my associate. But it’s a very small volume practice. I’ve always said, Jaz, small volume, high quality. That’s sort of my little niche. Just very personal, maybe three patients a day. On a busy day. [Jaz]Well, you are all about comprehensive, detail dentistry.I’ve seen some of your webinars and how you walk the patient. And what I love about your webinars, Basil, and guys, if you ever get a chance to go on one of the Basil webinars or live courses, Basil’s really good on teaching communication. Like how do you actually discuss comprehensive dentistry with patients? Which is a real plus point with Basil. It’s not just showing the beautiful dentistry. It’s about, okay, what is the diagnostic element and the talk that goes behind it? One question I had, Basil, if you don’t mind. Any regrets? Now, do you sometimes think, I wish I was in LA or something like that? Like in US, do you ever have that feeling? I mean, you know, I don’t imagine you do, but do you have that little voice inside of you? [Basil]Not dental wise, I think, career wise, the UK or London specifically, I’m very fortunate that I’ve managed to carve out the kind of practice I have because it’s quite rare that you have a full referral prosthodontic practice, which I’m fortunate to have that about 95% of our patients are all referral, which is rare here and in the States. I think coming here with an American degree, with a realistically or not put me on a little bit of a pedestal in the beginning. And so I was sort of a big fish in a small sea here, whereas in the States, I would’ve been a small fish in a big sea. I don’t know how it would’ve turned out. Hopefully I would’ve turned out the same. But I’ve got no regrets from a practice point of view, lifestyle, I don’t know, you could say South Africa, America, but I always say to people, just choose, you know, people say, where to set up practice, I’m specializing. Where should I go? I say, just go where you want to live and the dentistry will follow. [Jaz]Brilliant advice. And speaking of all over the world, people from Pedro, from Portugal, today we have Tom from Ireland Alex from Peterborough. We have Shabana from Malawi. We’ve got Sarah from Sunnyside, so we got a nice little international audience today. So guys, you’re here for shell crowns, you’re here for Basil Mizrahi, you’re here for shell crowns. Before we actually touch on shell crowns, just a minute on the following, I want to know, does Basil Mizrahi still do the bog standard temporary crown? You take your putty or your alginate or whatever, and then you prep the tooth, and then you put your bisacryl inside your protemp, your integrity, whatever, and you plonk it back on and you trim it. Is there still a place in your practice for this kind of work? [Basil]If you’re asking me personally, I don’t use bisacryl, not because it’s bad, and the first thing I say whenever I give a course is don’t throw out your bisacryl because it’s a good material and it’s got a good indication. I don’t use it because I grew up on a critic. I’ve got used to it, but I know I’m the first one to tell you that don’t create complications when you don’t have to. So, for a single tooth, bisacryl is cheap. Well, not cheap, but easy to use and efficient. So if you try and make a single acrylic crown, you’ll be there for 35 minutes where you can push one out with bisacryl in five minutes.So I’ll say, always say, look at the criteria, what you’re looking for, bisacryl can give you what you need from the temporary on that specific case. [Jaz]Well, it was that mentality, Basil, because you’d said that before on a webinar. I remember listening. And then that inspired me in 2016 to do my first onlay, and then decided based on being inspired by you to use acrylic for me, I was using trim, Bosworth trim, to make an emax onlay temporary out of acrylic. And I made such a mess of it. I then quickly got the bisacryl out, let just fix it. Right? And what I didn’t do stupidly was that once I had the putty inside with the acrylic on my prep, okay, I didn’t do that really important thing. Remove, insert, remove, insert, remove, insert. To get that path of draw, I just let it lock in. And that was a shambles. So, we’ll talk a little bit about that today in these nitty gritty details, but, so tell us, you obviously have been using acrylic. You’re comfortable with acrylic, and that’s a good reason to do what you do in your practice. When it comes to shell crowns, what are the indications? So actually let’s take it one step back further. What is a basic, what is a shell crown for the dentist listening out there? [Basil]So shell crown is like those Directa crowns you get from Schein or Dental Directory, just a hollow piece of temporary crown that looks like a tooth that’s customized by your lab. So you get back a shell and then you reline it. So what it does, it saves you having to use a matrix because when you use a matrix, you can’t see what’s going on under the matrix. It’s a lab putty or it’s alginate. So, you know, especially with multiple teeth, you can’t really see what’s going on. So the timing is difficult. Firstly, you’ve got a soft piece of material, then you’re sliding it up and down, and it’s difficult to get the timing right. So a shell takes you halfway to where you want to get, because you’ve already got the backbone. You don’t have to work under a matrix, so you have a hard backbone that you can grab with your fingers without worrying that you’re squashing or distorting it. So it’s just a hybrid. Between, it’s not a full, what I call laboratory provisional, which is when you take an impression and the technician makes a temporary that literally comes off the model onto the tooth. This is a hybrid between chairside and a little bit of help from your technician. So that’s essentially what a shell crown is. [Jaz]Sure. Now, when you started to use it and started to work with labs or when dentists may be inspired today and maybe go on your course and learn more about this or read up on it, and then they want to use it in practice, and then when they start liaising with their technician, do you think most technicians are well versed with this? It’s my first question and my second question leading on from that is, traditionally I imagine what you would have to do is the lab would have the model and then they would prep by hand on the model and then make it. But now with digital, I imagine that’s very different. So, firstly, technician experience and also has anything changed from the traditional techniques digitally? I’m sure there’s clever ways to do that now. [Basil]To be honest, yeah. Digitally you can, but I think analogs still actually works better because you’re going to have a study model or a scan model anyway. So the technicians, they have ways of doing it. I personally don’t mind how they get it to me. So, I’m not too worried if your technician has a way of doing it digitally, let them do it. Essentially, you want it to be very thin and, but the indication, just going back to one of your questions, you got to understand where you need to use shells because firstly, shells are biased towards acrylic. So I use shells because I use acrylic, which is pushed me in to that area. So when would I use shells? I would probably need a shell more than anybody using bisacryl, because the reason I use a lot of shells, more shells than you guys using bisacryl is because my aesthetics on my acrylic is horrible compared to your bisacryl. Your bisacryl looks much nicer. I have dark, medium and light in acrylics, so if I’m doing two front teeth, you may see in some of my lectures I use a shell. Whereas if you were doing bisacryl, you would say, ‘Basil what are you using a shell for?’ One of the main reasons there would just be almost pure aesthetics because the technicians can get me much better aesthetics with acrylic. in a lab, then I can get chairside. They all use their enamel shells and they can give me a thin shell of enamel and I reline it with my ugly yellow. But then it actually comes out quite nice. If you are using bisacryl, you probably wouldn’t need a shell there. So that’s why I keep saying work. Don’t do shell because Basil Mizrahi does shells look at your limitations and say, actually could I do this with bisacryl? Yeah, I don’t need a shell. So where I use shells is, if I got, and where I think everybody can benefit from shells is if you’ve got four or six anterior teeth, I often don’t you shells on the back because again, for aesthetic reasons on back teeth, there’s no real benefit to using a shell. If my temps come out a little bit dark or light it’s not the end of the world, but on anterior teeth, I want nice morphology, and I want good aesthetics, and I want ease of handling. If I’ve got six preps and then I’ve got to start, whether it’s bisacryl or acrylic, taking a putty matrix, working blindly, lifting it on and off, it’s messy. It can be toxic to the teeth underneath. Another reason why with acrylic, I have to be a bit more careful than bisacryl. It’s more toxic. It gives off more heat. It shrinks more. So the last thing I want is to fill a putty matrix or an alginate matrix full of acrylic on six anterior teeth and worry about heat parallelism. So the shell takes, gets me a lot of the way there, and then there’s still a good 45. A lot of people think oh you’re doing a shell, okay, reline it and it’s done. I always say when I’m prepping and fitting temporaries, it’s 50% prep, 50% temporary time-wise of the appointment. So if my appointment’s two hours, one hour is getting the old crowns off or prepping the teeth, relatively, roughly, not taking to the end and one hour to get those temps because that temporary appointment is the make or break. That’s the first time or often where your patient is getting to know you, you’ve talked the talk, and told them how good you are, and showed them all your pictures. Now you’ve got them in the chair. It’s a big step. You’re taking the old crowns off, which often are quite decent and they got to walk out that surgery. Not with yellow, ugly temps, which are sensitive and falling off. They want to walk out with teeth, whether they’re bisacryl or acrylic, that look good. And that takes all the pressure off of you time-wise. So that’s a make or break appointment. So you never short sell yourself on that at that first appointment because that’s when the patient buys into you. And then eases up and becomes putty in your hands to carry out the more comprehensive dentistry. [Jaz]So food for thought for us, because the way we are doing it in the real world is we’ve got that two hour appointment, we’re doing two hours of preps and then we’re running late, then an extra five minutes to quickly do our bisacryls. But I totally agree with everything you said, and where I am in my journey with shells is using it more and more in the last couple of years. As I’m slowly, incrementally becoming more and more comprehensive, moving beyond single tooth, doing a few full mouths now, saving me time, but at the same time I am doing lots of polishing, finishing. I do a lot of vertical preparations at the moment, so really important to get the gingiva level where I want it. So I do spend a lot of time with that. I initially made a mistake and I think this is a mistake and one of the question I wanted to ask you, Basil is, can you reline a shell, an acrylic shell from the lab with bisacryl? A) why would you want to? Because I did that and I was like, why am I doing this? I should just skill up and learn acrylic. But any reason in why a dentist should not or cannot? I’m sure there are a few. [Basil]Yeah, you want to reline with acrylic, because one of the nice properties with acrylic, if you’re doing a shell, you’ll probably be working on four, five, or six teeth. So you needed to go through a long doughy stage. Acrylic has a much longer doughy stage and it gives you the time to slowly work that shell up and down. Bisacryl is basically composite and it sets rigidly, so you want to, the acrylic gives you the chance to move it to, it goes through a longer setting time. It takes longer to work. And then also you want that flexibility when you’ve got the shell. Another reason, why I use acrylic in comprehensive cases because when you’re doing single tooth dentistry, the temporary’s on and then it’s off and the crown’s fitted. So it’s short. It’s a stop gap between impression and fitting. When you do more comprehensive, you can’t squash everything into two hours. Okay? You want to be able, but that temporary needs to come all the way through treatment with you. You don’t want a temporary, next visit, take it off, break it, make a new one. And that’s sort of what happens with bisacryl. It’s on, break it to get off. I’ll make a new one quickly. So you’re taking two steps forward one step back. So if I spend the time and invest the money in getting good temporaries with shells up front, those temporaries, because they’re acrylic as well, acrylic relines and modifies it’s much better than bisacryl. So if I remarginate, if I drop a margin, I can remarginate. So that’s another reason why I wouldn’t want to reline. [Jaz]I said it once and people like, oh, what’s remargination? Just explain that a little bit. [Basil]Okay, so you get relining where you take a shell and you fill the whole shell with acrylic and shove it over the tooth. That’s relining. You may do that. You need to do that the first time you get a shell. Subsequently, remember I said you don’t always get, most times I don’t get to the end of the prep on day one because you run outta time. You want to just have enough time to get temporaries on. As you modify your preps at subsequent visits, then you’re only really worried about the margin. I don’t care that the inside of the shell of my temp is not fitting. I’ve reduced the incisal edge or I’ve reduced the labial edge. And now do I have to reline a temporary every time I modify the actual prep? The answer is no. When I modify the margin, you want to remarginate. So what you do, you paint a little bit around the margin on the tooth, not in the temporary, because if you reline, every time you reline, the temporary just gets longer and longer and longer. So you again, on day one, you’ve made your nice shells. Patient comes back, you say, okay, I’m going to reline , fill everything with acrylic, your temporary won’t seat all the way. And you have then the incisal edges drop. So remargination is really the important part, once you’ve relined at subsequent visits, most times I’m just remarginating. Yes. If you change a whole, if you fit a post or you change something on the side of the tooth then you’ll reline. But if you’re changing a margin and you’ve just done minor modifications to the tooth prep, don’t reline just focus on the margins. [Jaz]I want to ask you a question which I hope it doesn’t offend you, but let’s say you’re a dentist. We’re really running outta time and we want to be all fancy. We’ve got the, not fancy, but we want to do the appropriate thing. We’ve got a sick, three to three, we’ve got the shell crown. Some of these might be linked, maybe one to three, one to three, whatever. And then you just realize that your nurse is giving you the looks because it’s lunchtime and then instead of working with acrylic, because you’re not experienced with acrylic, you want to use bisacryl. What I’ve done before, ask me how I know is air abrade, put some bond then put some bisacryl. Is there any advice you can give to make it work in those get out of jail scenarios? [Basil]What’s the problem? What hasn’t worked? Let me ask you, what went wrong when you say make it work? [Jaz]Great point. The main problem I find is, one time I did it and then I took it off. And parts of the bisacryl on the intaglio inner lining delaminated in certain areas. So it was a larger cement gap in that area for that patient at that time, basically. So how can we get a more predictable bond between the bisacryl and the inner lining or the intaglio of the acrylic? [Basil]Okay, so first to answer that directly, don’t use bonding agent. Use acrylic monomer. Anytime you want a bond acrylic to bisacryl, use the monomer from the acrylic, not the bisacryl bonding agent. I know they all come with bond. [Jaz]Universal. [Basil]Yeah, just use the monomer. Okay. And that’ll attack the acrylic and your bisacryl bond better. But you do have a compromised bond between bisacryl and the acrylic. But normally if if you’re filling the, if you’re relining a whole acrylic shell, there’s enough surface area that it shouldn’t pull off. So especially, so I would say to use the monomer instead of the bonding agent. [Jaz]Very good. And then if you are doing it the proper way as you should do i.e., relining the acrylic shell with acrylic, do you still need to bother with the monomer? Just describe the process. [Basil]Yes. [Jaz]You got your shells back. How do you verify that it’s seating well aesthetics wise and that you don’t need to prep any more in any areas? How do you verify that and then how do you seat it? Do you always need a seating jig? [Basil]Okay, so firstly, whenever you get shells back from a technician, they’re not going to go down. It’s one of the hardest things for a technician is to get them thin enough and to go down. So always expect that they will need some adjustment. It doesn’t mean you’ve got a bad technician, because I hear this time and time again, oh, I tried shells, I got them back from my technician, and they wouldn’t seat. That’s normal for me as well. Very difficult for a technician to get them. So that’s why you do need, and even if you think they’re seating, you always want to check the seating jig, because if you’ve gone to the time and effort to get a nice looking set of shelves, if your technician’s gone to that time and effort, and it looks perfect on the model and then incisal edge where it should be, the last thing you want is you want to make sure that you copy that exact seating location that the technician’s made on the model in the mouth. If you don’t bother with the seating jig, and I’ll explain that in a minute. There’s a very hard chance that you think it seats, you’ve put it on. Say, okay, that’s good. The technician’s done a good job, seats. Okay. Then you reline it and you trim everything. You spend your half an hour trimming, 40 minutes trimming and patient smiles, and you’ve got a cant. Or you say, oh, it didn’t look like that on the model. And then you take your soflex disc and all the nice work you have to reduce the labial edge because now it’s proclined and it wasn’t proclined on the model. So you end up taking the nice enamel layer off, or it’s longer you take off the incisal translucency, the technicians put off. So it is an important step and do it every time as much as tempting as it is to shortcut the step- [Jaz]Seating jig wise, what kind of jigs? The last case I did, I used essix retainer type jigs. Do you like those or do you like putty or do you like duralay jigs? Like what kind of jigs do you favor? [Basil]I like a hard, the two jigs I’ll use is either get the technician to just extend the shell onto the adjacent two teeth. So say you’re doing canine to canine, I’d say go back occlusally on the two pre molars on each side. So, and I want it rigid as opposed to putty or to essix. That’s one way where it’s actually attached to the shell and you just trim the wings off afterwards. But you want some kind of definite seating. So not tiny little sort of Maryland wing kind of bridge. You wanted to go over the actual premolars. A little bit over the buccal and lingual, if I’m not using it, I’ll use a separate, duralay jig, which is sort of a separate piece of plastic, which once again engages the pre-molars and the edges of the shell. I do want to get access to the edges of the shell, so that would put me off putty or essix retainers especially because unless you cut your essix right back, you can’t. When you reline, I do go, as soon as I reline, I go with some wet monomer. And I’ll do what’s called welding that joint so you don’t see the joint. So I need access, I reline and seat it. And then quickly I’m taking my brush of almost pure monomer and getting access to the margins. So if I’ve got an essix I can’t get underneath it. So I do like to weld it so you get an invisible joint. [Jaz]That is a top tip right there, Basil, because I’m going to relay that back to my technician. And request the way that you do it so that I can have that effect. This is the news to me. This is new to me. I’m not very experienced in shells. I’m learning as much as everyone else is, so it’s great to have this tip. So when you dip the brush in the monomer and then you sort of paint around the margin and that blends the shell crown, the recently relined shell crown into the tooth. Is that right? [Basil]No, you don’t want to dilute it too much. It blends the new reline material with the existing shell. So you don’t get sort of a stark joint. And another tip, you should always sandblast your shells on the outside, not only the inside, on the outside around the margins, because you want that new acrylic to bond. So I would sandblast, paint it with monomer, then reline and then be careful when you take your wet brush of monomer, acrylic is a messy material. You don’t want to work neat. So a lot of people are tempted like or bisacryl to quickly wipe off all the excess. So it’s a nice, neat shell. You do that with acrylic, all you’re doing is diluting that margin where you’ve added, so it’ll never set, it becomes doughy. You take it on and off and it looks floury, and that’s why acrylics get that bad name. Very technique sensitive, but don’t over dilute. So I’m painting, but not to wipe off all the excess. I’m painting to blend. [Jaz]Top tip right there, guys. I’m just saying that we’re approaching that point where I will be doing the questions basically. So we’re almost there. We know what a shell crown is now, we know when is a good idea to use it, these shells, instead of using bisacryl, like the standard way that we do it. We discussed a little bit about the technique and the protocol. We talked a little bit about jigs, which is important. How to condition the intaglio surface. So we put the monomer a really great tip shared by Basil. In case you missed it was air abrasion inside and outside to allow the acrylic to stick. And we also know Basil’s favorite type of seating jig. So we’ve covered all the important questions I wanted to ask. Anything you want to add, Basil, before we now start taking questions from the Protruserati? [Basil]This is one thing doing shell crown. You should become familiar with acrylic before. Shell crown is a relatively advanced technique. So not something you want to jump into before you’re sort of quite comfortable in turning out a single acrylic crown, not just do- [Jaz]I’ve been there and I’ve locked it and it’s messy. Definitely go on a course or learn more. Not just on this podcast, take consideration of that. [Basil]Yeah, so get familiar with acrylic first. Make sure you can stamp out an acrylic single crown, even if you don’t think I’m ever going to do it. But you need just to get comfortable with acrylic, otherwise you will run into problems and give yourself a lot of time. If you do want to try just like any new technique, add on another hour to the appointment. It’s not a shortcut, it’s a long cut. [Jaz]Very good. And the reason I am more familiar with acrylic, I was happy to advance to shell crowns is because I do a lot of FOS splints basically. The flexi orthotic system. They use the acrylic to reline the intaglio these direct splints. So I got very happy working with acrylic even three years ago, I got one locked in someone’s mouth, so I know that, how that room smells when you have to cut all this off. So yeah, I made, I’ve been there, I made my mistakes, so I’m much happier with acrylics. And one last question I’ve got to ask you, just for the young dentist to realize, because a lot of young dentists, I say to them, okay, this patient will be in temporaries now for six months or nine months, whatever, and their jaw drops. Like wait, isn’t a temporary supposed to be there for two weeks, so just give perspective. When you’re doing these shell crowns, what’s the longest they’ve ever been in someone’s mouth until they come back for their definitive? [Basil]Be careful. You don’t want to leave any temporary in for too long a time, whether it’s shell temps, or a good temp. So I won’t let them go for longer than two or three months probably. Don’t forget, when you’re doing these temps you’re normally in a comprehensive case, you’re doing other stuff. You would never just put temps in so people get confused and say, well, okay, so I’ll do the temps now I’m going to leave them for six months. There’s got to be a reason for everything you’re doing. So I’m not sure what the reason would be. I would never leave temps in just for six months because for the sake, either I’m trying to get the tissues healthy. That can happen in four to six weeks. Otherwise they’re coming back, you know, every four weeks I’m doing some endo under the teeth. I’m maybe putting an implant somewhere. But I’m seeing that patients so those shells. And that’s why I use acrylic. Acrylic lets you take the shells on and off without breaking putting them back. So, they may be in the mouth for six months, but I’m not leaving a patient unsupervised for six months because that’s asking for problems. And if you are going to leave them, use polycarboxylate if for any reason you think they’re not coming back or just be safe and you may have to do a little bit of cutting, but otherwise go with polycarboxylate. Otherwise, I use tempbond for 99% of my cases because I’m seeing the patient throughout treatment, but if for any reason, it’s going to be over like two or three months. Just play it safe and go. [Jaz]So what brand of polycarb? Durelon is a good one. Poly-F is another brand. You don’t like Durelon? Okay. I was giving brand names in case someone’s like, I don’t know what polycarb is. So you don’t like Durelon? I didn’t know that. So tell us why you don’t like Durelon and what do you like instead? [Basil]Durelon I just can’t get on, the reality, the irony is I like the cheapest and cheerful poly from Henry Schein cause it’s water based. Okay. Anything else? Anything else? Impression, materials. I say go for- [Jaz]Are you Indian in disguise? [Basil]But this is for temporaries. Jewish. Same. Same blood. [Jaz]Brilliant. Okay. That’s good to know. So yeah, long term don’t use. If your preps look like Basil’s, yeah, you can use tempbond. I hate tempbond because my preps don’t look like Basil’s. And that’s why when I use tempbond bad things happen. Can you just tell everyone how they can learn more from you? I want to know all about your courses, your webinars. You did a wonderful series during lockdown I saw as well. Please tell us more about how we can learn more about these techniques from you. [Basil]Yeah, I mean, acrylics is a big learning curve and the only way you can learn, it’s one of the things I don’t think you can do online because you got to get your fingers wet. So we do a three day. I do a 15-day course on comprehensive dentistry, and three of those days is intense temporaries, just working with acrylics, doing onlays, crowns, bridges, shells, and we do veneer temps. Just a quick thing with veneer temps, I don’t use acrylics, so be careful. Veneer temps is bisacryl, crown and bridge. Traditional acrylic is conducive to traditional mechanical dentistry, so even onlays, you mentioned onlays. That would probably be the last thing that needs acrylic because there’s no advantage putting an acrylic temporary on an onlay. So there, you know, bisacryl, you’ve got to look where your temporaries, your usual temporaries aren’t giving you what you need. Subgingival margins, acrylics better, long time in the mouth, acrylics better, on and off, acrylics better. Otherwise stick with the bisacryl. So yes, we do a, probably one of the only courses, we actually teach a lot of acrylics because it has got a niche. It’s not for your everyday- [Jaz]Smelly course. [Basil]Your single tooth dentistry, but when you want to progress to comprehensive, I don’t think that bisacryl is as good in uses as the acrylic. So that’s where the acrylic comes into its own in more comprehensive cases. But for single tooth dentistry, bisacryl- [Jaz]What’s the website? Is it your, just type in Basil Mizrahi in Google and find your courses or? [Basil]Yeah. Type in Basil Mizrahi or Mizarahi Dental Teaching. [Jaz]Excellent. And I think, are you doing tubules congress this year? [Basil]No, I’m not. I’ll probably be there. [Jaz]Oh, amazing. But it’d be nice to catch up guys. I heard great things about the one that you did recently. When I mentioned earlier about the many years ago, doing an onlay and messing it up, cause I was a new to acrylic, it was, the reason I did it in acrylic was to actually just get some experience. I had a bit of time, so let me play with this acrylic stuff, you know, so that was for that time. Right, so. We got a question, from Jhann Marco, a very loyal Protruserati. Just before remarginating, can you use another material, eg Vaseline to aid cleanup or acrylic from surfaces you don’t want acrylic additive? So how can you actually make sure that your remargination of acrylic goes where you want it to go? [Basil]I’m not sure if you mean on the actual shell. I don’t really use Vaseline. You could, you know, if you don’t want the reline material to go all over the front of the shell that the technician’s made and ask for you, you could use a little bit of Vaseline on the actual teeth. I’ll never use Vaseline because saliva is normally good enough. If you’ve got a composite core that’s the only time I would use Vaseline, because you’re acrylic will bond but on a normal tooth, saliva is normally good enough as a lubricant, so I generally don’t use Vaseline. [Jaz]What about when you’re happy with your relined shell crown and then a few weeks later you then refine the margin. You only because you’re really happy with everything else. You only want the acrylic to remarginate at the marginal area and you don’t really want it to run up and become messy on the labial surface. Is that just you being good with your control of the material or is there a place for Vaseline there? [Basil]Well, there’s different ways of using acrylics. So if I’m just looking to remarginate a little area, say the labial margin that’s dropped and then I may use the powder liquid technique, which is just lifting up the shell and just putting a bit of powder liquid under the margin. You don’t want to reline remarginate on the shell I always put the material on the tooth. Because otherwise you, the less material that goes up inside the shell, the better. So, but most times if I’m remarginating, I’ll cut back and it is a little bit messy. There’s a lot of chairside. That’s another thing with acrylic, you have to be get comfortable working chairside. So half the time when I say to a patient, I need two hours, and I will, they’ll say, oh wow. I’m going to say half the time you’re going to have your mouth open. I’ll be in there the other half, I’m working next to the chair. So there is a lot of chairside. Elbow grease needed for acrylics. Much, much more than bisacryl. And that’s another big paradigm that delegates on the course can’t get their head around because bisacryl sort of goes on and off and you get a good copy. Acrylic shrinks when you add to it. It’s messy. It has to set hard. You can’t neaten it up so it sets hard in excess. Then you got to sit there cutting it back again. So it’s a good material, but it, you need to see the benefit. Why am I doing this? And if you can’t, you’re over complicating your life. That’s what we teach in the course where you see, okay, I can’t get this from bisacryl. This is where I need my acrylic, let me do acrylic. [Jaz]Brilliant. Thank you. And Michael Davies has asked, and the reason I brought up that photo of the Fit Checker is for posterior shells, do you use Fit Checker? And two, is there any difference in technique compared to anterior shell reline? So, difference between anterior relining and posterior relining was the second question. But, let’s hit the first question. This is a photo of me using Fit Checker for when that time I got some shells back, which were just way too thick. My preps were very minimal cause I was making, working with vertical margins, so I had to go back and really make them, thin them out. And then they were still binding somewhere. So then I use GC Fit Checker to see, okay, where is it binding, color it up with the pencil. Made it thin, end up, perforating certain areas. There we are. So do you use Fit Checker, Basil? [Basil]I use a fit checking technique. I just use a light body impression material. [Jaz]Okay. [Basil]So I’ll squirt it up and when I’ve got my seating jig. And the same as you I’ll mark it through there. So, you were using the essix, that’s where you- [Jaz]No, that was the jig was separate on the inner lining. Oh, was it in the essix okay. That was a soft one. Yeah, you’re right. That was a soft, that was a soft seating that, that particular time. But yeah, it was where to figure out just where it was binding and then to thin it out the area to allow it to seat. So fine. So you use light bodied, and is there a difference between anterior and posterior relining technique of shells? [Basil]Not really, as I say often posteriors I will just use a matrix cause there’s much more leeway that doesn’t have to look great. And if you hoover out half, half the occlusal surface just to get it rough it really doesn’t, you’re not missing the incisal edge. So you can be a more forgiving if you are going to use a posterior shell I won’t use a seating jig because if I get the seating slightly wrong, it just means when a patient bites at the end I have to hoover off a bit more occlusal surface on a molar, which is not the end of the world. I just don’t want to do that and mess up aesthetics. So in the back teeth, I may get a shell temp, but I’m not going to mess around with jjgs. [Jaz]I love that you said that you have to hoover off the occlusal. I love that Basil says that. Tom Murphy. Hi Tom. He says, okay, I will typically have a wax up done. Prior to preps. Fine. That’s good. And use this for bisacryl temporaries and transfer this into PMMA temporaries one week later. Okay. Outside of that first week’s aesthetics, what are the additional benefits of the shell temps over lab made PMMA temps? Okay, so he’s going from bisacryl, but he’s taking impressions that day to get lab made PMMA temps. So is there any benefit of doing the shell temps and not going for lab made acrylic provisionals? [Basil]I like to get the shell temps. I like to take them a long way through the case before I go to lab provisionals, which is what you were describing, is done the next week. So there are two ways of doing it. You can either put your rough and ready bisacryls on and move quickly to lab made provisionals, which will look nicer and they’ll be acrylic. The problem though is in a comprehensive case, you don’t want to be messing around and then remarginating and relining. And then when I get to my lab provisionals, I’m quite close to the end of the case because I’ve brought my chairside shells with me all the way through. And I’ve done all the rough and ready stuff, the hollowing out because the temporaries start to look a little bit shoddy after time, after you’ve hollowed them out in a comprehensive case. So there’s no real disadvantage. You can do the technique that was described. But you don’t want to mess up the lab provisional so that by the time you’ve done all the foundation work, you say to the patient, smile, now let’s look at the aesthetics, and the lab provisionals have got margins that have been added to and you’ve chopped the incisal and so they’re looking shoddy, you can’t really focus on the aesthetics. Cause one of the main reasons I’ll go to lab provisionals is when I’m getting towards the end of the case, I’ve done all the rough and ready, the implants, the post and cores, now I want to start focusing on aesthetics and now I get rid of the shell temps. They’ve done their purpose and now I’ll get the lab because there’s nothing lost in translation. When you go from lab provisionals, it comes off the model onto the teeth. There’s no reline, there’s no adjustments. Don’t forget, with shell temps there’s a lot lost in translation, relines, even with jigs in there there’s a lot, it never looks the same as the wax up. But yes, you can initially when you’re starting out you’ll move quicker to the lab provisionals. And as you get better chairside, you’ll able to bring your chairside temporaries longer through the case. And then, move to the provisionals. That’s what will happen in your career and as your skills improve with chairside temporaries, but there’s nothing wrong with that. [Jaz]Brilliant. Thanks so much for that question, Tom. Now you mentioned aesthetics. So we have an aesthetic based question about shade. So this is from Michael Davies. Hi Michael. When relining, do you do anything in particular to match the shade? Or reline the acrylic to the shell? Now you mentioned you had light, medium, dark. Just tell us more about shade decisions and actually relining the shells with shade in mind. [Basil]Well, firstly, when you’re doing shells, it’s normally going to be four or six teeth, so the shade is not matching to a single. I would get the shell always made in enamel acrylic, generally an enamel shade, A1 or A2, relatively light, and then I’ll reline it again, it’s four or six teeth, so it’s going to look uniform. I’ll probably reline it with A2 or A3, which would be medium, dark medium, that kind of region. If I’m trying to match a single tooth, sometimes a patient comes in and you need to nail a single tooth temporary, which is pretty hard. Again, there I will use a shell. You guys can use bisacryl because you’re comfortable with it and you get better shade straight away, and if you get the shade wrong it takes five minutes. Using acrylic, I could never do that chairside, so I’m at a disadvantage in that specific aspect. So I’ll use a shell made in enamel and then I’ll reline it with either a light or a medium. Again, if I get it wrong, it sometimes happens. I’m in a little bit of trouble. Either the stains can get me, I do sometimes can have to stain. I’d rather come out too light than too dark. And every now and again you get caught out and you reach for that sort of emergency stain kit and you’re toning the temporary down. [Jaz]Excellent. We’ve had a really nice wet fingered question here, which I like, but there’s two facets to this question. Very simple question, like six words. How do you remove shell crowns? Now do you mean Tuli, thank you Tuli for the question. Do you mean how do you remove it once you put the reline material inside and then how do you remove it? Or the patients had shells in for like, you know, three months, and then how do you remove it? Tackle both of you don’t mind. [Basil]So while you’re relining, you are using your fingers just to slide up and down cause there’s doughy acrylic, so that should be relatively easy. I think the question was aimed at, I mentioned that in a comprehensive case, the temporaries are coming on and off every couple of weeks and you don’t want them to break. So the question is, well how do you take these off? That’s one of the big advantages of acrylic. I can take all my temporaries off with big aggressive artery forceps and they won’t crack cause they’re acrylic. It has some give. The problem is bisacryl, and now you’re starting to see from some of your questions and bells ringing in people’s heads. Well, I can’t do that with bisacryl. And that’s what happens. Bisacryl, you grab it with artery forceps and either it doesn’t come off cause it’s got no give. It’s like trying to get a porcelain crown off and it’s just not giving. Or you squeeze a bit harder. Sometimes you break the tooth inside or most often, what happens when I say to my delegates, how are you getting your temporaries off? Oh, we are putting a flat plastic under the margin or an excavator, you’re cracking the temp. So bisacryl are hard to remove. Ideally, you want to take your temps with artery forceps so they don’t break. Acrylic is conducive to that. Bisacryl is not that conducive to taking them off without breaking cause when you squeeze them with artery forceps, it’s so rigid it’ll crack. Especially if they’re thin like your verti, you were saying verti preps. Those ones you try get on and off, you’re liable to crack the margins. With the acrylic, you’ve got lots of give in it, it’s more elastic so it doesn’t break. [Jaz]Brilliant. So guys, I have time just for two more questions and that’s what we’ll take. So, we’ll take the very last one from Michael. Michael, you’re very lucky to get two questions today and then we’ll take Pedro. So, Michael’s question again is, last question. Sorry Saeed, I might not get time for yours. What burs do you use in the mouth to adjust the acrylic and get it polished back up? So polishing and making it look pretty after you’ve done some relining. [Basil]Well, I would never use, I never say never, but all the temporaries, and that’s the beauty of temporaries is you’re working outside the mouth. So I have a temporary kit on a straight handpiece. Very seldom do I work inside the mouth. Put them in, look, take them out. So it’s different to doing a composite where you’re forced to work in the mouth. If I do need to do a little bit of adjustment in the mouth, it’s often a soflex disc on an incisal edge, but 99% of the work with temporaries are polishing. The embrasures, all done with that sort of little kit I put together, but outside the mouth, so I don’t do much, not the polishing or anything inside the mouth. [Jaz]So it’s all outside the mouth. Perfect. I will take one more question. ‘Cause Saeed’s is really good. If you’re raising the OVD in a comprehensive case and you’ve prepared multiple posterior units, how would you temporize them? How do you ensure you get the shell temps in a correct position to conform to the new desired OVD. So essentially where it may not be as conducive to put the jig because there aren’t enough teeth for a jig. How do you work that scenario? [Basil]Well, very seldom would I ever prep and temp a full arch. Most of my cases I do open the OVD, so I would build up the, I won’t try to do too much in one appointment. Okay. And you lose quality there. Okay. Everything in dentistry you can’t rush. You have to break up. And that’s again why I use temporary so much because it allows me to break up the case, so I would never prep and temp a full arch, and I know many people do. I would do the front six the same way I’ve just described. They would be at the increased vertical dimension. The patient would go away for a week, almost got a dhal appliance in, not dhal, they’ve got an anterior deprogram, so their jaw is relaxed and I’d come back. Then I’ll do the upper right quadrant and I’ll do the upper left quadrant. Okay. If I’m worried about space, I may put a bit of composite on the occlusal surfaces. So that’s the way I would tackle it. Increasing OVD I would do it segmentally. [Jaz]I guess if ever you had to do it that way. Again, I asked these really naughty questions. In my mind, one way that you could perhaps work it would be use any teeth as a guide to rest on that you can, but also maybe the pallet to get the lab to extend onto the pallet maybe. [Basil]Ah, yeah. I have done, yeah, sorry. Now I see the question. Yeah. I’ve not often but if there’s any teeth to rest on, you can. The second best is a pallet and then cut it off. [Jaz]Perfect Saeed. Brilliant. So now genuinely last question, guys so the last question from Pedro, can you consider a shell crown if it’s made by the clinic between appointments? So presuming you have some time between the practice days, now I imagine what he means is a scenario where you, yourself will prepare the teeth on the models and then make the shells yourself. Do you think that’s what he means? Do you think that’s what Pedro means? [Basil]I’ve got a feeling he may mean you take an impression of the preps before you put your temporary on, then during, before the patient comes back, you make your own temps. [Jaz]Yeah. Yeah. You’re making you’re lab then. Okay, fine. But I have seen this before, Basil, on that note, that dentists will prep their own teeth and make their own shells out of bisacryl. Interestingly, I’ve seen that on Facebook and whatnot, and then just use that on the day to reline. I have seen that, so. [Basil]Yeah, you can do that. Again, you’re not relying on the lab, which is good. Any time a dentist can do more lab work and less reliant, I encourage it because I think that’s also what’s evolved. There’s too much of a line between what a technician does and what a dentist does with temporaries. Okay. And too much we think dentist is intraoral and technician is anything outside the mouth. So most often my appointments, I’m working outside the mouth with temporaries. So that’s, I would encourage people, pour your own models, make your own temporaries. Okay. Just makes you less reliant on a technician, but also gives you more comfort in handling situations that you know, nothing ever goes smoothly. Okay? And if you flummoxed a bit or you get something back from a technician and think, oh, it doesn’t fit, so I better add some acrylic. You don’t want to think, I better send it back to the technician. If you are a little bit familiar with waxing up, with pouring up a model with using acrylic, modifying, you know, it’ll get you out of so many, your confidence grows and you know, you can handle most situations and when things go wrong, you don’t get too flummoxed. So, yeah, I’d encourage any kind of temporaries you can make. During between appointments, make your own temporaries, make your own shells. It’s all simple stuff to do. [Jaz]Amazing. Basil, it’s been absolutely brilliant having you on. You’re one of my heroes and it’s been so nice to speak to you and bring on the podcast. And I’m actually going to, I’m going to do this. I’m actually going to make the apex of my turban lower to signify how much more rejuvenated I feel from speaking the conversation. So if you missed the beginning bit, guys, you have no idea why mentioned my turban. If you were here from the beginning, I hope that made you chuckle. [Basil]How about turban recession was the same as gingival recession. I thought turban recession was the same as gingival recession. [Jaz]Oh, I’ve just done some surgery. So there we are. So guys, it was, I’m sure you agree everyone. It was amazing. We got some thank you’s and some love on Facebook. Basil, I’m going to make a little email infographic that I’ll email everyone, just the key points, the key lessons that you shared today. But guys, remember what we said today barely scratched the surface when it comes to all the different techniques with temporaries, different indications. I would definitely encourage you to look into Basil’s course, so I’ll send you a link in the email as well to check that out. He has got quite, from delegates have been on it. It’s not like hundreds of people. It’s probably like 12 people. How many people? It’s quite limited attendance. [Basil]Yeah, yeah, we keep it to 10 or 12. [Jaz]So one of those courses where you want to get in early. So I will email you that when I email the infographic or guide or the key learnings. My favorite thing today was learning that I’m going to start using the cheaper polycarboxylate cement, which I do already. I think I use the Dentsply one, so not the Durelon so there we are. I’m going to go even cheaper now. So thank you so much for that and everything. Basil, I really appreciate it. Thank you. Have a good evening my friend. And thank you guys for tuning in. [Basil]Thank you guys. Thanks, Jaz. Jaz’s Outro:There we have it guys. As Basil said, don’t worry about being half the dentist that he is. Be the best dentist that you can be. Be the full version of the dentist that you truly can be. So, I love that sentiment. Do check out the show notes either below on YouTube or on the blog, which is protrusive.co.uk/122. So any of the episodes I’ve ever done, if you just do forward slash and then the number of the episode, you can get to the blog post, which usually has a lot more information, how you can learn from our guests. So for example, if you go to /122, you’ll find all information about Basil’s courses and all the things that he’s up to if he’s teaching near you and how to learn more from it. Or his restorative programs. Stay tuned for the next few episodes. The next one’s actually TMD and botox. You know what I mean? I couldn’t go too long with having something TMD or occlusion related. So that was Sheila and Yuen. It’s a cracker. It answers all the key burning questions that we have when it comes to botox and the use of it for the management of TMDs. And the one after that, oh my goodness. I’ve got Linda Greenwall on again, and this time we’re discussing ICON resin infiltration for white patches. So, we’re going to really make it crystal clear, step by step, how to use ICON how to charge appropriately for ICON, how to know if your ICON’s going to work or not. Right. That’s a big question I get asked on social media and I’m still carving some time to figure out how I can get out Pasquale Venuti’s series out to you. It’s just taking a lot of time to do that. But thanks for sticking with me guys. I really appreciate you listening all the way to the end. Thank you so much my friend, and I’ll catch you in the next one

Listen to that voice inside your head! We all get those clues and a bad feeling in your gut when you see a red flag patient. The challenge is being receptive to this feeling and acting upon it tactfully. I share 2 examples of encounters where I either ignored the alarm bells, and 1 scenario recently where I avoided a disaster. https://youtu.be/UBvJxhgzQp0 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 1:34 ‘Alarm Bells Scenarios’ 2:20 Case No. 1 (Extraction on a 78-year-old patient) 7:47 Case No.2 (Heat Burn on Patient’s inner cheek/lip) 9:20 Warning Signs If you loved this episode, you will like 12 Rules for Dentistry  Click below for full episode transcript: Opening Snippet: Hello, Protruserati. I'm Jaz Gulati and welcome to one of my ramblings, okay? We're gonna do this as an interference cast. And I'm gonna teach you a few lessons that I've learned before, I guess I've learned them in very traumatic ways. Jaz’s Introduction:When you make mistake and think, Wow, I never want to make this mistake ever again. And then you want to share it with everyone so that it helps others too. So the theme of today’s rambling is the following. It’s about listening to that voice that we all have inside of us, during a consultation or during a patient interaction, you know that deafening sound of alarm bells you sometimes get. And yet, for some stupid reason, you might decide to ignore it. Well, today, guys, I’m happy to report that I didn’t fall for it. I heard those bells, loud and clear. And I acted appropriately, and I dodged a bullet. Okay, let me give you the exact example. And in fact, I am going to liken this example to a really significant thing, which I picked up from a book, like one of my favorite books is Outliers by the author Malcolm Gladwell, if you haven’t read Outliers yet, please check it out. It is my all-time favorite book. And I think it’s in chapter seven, where it discusses why aeroplanes fall. It’s a random divergence, I know, but hear me out. Aeroplanes fall not because the engine has an error. And that’s it. And that’s why airplanes fall and that could happen. That’s rare. ‘Alarm Bells Scenarios’Airplanes actually fall, when they do fall, when there’s an issue, a big problems do happen in aviation when lots of little things, lots of minor things that all happen at once. And they usually surrounding communication, and teamwork so it’s accumulation of all those minor errors that would result in it. So for example, the pilot was hung over, right? That’s one thing, right? And then the pilot was working with a co-pilot, and they’ve never worked together before, okay? And the guy who was supposed to do the final checks on the aircraft vehicle, had COVID or something, and he couldn’t come into work that day. And therefore, all of those little things combined and bad weather that day, is the reason that the airplane fell not because of one big error, it’s accumulation of little errors. Main Episode:So what lessons can we learn in dentistry? Well, think of those little errors lining up in your patient in front of you. So let me give an example. Case No. 1 (Extraction on a 78-year-old patient)I saw a 78 year old patient today who was referred to me for some surgical extractions, okay? Age doesn’t bother me too much. Yes, we know sometimes it can be more difficult to extract and we need to take care, but it’s a medical history that really bothered me. So let me tell you the accumulation of minor errors. So error number one, there was no up to date medical history, it was last filled-in in 2019, okay? So I was like, oh, god dammit, why is this patient referred to me without a medical history? Error number two, he comes in and I get an update of medical history from him. And he conveniently has forgotten his sort of long list of medications and he’s going by memory, okay, that’s another little alarm bell that I’m hearing in my head. Error number three is that he was taking Apixaban, which is an anticoagulant, so it’s a blood thinner. So that is, for someone who’s doing surgical extractions of upper canines, and I’ll show you the X ray of these upper canines, long roots, but really mushy crowns, subgingival dentistry, I was planning, based on a radiograph I was planning already to raise a flap and remove some bone because I was anticipating a difficult extraction. So he’s on Apixaban. And error number four is that he wasn’t instructed to miss his morning dose. So the usual way I would manage someone who’s on Apixaban, is that what we would instruct them if it’s safe to do so to skip their morning dose and see them first thing in the morning, so he had his morning dose already so that was increasing his bleeding risk. Error number five, or complication number five is that this guy had a stent placed three months ago following a suspected heart attack, right. So that is also a real big concern, doing invasive treatment, and someone who only just three months ago, had a heart attack. Okay. Error number five or six, I’ve lost count now. The next one is that he had, believe it or not, his toes amputated around about nine months ago and he had a major bleeding complication. So why did he have his toes amputated? It’s because he’s severely diabetic. And that’s a negative cinquante of that. So that was also ringing alarm bells that this person already had some surgery before and that didn’t go so well. There were some complications with bleeding. And the final issue I had was that he was on lots of antihypertensive medicine. So his medical health, it was poor health combined with all other factors and I did not feel comfortable treating him today. And he wasn’t even in pain. It was just teeth that need to come out their, but he wasn’t in pain today. So I made the judgment call to refer to a hospital and explain to him all the things that were all the reasons and he took it really well. He noticed that okay, this guy really cares for me, I didn’t want to do anything risky. So sometimes I’ve in the past, not weird, like extractions or whatever, sometimes are difficult extractions but taking on patients or cases or treatment plans that had all the signs there, when you look back, you can see that, hey, why did I ignore all those signs of the small errors? Why did I take this patient on when all the alarm bells were there? And sometimes you don’t listen to that voice. So it’s important to listen to that voice. And it’s a totally an acceptable thing to do to say to the patient that look, I don’t think we should proceed with this and justify why and stick to your guns, okay? Now I’m going to admit to you another mistake that I had made around about a year ago, and I’m embarrassed about it, but I want to share it with you because it was a clear example of the many small accumulations of errors that resulted in my patient’s inner cheek getting burned, and a massive, painful ulcer or a significant burn that took a long time to heal. Well, I say a long time was it was a week of me feeling really bad for the patient and the patients send me photos and it’s not nice. No, I’m really sad. And sorry that happened. In fact, she very kindly let me share the photo. So those who are watching, can see the photo now up there. That’s her cheek about two days later, in a lot of pain. That’s a nasty ulcer there. And I asked her I said can I please share this story with my colleagues so we can learn something here. So let me tell you what happened and how I burnt this patient’s inner cheek. I was doing some routine composites in the lower quadrant I think it was like lower right second premolar DO composite, right? And I’m a big fan of using rubber dam especially for lowers, the tongues in the way, anything that’s, you know, deep caries subgingival etc. I’m all rubber dam, right? But the problem that we had this day is that my usual blue, non-latex rubber dam wasn’t there. We had that horrible green rubber dam and I really don’t like working that green rubber dam. I think I was just being a little bit of a diva. Okay, so my hands up in the air. My bad that was not a reason to not use rubber dam I guess. But for me, on that day in the mood that I woke up in. I was like, No, I’m not going to use this rubber dam. This is disgusting. I don’t have my usual rubber dam. So yeah, I didn’t use rubber dam and 99% of time I do. So A) I wasn’t using rubber dam and then B) it was like stressful for me. So as someone who’s regularly using rubber dam, rubber dam reduces my stress, but now that I had no rubber dam, my stress was greatly increased. 2) It was subgingival. It was difficult dentistry. Okay, so that was stressful. Okay, 3) and this is something I really should have picked up on. The handpiece was making a funny sound. I didn’t think much of it was like, Oh, this sounds a little bit higher pitch. This doesn’t sound right. But I ignored that. And then I can’t believe I look back at now, I just felt as though the hand piece was warmer than usual, okay? Case No.2 (Heat Burn on Patient’s inner cheek/lip)Now the patient was anesthesized. And the patient didn’t feel any of this. But as I was doing her prep, the handpiece was actually burning her cheek. And then I realized that Woah, my gloves getting really hot here. Let me see what’s going on. And then once I finished my restoration at the end, I had a look at the cheek and I could see that it was a bit traumatized. And I realized what happened So all those little error I didn’t pay attention to A) I didn’t use rubber dam. So that’s a small, you know, a small error. I anesthesized the patient so the patient can give me feedback, obviously. So that’s another alignment that not an error, but another reason why it happened. I didn’t pick it up. It was difficult dentistry. The handpiece was making a funny sound, and I did feel a bit warm and I didn’t stop to think why is this handpiece warm. So naturally I felt devastated. So how did I settle this? Well, when I found out what happened? I made sure that I got I went on Amazon and I’ve got delivered a gift to a house So it wasn’t like flowers or anything. It was some Gengigel, right? So something that contains, I believe it contains hyaluronic acid. I might be wrong here but I know that Gengigel was good for soft tissue lesions. So I got some delivered as a gift to her house. I was following up daily, I recommended some benzydamine hydrochloride or aka Difflam mouthwash and all those things and she got better, and actually ended up refunding of her money as well. I just felt so bad that I refunded her money of that restoration appointment because I felt like I let her down, right? I wasn’t acting in my best interest. And so I think she was quite pleased about that. And she thought I handled it really well as well. So that’s my admission to you that I burnt my patient’s cheek, and I’m not going to let it happen again. Warning SignsBut it’s a time that I ignored the warning signs. But that first patient I told you about that as for today, I didn’t ignore all the warning signs. Another classic warning signs to find out things I sign off is another classic warning sign is that the patient has seen another dentist and the other dentist for whatever reason has declined to treat the patient for whatever reason. That is a massive red flag. So I remember seeing a patient who saw a dentist I don’t know which dentists but she, the patient told me that, that dentist won’t treat me without orthodontics. That dentist thinks that I can only get a good result with orthodontics. And me being me a young dentist at the time, I’m still a young dentist, but like one or two years qualified, I was thinking well, I’ve been to few composite courses, I think we can do it composite. And I look back and I think you know what, I do regret not sticking to what I should have done, which was yes, I should have agreed and recommended orthodontics because the result in the end wasn’t quite as wow and I do feel it could have been better with orthodontics. So anytime a patient says that I saw dentists X and the dentist X strongly believes that I should be treated this way. And you might disagree to that Dentist and that’s okay. But take that as an alarm bell. Take that as one of the alarm bells. And if you start to see all these alarm bells, sort of accumulate all these small errors if you’d like accumulate, then that could be why the aeroplane could fall. Jaz’s Outro:So I hope that was useful. And it’s a reminder for you in that consultation or at that moment in time that when you get that funny feeling in your stomach, don’t ignore it, act on it. There’s no shame and picking things up before they happen, before they go wrong in the best interest of your patient, and so that you have a smoother ride throughout treatment. Hope you enjoy that little quirky, little short episode. If you enjoyed it, please do leave a review on Spotify or Apple or YouTube or wherever you watch it. It means a lot to me. Thanks so much.

In this episode with Dr. Carlos Sanchez, we’re going to take a look at the concept of additive equilibration as a way of managing tooth wear. In other words, it’s an occlusion-based technique that involves adding composite or ceramic to achieve the ideal restorative results and we’re going to try to help you understand what that is. There are also some themes that are discussed in the same way as the Dahl technique. https://youtu.be/TZ5FKkiscco Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive dental Pearl: Keeping PTFE tape secure – a straightforward trick I found to keep the PTFE so it doesn’t get sucked away is to floss the PTFE through more distal contacts. It gives the PTFE some security and resistance to being sucked away. So it’s not going to make that horrible sound and you get to keep that PTFE in the stable place! If you want to improve your skills and your understanding of occlusion, I’ve set up a free monthly resource for you starting this August! Just head to www.occlusion.wtf to sign up for monthly occlusion goodness. Highlights of this episode: 2:40 Protrusive Dental Pearl – Keeping PTFE tape secure  9: 43 Fundamentals of Additive Equilibration 37:28  Journey of Additive Equilibration 44:22 Additive Equilibration workflow in generalized wear cases 1:00:37 Restoring lateral and central incisors for aesthetic reasons (after canines) 1:06:36 Anterior coupling in class two increased overjet cases Check out CaSi 3C Instrument and all the other instruments that Dr. Carlos has made. Distributed by CosmeDent and Enlighten Smiles in the UK Another instrument you need to check out on Dr. Carlos’ website is this Vacu-Grip. This little plastic insert that fits in your suction would hold your crown like an extra gravity.  Check this Easy Peasy technique that Dr. Jaz mentioned: The ESIPC Jig ESIPC-JigDownload If you liked this episode, you will also enjoy Basics of Occlusion Click below for full episode transcript: Opening Snippet: Hello, Protruserati, I'm Jaz Gulati and welcome back to your favorite place to grow as a dentist. In this episode, we're discussing ADDITIVE EQUILIBRATIONS for managing tooth wear. Jaz’s IntroductionSo, this is an occlusion based one. Dental students and young dentists, it’s a lot of things that we discussed that might stretch your mind a little bit. So, if you’re new to the world of occlusion, you might have to listen to it a couple of times, you have to hit the books, you have to speak some mentors. It’s okay to listen to something that might be a little bit beyond your depth at this stage. Certainly, when I was learning occlusion, I had a lot of that. And I slowly, slowly, slowly, you know, gained more knowledge, spoke to more mentors, gain new perspectives. So, just because we cover some themes that you might not understand in this episode, doesn’t mean you shouldn’t give it your best shot. Now on that note, if you are looking for some basic, but powerful, impactful, actionable, and practical occlusion tips, then I’ve set up a free monthly resource right to your inbox. Starting from August, it’s worthwhile just joining now, if you head to www.occlusion.wtf, that’s right. It’s www.occlusion.wtf. Listen, I’m on a mission to demystify occlusion. So, with this very practical gem that I’ll send you every month, I’m hoping to go a long way to help our peers. So do check it out, sign up, and I look forward to sending you some occlusion goodness. In this episode with Dr. Carlos Sanchez, from North Carolina USA, we discuss treating the worn dentition with something called the ADDITIVE EQUILIBRATION TECHNIQUE. So people think a equilibration is usually when you get to a bur and start drilling teeth away. Well, this is additive equilibration, we are creating the “ideal occlusion” or “ideal occluding” scheme by adding for example composite or ceramic or whatever it might be to get to our ideal restorative results. So, it’s not so much equilibration as you may know it before, it’s additive. It’s restorative. There are some themes discussed, similar to the DAHL technique, which is quite refreshing because in the USA, it’s not used as much so it’s nice to hear it in American dentist, Dr. Carlos Sanchez talking about the DAHL technique and the way he did so I know you’ll enjoy this perspective. If you listen to the last few episodes with Dr. Javier Quirós. You know how much I love the CaSi instrument, well, actually Dr. Sanchez invented this instrument. So it’s something that’s distributed by Cosmedent or Enlighten Smiles in the UK, and I’ve raved on about it already. I’m not gonna go again. But I want you to check out all the other instruments that Carlos has made. They’re really amazing. I’m gonna show them off in the clinic. The other thing I found on Dr. Carlos Sanchez’ website is the Vacu-Grip. This is like $10 for five of these little things. And let me tell you why I fell in love with it, because I’ve got one now. So, you know when you’re washing your ceramic, so you’ve etched your ceramic, maybe with a hydrofluoric acid for 20 seconds, like your Emaxs, for example. And then what I usually do what I hold the crown in tweezers or my glove, and I’d wash it, and make sure that I wash it over the sink, and that the sink has got some wet tissue paper inside. And the problem with that is it’s over the sink and it’s away from where I was initially, and it’s get a little bit messy. So, what the Vacu-Grip is, is a little insert, little plastic insert that’s got foam inside, that fits nicely into your suction. So, I try this by putting the crown into the Vacu-Grip which goes in your suction, it’s like a little tiny black bit of plastic piece. And now I’m holding the Vacu-Grip that entire unit upside down and my crown is not falling. So, it’s like extra gravity, it’s sucking the crown so that it’s not going to fall out. So, I can even turn it all upside down and the crown will not fall. So, you can imagine that when you’re washing your ceramic, now you can do it into the Vacu-Grip and the Crown’s not going to go anywhere. And it’s a nice and safe way to do it. So, check out the Vacu-Grip and all the other products that Carlos Sanchez has on his website, that’s aesthecon.com. Again, I’ll put the show notes on the website protrusive.co.uk, and on the YouTube watching there. So, you can see all the awesome instruments including the CaSi and a Vacu-Grip and all the other lovely brushes that he has on his website. There’s some really brilliant instruments that Carlos has invented. So, he’s a true innovator when it comes to instruments in dentistry. And I hope to share some of those with you. The Protrusive Dental PearlToday’s Protrusive Dental Pearl is HOW TO USE PTFE. So for example, we use PTFE in so many different scenarios, and one of the most annoying scenarios is when you are preventing the etch and the bond from contacting the teeth that you don’t want it to touch. So, it’s a great way if you’re doing onlays, bonding onlays or resin bonded bridges or veneers or whatever, you know, I like to floss some PTFE into the contact so now the etch won’t hit that tooth, but the issue that we have in this scenario is that unless you are with your finger and thumb holding on to the PTFE it gets hoovered into the suction. It makes that horrible noise which is not very pleasant for your patient and gets very messy and it’s not so nice. It might even pull off your PTFE or just make that horrible unbearable sound which I absolutely hate. So, there are a few ways I’ve seen some dentists manage it. They often get some liquiddam or, some flowable composite, and they sort of tack cure the composite onto the adjacent teeth to keep the PTFE there so it doesn’t get sucked away. But what I found really easy trick that many of you probably already do is once you’ve placed your PTFE, and then you manipulate it onto the more distal teeth, either will then floss that PTFE through a more distal contact. If you’re watching the video here, great, you get the idea. If you’re listening, just imagine you’ve put some PTFE through some contacts, and now you’re extending it. So, let’s say you put it between the premolars, lower left first and lower left second premolar, you put it there, and now you can extend it on to the first molar, maybe even to the second molar, so that it’s long enough to cover all those teeth. And then you’re gonna floss it between the first molar and the second molar. Now that you floss that PTFE in that area, it’s no longer gonna get sucked into your suction. And it’s not gonna make that horrible noise. And it gives your PTFE some security and some resistance to being sucked away. So, it’s not going to make that horrible sound. And you get to keep that PTFE in the stable place. So whether you keep the PTFE there the whole time, or you remove it after your etching and bonding, it’s up to you, obviously, how you want to do it, but it’s a great way to keep that PTFE stable. So, hope you liked that little pearl. Main Episode:And let’s join Dr. Carlos Sanchez to talk about all things, occlusion and additive equilibration technique. Dr. Carlos Sanchez from North Carolina, USA. Welcome to the Protrusive Dental Podcast. How are you? [Carlos]I’m doing great, Jaz, what a pleasure, man. It’s a pleasure to be here with the Protrusive Dental Podcast. So it’s a joy. [Jaz]Well, it’s great to have you and it was amazing again to find out that you’re also someone who listens to the podcast. And as we had a zoom session a few weeks ago now just to catch up and learn about each other’s interests and stuff. I mean, your occlusion background really interests me, your sort of reflective practice that you’ve been doing in North Carolina, I think you said you’ve been in the same practice for many years. Is that right? [Carlos]27 years. [Jaz]Well, tell us about yourself. Tell us about your practice. And tell us about your journey within dentistry and occlusion? [Carlos]Absolutely, I’m going to disclose my age, been practicing for 30 years. I’m a general dentists but I’m a geek. I love all facets. I’m not into the academics, but I definitely like to get in there. And you know, as I do my stuff, I’ll make sure that it is a science base. But, I was in the military for about three years. That’s where I got my experience in everything. My wife is a dentist. But long story short, we were able to settle in Kannapolis, North Carolina, love the environment, and from there, I journey into different intrapreneurship with practices and so forth. And interesting just leading to the occlusion. You know, you get out of school. I was very fortunate that I went to University of Iowa, shout out to Iowa. But I feel comfortable with giving me a pretty good foundation. Not perfect. Not perfect, but a good foundation. So I thought when I got out there, it’s like, Okay, I’m gonna get out there. I’m gonna rock and roll do this and that, three, four years into it. Guess what? I got burned, man. I got burned. I learned my lesson. There was a particular case, did some Crown Lengthening on top and bottom. Nothing that posterior. The gentleman left, long story short, it was a journey. A good year with the insurance. I didn’t get sued or anything like that. But I learned and I learned and I said to myself, You know what, I don’t want to catch myself in this position again. And so that propelled me, that’s how I started in this journey as far as occlusion. [Jaz]What happened in that case that made you think that okay, I need to go back and and do further learning in occlusion. What was it? Was it a failure? It was a premature failure. What was it? [Carlos]Two things actually, lack of my communication with the patient. That was another words, I just assumed. And I didn’t explain myself well enough. And I’m just being candid with you. That was so- [Jaz]It’s very humble of you. [Carlos]No, I mean, that was one. Second was that I think that was the big picture. The second one was standing in touch with him because he moved, so basically what it was, worn dentition, top and bottom, missing from, I know the nomenclature is different from the US and in Europe and everything but from the canine bags, he was missing those very short, efficient, like so and so naturally back then you do crown lengthening, build him up and so forth. I didn’t pay attention to this angle right here. That needs a coupling and the disclusive angle. Looking back, I made it too steep like this. So, I didn’t pass- [Jaz]Too steep of a envelope constriction? [Carlos]Yeah, the envelope of function, I violated the envelope of function, I constricted it. Rather than open it, I constricted. Absolutely. And so he moved to the beach. And that’s where I got the letters saying that, you know, this whole case needs to be redone and so forth. But long story short, there were some good colleagues. That’s why you know, as colleagues, we have to be attentive, you know, help each other out. And there were two gentlemen over there that evaluated the case says, ‘Carlos, you haven’t done anything wrong, everything. The only thing was, you know, the posterior we needed to build them up and so forth.’ And my thing was that since he left, there was no way I could do it. I even propose to the gentleman, ‘Well, come over, whatever you need to do. I’ll do it.’ So long story short, that was the big aha. It’s like, okay, I got to make sure that I side move in progressing my evolution in my field, that I don’t do this. You know, you don’t want to make the mistake again. Make it more predictable. And so I started my journey with Pankey. I remember Pankey for the whole week. I again finished the whole Pankey because it was such a long process. Did the Peter Dawson, listen to Spear, let’s see who else and then I was very blessed to meet that to be on my chorus. He’s a gnarthologist, this is how you know what I call them as they’re the ones that foundation for prosthodontics and so forth. You know, those are the guys that say you had B.B McCollum, you had Stuart and Skyler. They started the whole, this whole journey of occlusion. [Jaz]You mentioned some real big hitters that in the field of occlusion and dentistry in general, a question that I get a lot is how do you pick, now I really admire like many of my guests who I’ve had on, what I admire is that they haven’t just listened to one’s growth or and then ran with it, which is fine as well. There’s nothing wrong with that. But a lot of the guests I’ve had on very privileged, okay, the done Kois, but they also did Pankey. And then they listened to Dawson, and they respect Spear and they listen to everyone, you know, and they develop their protocol that works in their practice. How does a young dentist choose which path they will go for first, and you think it matters so much exactly, you know, between Spear and Kois, who they ended up going for first? [Carlos]No, you know what I think and this was the hard part, I think in dental schools is understanding the basics. You know, the anatomy and the physiology. That’s the most important part. Because if you look at, you know, there’s different, you have the CR camp, you have the LVI, neuro-musculature, you have those. And we can all agree that you know, you want simultaneous contacts, guidance that’s both, but where they vary is where you start, which is joint position. And among those is those positions, how to get there. And to me, doesn’t matter how you get there, just get there. You know, once you get there, just get there, you know, if you want to use a Kois deprogram or use it, use a leaf gauge, get use a cotton roll, just get there, make your diagnosis and move forward, right? And then how do you put stuff together? Well, you know you got to respect that, a Kois is mentor, was that to be on my course. We had a long talk and everything. He was from the Air Force. One is an incredible clinician, but, you know, he has a certain way of where he likes to start on the Posterior. There’s nothing wrong with starting the posteriors. I like to start in the anterior because I think the actual, I do more, get more from the, as far as the aesthetics, phonetics, I test the joint, if I started the front. But started the joint. once you get your diagnosis, then it’s just a matter of what you have in your toolbox to implement the final result. And always start from the end and look back. You know, look at my nice picture and look back, don’t get intimidated. [Jaz]You’re very much Carlos, you’re very much echoing the same thing that you know, we did a two part episode with Dr. Bill Supple. He’s the president of the AES. Have you been to the AES before? [Carlos]But one of these I have not- [Jaz]I’d love to go, maybe 2025. I kind of sounds crazy thinking so far ahead. But I’m a family man. And I’m just thinking kids and stuff. So I’ve been I’ve actually emailed 2025 Bill Supple with that. I said, Okay, I kind of told him at 2025, I might see you in Chicago, for AES. But anyway, well, what he said in the episode was very similar to what you said, like look, the endpoint between all of them is very similar. And they all care for the patients and they will all, if you follow one of them to a tee, you’ll get a good result. It’s just how you get there. And the little micro steps will vary that little squiggle from the point A to point B will vary. But the point A and point B are invariably the same, ie getting the correct diagnosis and being able to communicate that to the patient and then getting something that you’re proud of and the patient is going to be able to get longevity from is the same. So I’m glad we covered this again, because it’s important to remind ourselves we get very worked up about Oh, but you’re Kois and you’re Pankey, it doesn’t matter. [Carlos]It doesn’t matter. It really doesn’t matter. You know, I was one of those back in the DNS. And I try to, you know, talk to, it’s like politics and religion. You cannot convert anyone, you just can’t. But no, with occlusion, it’s the same thing. You know, the occlusion and here’s one thing and I’m gonna say a couple things about gnarthology that I’m a little bias, little bias. I want to keep things simple. Well, you know, joint position. That’s what we sell. We do our diagnosis, right? But as far as finishing the cases, we’re not worrying about the lateral and the central, we just worried about the coupling and the anterior, you know, the envelope of function. So I’m like, for example, of course, a lot of the viewers know this, your traditional Pankey Dawson and so forth. You want 28 contacts simultaneously. Well my friend, it’s hard to get freaking 28 contacts especially in the anteriors, and it’s hard, I mean, there’s just no way. Okay? Now, I’m not bad, and I’m not gonna bow my head, there’s no way you can tripodize a full mouth in gnarthology. There’s no way but the beautiful thing about this, if you understand the big picture, understand the stabilizing the tooth, it doesn’t matter, just stabilize in that tooth. Then, with that, first of all, if there’s instability against with the patient and everything, if you start stabilizing one or two teeth, it’s amazing how the body starts saying, oh my gosh, I think this guy knows what he’s doing, the body does, right? And then you start seeing some progress. So what I’ve learned in my 30 years is not the big picture. But you then you can pick and choose, some patients don’t have to go to the nth degree, you only need to do one of a couple things, you know, just a man working in offense here and there. And bam, they do well, another person and the other one you may do is before you get started you and I know this is before you start on upper posteriors, make sure where the first point of contact is because if you change that, depending on how that patient react, some people have wide zone, some people have smaller or you can put a rock on me and I’m fine. My wife, you put something oh my god, what have you done? So you have to be able to have that in your toolbox so you minimize your problems, right? Right. That’s what the thing is we want to minimize it and we want to look good, we want to look good in front of the patient and so forth. And so with gnarthology was, the way and the right time when, I’m a liberal gnarthologist and I’ll explain why I’m liberal gnarthologist because yes, I understand the tripodization, I understand this for what up disclusion. Yes. But hell, I can’t do that all the time. But what I realized if you can do it one or two, bam, it’s amazing how that patient does. Now- [Jaz]So really, just to really make it clear to those listening and watching our dear listeners, the Protruserati, when you say stabilize a couple just, what do you mean by stabilize a few teeth, like just make it really tangible, like, describe what you mean by stabilize? In that context. [Carlos]I had a patient that came in and I have a document and so forth, woke up with a pain on the right side, lower right side, came to me and just was distraught. Let’s just say, I’m hurting, the muscles hurting me and the whole nine yards. So my thing was, okay, let’s take a look at this. How am I going to start with this? I’m like I said, I’m a leaf gauger. So I owe a medical history and so forth. Because that you know, that’s another topic we’ve met with the medications increasing muscle activity. So naturally, there was a reason why she was having an issue, that tooth was some in the way of her function or whether it was clenching, grinding. So it was instable. So I come in, go to my leaf gauge, to check out how to joint, the muscles and the teeth. I get the teeth out of the way, check the inferior lateral pterygoid to deprogram and see where it is in position, right? And then from there with the warm compress, figured out how she does and I also use pressure point readings. I think we talked about that earlier. It’s a modified dry needling, I’ll just go straight to the source, and just put it in, put that breaks up the lactic acid. [Jaz]Well, so using a like- [Carlos]I’ll just use a 27 gauge needle. I just take a wipe it down with alcohol. And I’ll tell, ‘Mrs. Jones, you’re going to feel a little pinch, I’ll find where the tight contact is.’ She has a leaf gauge, she’s pumping out muscle. I’m checking it, I go in one or two, warm compress, wait five, six minutes, go take a cup of coffee, do whatever you need to do, come back and you’d be surprised. You’d be surprised how the patient, so naturally on this particular case, that on the right side was number 31 was had a distal buccal fracture. And wants it stable now you had one, having tried this back in the day, well you can put it, you can add to that too. So I need to do that. But my thing was this I went to the front, stabilize with the canines, I added that was my first point of contact. There was about a millimeter or two, went ahead, use the leaf gauge, created my vertical, use my restorative adhesive, place a composite and immediately she was able to respond. Why? Because no longer was she coming in straight lateral enough The non working interference are already removed, because you have the anterior. [Jaz]Essentially, you created a more harmonious occlusion as I say in the textbooks by removing the posterior “interference”. So that, that tooth was no longer taking all the brunt of the parafunctional forces. And then you recreated some form of anterior guidance, right? [Carlos]That’s it. That’s it. That’s it and and I used to Canine. Now bring it back again to the gnartholical is what the beautiful thing about it, all I got to do is worry about the canines and back for you know, equal contacts. And for the anteriors, what is the purpose, the function of the anteriors are there for disclusion, they’re not completely touch, they’re ready and set for disclusion. So as soon as you move boom, you get the disclusion, left and right, you get the disclusion. That creates a labor three system, it’s the least mechanical offensive. Right there, is anytime you have a posterior interferences, a class one, that’s a seesaw, you have the joint and the muscle, they’re going to be sold. Especially remember, you have you ever seen a patient comes in, and they have wear on the canines and you wonder why they wear in the canines, you know, this happens at night sleeping postures. So if you see, if your left eye sleeper, you’re gonna put your head like this, it just goes this way. And you’re going away this what’s going to happen, this joint is going to be the painful one, that mall or back is gonna be a fulcrum, like, you know, you’re number 14, 15. And you’re going to see canine where the opposite side, now the person toss, in turn, you’re going to see on both. And what’s beautiful, I have documented cases that patients in the back, you barely see a little bit of wear in the front, because the teeth, a very revealing, let me put it this way, the teeth are very revealing. They’ll tell you how stressed they are and everything. Just think about it. Because you know what 24/7 goes deep, and so forth. So leading to the knock knock- [Jaz]Before you progress on, and that fluctuates, I just want to make a point that I actually posted an Instagram story maybe a few months ago. And it was just like my nurse who’s been working with me for almost two years now in this practice, I joined this post pandemic, or just middle the pandemic, I guess. And she has been amazed exactly at that finding that you suggested whereby you can predict the sleeping posture of a patient based on the wear patterns on the teeth. So my success rate in getting this right is about 95%. So you would think that if I guess left, the right would be 50%. Right. But it’s that 95% Even then I think some patients just get the left and right confused, really. And I actually know which how they sleep. And they basically might start one way, but in the middle night, they go to the other way. So essentially, if they got more wear on the right side, they’re probably sleeping on their left, and they’re grinding away from the mattress, too. And it’s amazing when you start picking these things up is so the patients start getting freaked out. [Carlos]And you just tell your significant other, if that patient comes in and you have an issue, because a lot of time 80% of the issues with the muscle, it’s all muscle induced and so forth. We don’t have to do a lot of stuff, and that’s another step you have to do. But you educate the patient, you know, you take a walk to oxygenate, you give them a little deprogram on the front, it doesn’t matter what if the cotton roll, you can put a cotton or you can use anything. Warm compress and sleep on the other side and have your mate sleep on the other because you don’t sleep facing each other. Right. So anyway, so yeah, and so you know, going back to the, as far as the gnarthology Yeah, the occlusal scheme is I don’t have to worry from the canines back. So that’s beautiful. I don’t have to worry about you know, getting this perfect. Don’t get me wrong. Do you want to have in an hour? I can show you all share videos later on? [Jaz]Yeah, sure. Whenever you want. [Carlos]You can take the articulating paper. And once you do the canine guidance, you slide it, you automatically create that half a wing. And that minute disclusion or no contact that is necessary because just think about it. If you put all the teeth together, it is hard. If you have a little interference, mesial incline of the upper one against the distal a little, is going to push forward and guess what happened? Teeth are going to spaced, your lower teeth are going to be sensitive. So it’s important to have the little neutrality that little space in there because we’re not perfect that inevitably we have that means you’re drifting when we’re born in teeth setup. We have a means you’re drifting that with the teeth are not perfectly nobody’s walking with CRS and MIP equally no one it is so inevitably you’re going to keep going forward and you’d get this thing like this. What’s beautiful is when you get mobile teeth and you add to the canines and so forth, is how things start torquing knob, hygiene improves, it’s insane now this is not an I will lead slowly to the canines. My thing through my process of Peter Dawson and all that, you know, they said okay, oh, I remember Tanaka, Terry Tanaka. Great, incredible if anybody wants to go see him, the guy’s insane. But I remember he’s saying that don’t ever make non-working interference or adjustments when you mount them unless you have canine guidance. And it makes sense, it makes so much sense because you’ve been too aggressive. You know, anytime you start cutting away, that have an interior protection, you cutting away teeth to structure. So that’s stuck in my head. That stuck in my head, too, when I would build my chorus with the leaf gauge, and he’s a big leaf gauger. And he’s the one who made it popularized and now it’s now unfortunately, when Peter Dawson passed away, they’re starting to use a little bit more into camps, Spear, as you know, one thing with this- [Jaz]It’s great tool. I’m a huge fan of leaf gauges for about six years myself now. And it’s great. [Carlos]You know, when people say to me, you know, people, oh, you’re gonna posture most of your life did they join or- [Jaz]Distalise the condyle, or whatever. I agree. [Carlos]You can. Pass the relaxed length for the inferior lateral pterygoid. That’s a partial go. You can’t go any further than that. [Jaz]And also, the vector, the masseter and anterior temporalis. The vector that is made, it won’t allow your condyle to go all the way back. Now, in a very deep class 2 Div 2 you’re probably a little bit more mechanically disadvantaged there. So it’s gonna be a bit careful, right? But yeah, on the whole, in most cases, it’s very safe to use. And for a lot of dentists, that what they told me is that their occlusion, their journey in occlusion became a lot easier. And they were able to progress in their journey. Once they were able to get a leaf gauge, because a lot of dentists when they’re starting to think full mouth, they really stumble on, you know, the lucia gauge and then checking and verifying the contacts. Sometimes, CR is like what Ian Buckle teaches one of my, he teaches Dawson in the UK, so it’s a buddy of mine, a really fantastic dentist, great communicator, and he says, centric relation is like playing golf, okay, you’re never gonna get a hole in one every time. Okay, with the leaf gauge, you get like 97. There, right? And then you get your temporaries. And then you get a little bit closer. And finally, you get in the hole, basically. Okay, so the leaf gauges is that first swing that gets you almost there. And sometimes you get fully there, if the patient’s relaxed enough. But if there’s few engrams, and their muscles are upset, it still gets you closer to where you need to be, would you agree with that? [Carlos]Oh, my God. 100%. And here’s the thing going back to the diagnosis and the muscles now, you know, and the engram you mentioned is, you know, naturally we have this normal stimulation that our muscles develop this pattern. And with the leaf gauge, as say you separate the posterior teeth and and the 8 teeth will in contact and so fort. They showed that you don’t use, you don’t shut down but you reduce the electrical component of the masseter medial pterygoid, you know, climb down and so forth. But what you also do on loading the joint right you load him by putting everything in the front loading the joint you test them that joint is during inflammation is that capsule on the lateral side and everything. And I want to say one little thing about the joint because I’m a geek, I want to share this with everybody. Let’s remember that the capsule is made of dense fibrous connective tissue. And what that means is it has mesenchymal cells and it has the ability to reshape, reform itself, all we have to do is create the right environment. So, what do we do? We do the diagnosis and then we create the environment. Okay, so that’s the patient has a dislocated disc and so forth. You put the leaf gauge, within a minute or two on their try-in, you take cotton rolls, put it in the back, because remember this, the center point of here is your first molar. What’s the first tooth that comes in the permanent is the first molar. That is that weight. That is your center point. That creates you guidance and mixed dentition you guidance is your first molar. Anything back of the first molar, you’re decompressing the joint and I don’t care what people say, you can decompress with my experience with 30 years I put something back there that feel better is good, right? And if I put anything in the front anterior to that you load in the joint okay? And in a lot of times is the medial pterygoid or the inferior lateral pterygoid that is thight. That you do is a we lose it releases what you have released. We released this what you have to do is be patient with the leaf gauge especially somebody has comes in as symptomatic and so forth that you pumped up muscle you pump it five to six seconds like Rocabado said. There’s something magical about six seconds pumping and release that makes up muscle finalize the contraction, it releases and so if we understand that disk, man, we don’t need to go surgically, and they’re just provided by the environment. Okay, so somebody has this problem. However, take the full apply. Here’s the other thing, you take a full mouth guard, I don’t care whether the segment or just the full, create the most pivot in the back, don’t go. In other words, don’t bring the jaw forward, you bring the jaw forward. We got two parts out of position, you got the jaw forward, and you got distal position, you have two parts. I don’t want to mess with that and stay home, just decompress, wait, monitor that patient, monitor that patients so that that pivot is in the back, nothing’s in the front. And I’m telling you, the younger that patient is, you get remodeler this is beautiful, and then you can rock and roll then you know a lot of times they need ortho as the other thing is we don’t utilize ortho that much. Orthodontics is underutilized. And it’s unfortunate. But that’s the thing about the disc, I want to make sure is it everybody can get that pay attention to this. All you have to do is make your diagnosis. And then it doesn’t matter what appliance you use psychology. Well, I used this appliance all the time. And in my mind, I said hmm, really? [Jaz]A lot of the studies Carlos that I’ve done on appliance type and generally TMD and conservative care, giving, you know, educating the patient home therapies, analgesics, and occlusal appliance, physiotherapy, they all show consistently 80% Plus success rates as not so dependent on the appliance type. So, I completely agree with you. A lot of appliances will you know just disrupt the system, disrupt the neural links and help the muscles heal. And it’s great that you mentioned the muscles because yes, we talked about the disc but the superior lateral pterygoid attaches into that disc so a lot of the issues are muscular based so once we can calm those lateral pterygoid superior inferior down then the disc has an ability to potentially return to where it wants to be. [Carlos]Yeah, remember the disc seats here and the front, the disc gets a superior head or lateral pterygoid is the top right. And the posterior of the bilaminar is on the elastic connective tissue and it’s made to go you know it is a component that goes down and back and so forth. When you’re treating like TMD you treat him, you’re targeted the inferior lateral pteyrgoid. It’s the lateral pterygoid that you’re trying to get those are the only muscles that are- [Jaz]They are the troublemakers. [Carlos]Yeah, they’re the troublemakers. And that’s what you have to gear your therapy. And so if you understand this, this mechanics is very simple. I just everybody, you load the joint, you put something back here you decompress. You make your diagnosis however you make it, if it’s joint problem, target your therapy to be in the back, if it’s muscle target your therapy to be for that. And that’s it. You know, people say oh, you use them, what use one use one orthotic. And based on that you make the adjustment. And remember the joint always trumps the muscles, it always says what happens is you get a cold a combination here and there. But what happens isn’t a true joint that I’ve seen in my cases and everything, when in doubt start in the back, when in doubt all your plans start in the back. And then what’s going to happen is if the appliance is too thick, the anterior portion of the temporalis it’s going to it’s going to you’re going to find out this and then to the muscle are going to be tight, but you can load the joint and it’s gonna be fine then you said, ‘Mrs. Jones, I got you covered.’ Now we’re going to move everything to the front use the same one you cut the back, you put the front and said go home, come back because all that was pretty good. There you go. [Jaz]So essentially just to make it very tangible for for listeners watchers, in this primary joint patient, you decompress the joint use an appliance that is thicker or, or more involved posteriorly than anteriorly until you get the joints to make some sort of healing and then you convert it to provide some sort of anterior guidance to relax the muscles. So, as you said joints first then than muscles- [Carlos]And I’m sorry to interrupt Jaz, but on the posterior, what you have to do is use one the most posterior tooth, the palatal use as you pivot. So in other words, what’s going to happen is you’re gonna use the maxilla. So the bottom, you’re going to use an upper appliance, most likely I use lower appliance, I use pivot. But if you say for example, if I was somebody came in with TMJ, I use a full appliance, I want to make sure that the most buccal functional cuspal, the bottom one just hits my top, the posterior, just one little point right there and just skate on that. All you want to do, you don’t want anything in the front because anytime you hit anything in the front, you load into joint and you’re gonna put pressure on the joint. That’s why- [Jaz]Wow. This reminds me, Dr. Andy Toy epsiode I think was 38 or 40. We talked about the PGO, posterior guided occlusion. So it’s very similar the concept of the PGO appliance to what you’re saying just to those my listeners who remember that episode, very similar, and I use the PGO appliance occasionally for primary joint patient, but it’s great that you say that in the interest of moving forward I’m Carlos, anything you want to add to this before we now talk about additive equilibration? [Carlos]And yeah, let’s so no, not that we can get another word now, in my evolution with mythology and so forth was I started noticing, you know, how am I going to treat this patients that have worried and impatient people that come in. And so when Tanaka said don’t do not working in offense and so forth, and then thought to build my chorus, he’s using the liftgate. I said to myself, well, first what I did was I started putting composite where it was worn down. That was my first time without using a leaf gauge. And it was a failure. It was a flop. Why? Because I didn’t have a reference point. I didn’t know my vertical, I will just add him. Patient will come back to knock it off. It was a mess. But I didn’t give up. I didn’t give up and then I had an epiphany. So why don’t you just leaf gauge, the first point of contacts. Ah, that’s not truly there that you know that it’s an actual point is and then I evaluated the anterior overjet, I started evaluating and this I just started slowly make sense, you know, this way too much like this is going to be an ortho case. That was another thing and I’m going fast. I had this lady for five years in ortho, poor thing. She comes to me and she goes, ‘Can you see- and I’ve been in four years I want to get my teeth corrected and so forth. Can you help me?’ So I put the leaf gauge you know, she’s already like this she went home like that. And I said dear, you’re- [Jaz]That’s a surgical case. Exactly. [Carlos]Exactly. So, I called the orthodontist I called you and I said you know what you’ve done I know that but you know, if you really want to, you want to present it in such a way if you want to be this will be orthodontics. Just remove everything and let’s figure this thing out. Okay, here’s a little tip Pearl, no one can afford you know, the correct this. What you do is use plastic, use a segmental appliance and a knife, you create your ramp so that when you sleep, you get disclusion. I learned that from my course. So not everyone has to be crippled and 24/7 you use your posterior teeth. So if somebody is like this, you stabilize the back and I’m jumping, [Jaz]So, just to make- because you’re doing visuals, I just want my audio listeners if someone has a very large overjet in their centric relation, so if they got a very large horizontal slide, how would you with issues and who may not be able to it’s not the right time in their life to consider surgery, what are you suggesting for that? [Carlos]Make them six through 11? Making a segmental, six through 11, a little plastic splint? And acrylic, yes, and you create your ramp and and you just adjust it. And that’s it. [Jaz]But that’s for nocturnal use only right. That’s for sleep use. That’s for nocturnal. [Carlos]Yeah, right. Yeah. Because yeah, you’re nocturnal, not during the day. Because you know what, how many times a day, if we use our teeth are functioning intended, we weren’t needed during the day their teeth don’t come together only when you swallow, in phonetics, you don’t so you really don’t- [Jaz]Those patients who have, who are parafunctioning because they’re clench and grind things that you shouldn’t be doing. So I’m not we’re very much cut from the same cloth. I completely agree. [Carlos]What I do some of those cases I’ll do tell him use it for about an hour or so in the afternoon. Dependent, you get the segment applies. But you have to make sure you adjust it to the vertical, the posterior don’t leave them open. Because some people love this thing. If you wait 24/7 Guess what the posterior teeth are gonna supra-erupt. So make sure you have you worked out the occlusal scheme on that. So canines, I had no success with just adding. Then I had an epiphany using the leaf gauge. So there, that’s where everything just changed. Go to my leaf gauge, find my first point of contact, evaluate my horizontal. [Jaz]Call us, I mean, I just want to stop me because I’m loving the drill. So now we’re talking about a journey of additive equilibration. And a common question again I get is when you’re using the leaf gauge and you’re so advanced in your journey now that you’ve been doing for so many years, the beginner dentist, the first stumbling point they get believe it or not Carlos is how do I know how many leaves to use, right? I’m like, it doesn’t matter just stick enough in to disclude the posterior teeth. There’s no magic answer depends on obviously the skeletal stuff but just put enough in to disclude the posterior teeth is any guidance they want to give on. [Carlos]I’ll give you a couple tips. Yes, that’s very good because it’s so dependent on what you knew by the 0.1 millimeter in thickness. Each one is supposed to be point one so you know 10 is supposed to be a millimeter with that said is arbitrarily arbitrarily you select the amount I usually go from 20 to 25 That’s my starting point. Usually 20. Depends. Now you put them if you haven’t put them in, you have a slide forward, slide back just just to just to keep it in place. And then you’re going to have a squeeze for five seconds, relax for six seconds. Why? Because if your inferior lateral pterygoid is tensed, you’re going to start you’re going to be working on you’re working on that on the inferior lateral pterygoid. [Jaz]It’s the masseters and temporalis and the medial pterygoid by contracting, which then should give the cue to the lateral pterygoid to say, ‘Hey, you guys are needed here. You guys need to relax.’ [Carlos]To relax. Yes, yeah. When I think of the leaf gauge, because I’m always thinking of the inferior lateral pterygoid., but yes. The electrical activity anterior temporalis medial pterygoid slowing down. And then also the inferior lateral pterygoid is also relaxed, because remember, the inferior head works opposite of the superior head, as the inferior head contracts the superior head, relaxes to allow this to come forward and back. But anyways, so you do that. Now what’s going to happen? Here’s the pearl. After five minutes, let’s assume you use it for five, let’s say you five minutes to patients some leaf gauge, going look, I tell him, if you feel contact in the back, add some more leaf gauge, because my experience has told me that what happens is yeah, as the inferior lateral pterygoid relax and the condyle seat, you get the posterior contact, more noticeable. [Jaz]As the condyle is sitting further distalising. Distalising is the wrong word. It’s just the lateral pterygoid seating- [Carlos]It’s going home, the doors open he’s getting home. But so that’s important, because what happens is, if you’re too quick with the leaf gauge now, if somebody’s not having any pain, and so forth, yeah, within five minutes, but if you have somebody suspecting that muscle problems, and you really want to work on this mountain, the case and so forth, then my thing is pay attention to the thickness after five minutes, if the patient is not hitting in the back and, go back and check with articulating paper that your photos are in here. And so I’m not hearing you go back there they are hitting. So go back and check. I like to look in there, it’s the second game before I start second again, you know, I think this patient is gonna hit on the left side first, you know, or depending on the rotation. So I’m making a game for me, you guys, which is going to be the first but here’s the thing is after five minutes, check and see make sure there’s no plans. Now, once you had the first [Jaz]Make sure there’s no contact, make sure there is sufficient posterior clearance. [Carlos]Exactly, just posterior tooth. So muscles are quiet, everything is good. You look at the canines, and then that’s why you have to make for me four millimeters is the maximum for the novice then I’m going to start adding composite. But let me also regress a little bit with the leaf gauge. And for those that are don’t feel comfortable, and you want to get in there, there’s nothing wrong with the patient, putting the leaf gauge get behind the patient like Peter Dawson has said and then just get a feel for it and get views I’ve had the assistant older and you get a feel and that’s how I develop my sense of manipulating the joint because I remember going to Peter Dawson over there you know romanting the joint and so forth, you know, you need a talented dentists and you need a patient is very cooperative. When the leaf gauge get on board, I use both up and then now you know it’s just alivio sometimes you can get them right I’m not gonna go there. But you can get somebody in this remember what is centric relation, it’s a muscle induced position. You don’t put the patient in centric relation they go there the inferior lateral pterygoid has to relax and wherever the condyle goes? The centric relation. Now, the question is- [Jaz]I think Pascal Magne uses the term passive deprogrammation. So, it has to be passive like you cannot lead them there, you cannot definitely not force them there is a- [Carlos]Centric relation should not be fortunate, it’s a muscle induced, you get the teeth out of the way with the leaf gauge, the inferior a lot of target relaxes your home. And wherever that that condyle is, that’s where it is, you know, people get, oh, talking about the joint and everything well, you know, anterior posterior, I don’t care where it is. I don’t mean, as long as I know that I’m there and I can load it and everything. That’s all I care about my clinical part, and so forth. [Jaz]Right, one of my mentors, Michael Melkers, he says that, you know, we get very worked out about exactly the seven o’clock 12 o’clock, all that kind of supposition. Well, you know, the only way you can verify is by getting a scalpel and cutting and then peeling it back and say, ah, I’m there, it knows how to do that. So therefore, you go with your signs from the muscles, and again, it’s your first record you’re taking, you have an ability to verify and refine in the future. [Carlos]Yes, absolutely. Absolutely. So, you know, with the leaf gauge, don’t be afraid to use it. You’re not going to cause and here’s the thing, and I’m going to give another tip if the patients as using the leaf gauge. You tell the patient, ‘Mrs. Jones, I’m going to split this deprogram on the front. This is what’s going to happen you’re going to feel some tightness what they do, they’re going to feel some tightness. It’s going to be okay after five or six minutes, it’s going to go away if it doesn’t, we’re sure if it’s a TMJ or capsulitis within three or four minutes, they will like to hate it and then and then what you do kidney stones you know what? Okay, I got you covered. Take cotton rolls immediately put them in the back don’t have any squeeze just relax and guess what? Pain goes away. Now you just made the diagnosis you got you got some some type of capsulitis, synovitis, muscle and treat that first before you go doing, measure twice cut once and you work with that. So okay, so you use- [Jaz]You described the leaf gauge beautifully so I think a lot people got value from that so very common question I get Carlos now let’s talk about it you have a generalized wear case maybe and you are using your diagnosis, you’ve got your leaf gauge in, you feel as though, ‘Okay, I’m gonna start adding to the canines here as you’re gonna say to to recreate some sort of anterior guidance and coupling anteriorly.’ Do you have the leaf gauge in place as you are doing your bonding or do you get a wax up first? I feel as though you’re you do a lot of freehand stuff, tell us your workflow. [Carlos]So let me let me let me walk you through the procedure. So the person will go ahead and of course dependent after six the patient has the leaf gauge, find my first point of contact, that takes time to find the first point of contact and that’s critical because if you get sometimes when I get a little bit too quick and everything and if I don’t pay attention to that then I’m having to adjust a lot so pay attention to the first point of contact and once you get that nail in and everything, you look at the verdict you look at the horizontal and there is going to be as such then you do your restorative protocol I use I’m a fourth generation opti bond and microetch canines, air abrasion . Air abrasion, etch. [Jaz]This is again, this is with the leaf gauge in place or is this-? [Carlos]This is out but I don’t have any close to the- [Jaz]Teeth together again because- [Carlos]No, you activate anything. No, you have to stick your hand in there and you work with your system, but you don’t have to close down you don’t do that. Once you have you’ve done you’re setting up your restorative your teeth you’ve gotten in prepare, etch, bond. Here’s the key is what I what I’ll do then is I’ll take a piece of plastic, this is the most expensive part. I’ll take a piece of plastic, layer it over when I put the composite, I’ll put the composite, put the plastic over it like that. And then I put my leaf gauge on top of that, have the patient now here’s another pearl have the patient bite on the back teeth. Because inevitably if you say bite down they’ll go forward, they’ll go back. Practice- [Jaz]Like rehearse and coaching. You have to coach your patient. [Carlos]Coach and guide him through coaching. Now I also use cotton rolls I have three cotton rolls buccal and he’s shy and on the lingual bandit and I’ll put the corner just to try to contain the moisture then I’ll put this, put the leaf gauge, have the patient bite on their back teeth imagine binary bite they’re gonna bite down, leaf gauge on, plastic in place, my assistant is going to come in and light cure [Jaz]Now, but just to just to verify because I’m kind of seeing where there’s going because I’m trying to visualize this way of doing it because it is new exposure to this exact way of doing it usually I’m led by a wax up and stuff so I appreciate the freehand the A) the complexities of it but B) I’m loving where it’s going so but you’re not planning to add composite where you’ll have the- This is we’re talking specifically the canines here- [Carlos]Just the canines. [Jaz]Okay, and the piece of plastic, for the guys to describe it at home.. It’s like thick cling film. It’s just like clear mylar. It’s like a piece of wrapper. It’s like a candy wrapper or something. [Carlos]Very clear plastic. Yeah, that’s the most expensive part. It takes a lot. [Jaz]Okay, so do you have composite on both the upper and lower canines? Like uncured? [Carlos]Good question. Yes, it varies. Usually, let’s assume an easy case. The overjet is not that great. So I’ll just use the most of the time. 80% of the time, I’m just adding to the lower ones. Very seldom our to the lingos of the posterior unless you have a really steep you know a big overjet Alright, so most of blindsides send the represent all the actions in Psalm 22 and 27. Just the canines. Those are the canines. Well that’s it. So what happens is- [Jaz]And the reason for using the wrapper is so that the upper and lower composites don’t stick together. It’s just some spacer- [Carlos]And also for saliva. control, even though try to get by my environments, I don’t want to lie they get in a lower. So what this does is it protects, it doesn’t allow this a lot to get in there. It minimizes, let me put it this, it minimizes the contamination of deposit. I know, I know there’s people that does that without this plastic thing. I like the plastic and and however you want to do it, let me put it this way. But the key is this Yeah, here’s the pearl is based on the thickness of the first point of contact the vertical. That’s how much composite you’re going to use in the front. So you don’t have to put this glob in there. So say for example, you have about a millimeter, just stick about a millimeter millimeter of composite. Now also pay attention or how that canine is. Because just the same thing is you don’t want to put say, if you put it on the distal side of the of the canine, it’s going to push your jaw forward, if you put it on the music on the bottom one. So pay attention to the position of the canine Where do you need to put the composite, that’s another advantage. But when in doubt, just put it over use a CaSi instrument that has the instrument becomes so easy just put it in, left right left, right, put the plastic bag down like your now when you remove it, you’re going to see a blob of material. And you’re going to see a little edge on the side. Before you do anything dried up, put some flowable composite, put a little bit of flowable composite, then if you’ve done your homework and is and you’ve done your vertical correctly, have the patient bend down and what the patient is going to fail. I tell the patient Mrs. Jones, as we do this procedure, when you first close, you’re going to feel two boulders, I’ll tell them you feel two boulders in there, you got two rods. And then now we’re going to go into the back and see how it is. So if you’ve done your homework, you take that in checking the back and you still have the first point of contact, which is usually the means you’re in kind of the top one against a disability plan of the lower one that pushes you forward. Okay. So I’ll go back there, and I’ll adjust it and guess what? Everything drops back. [Jaz]Okay, are you adjusting the posterior interference? [Carlos]The first point of contact of interference. Now some people are gonna say, Oh my God, that’s heresy. He has mounted the article, you know, have mounted the case. And what’s going to happen that my experience of 15, 10 What I’ve been doing this, I’ve yet to cut in anything. So you know, for those that don’t feel comfortable, that’s fine. But what I’ll do is I’ll just that and then what happens is the jaw drops back. It just dropped back a little bit. And you said Mr. Hyde, it’s not perfect. They still feel kind of a little heavy. And then what you do is you come in and you just shape it, you just reshape it, reshape it, make sure because you don’t want to because of the plastic, it gives you some irregularities. So just shape it, polish it up. [Jaz]So using the Soflex disc and that kind of stuff, right? [Carlos]Do you want to do it? Yeah, however you want to do it. Now. This is interesting. I will probably say 40% of the cases. This is crazy once I adjust this, everything because remember, the muscles are like your shock absorbers. Everything’s we settled in a lot of time. Guess what? Everything is balanced out any material because I have the spacing. I already have but right. Boom, you ready to go. I mean, it’s it’s amazing. It is amazing. I other cases, other cases, you’ll get a unilateral everything is contact, and you get an opening here, right? Unless you have bridges and so forth. That’s different but but I tell the patients who said I’m going to have to come back in two weeks. I usually follow them up in two, four and eight. By then by the eighth week if one tooth has not settled and you choose what you want to do, you can put composite you can just leave it alone. You can leave it alone you no one wanted me now. Now what happens is you asked when did [Jaz]You call us just to complete the visualization here. You’re sending the patient home now absurd compared to their preoperative state? You’re sending them home with four canines, a polished- [Carlos]Four or two. [Jaz]Yeah. Agreed, four or two, you haven’t yet done anything to the incisors. And other than maybe just gently adjusting their posture, first point of contact, you haven’t really done much to posteriors. So this is kind of like we spoke about on Zoom about this before. This is kind of like the start of a doll concept doll technique. And then when you see them again, at two, four and eight weeks, he said, What are you checking for? And what’s the next step from there? [Carlos]So what I’ll do is the following is I’ll check a document and say, Okay, let’s, let’s, let’s, here’s the worst scenario, one scenario, just canine guidance, and I’m not getting anything. There’s space in between them. Okay, that can happen if you don’t pay attention to the first year. So what I told the patient a lot of times is I’m going to put you in a diet. I’m going to, I’m going to put you on a diet because we’re gonna be hitting on the canines, right? You’re gonna go home, you’re gonna defend a diet. I’ve only had one patient that came back and says Carlos, you got to take this thing down. And I did one page, I remember though. But most of the time we told, ‘Mrs. Jones, you’re gonna go.’ And what’s interesting too is within 48 hours, maybe maybe three days, most everything is just feels fantastic. So sometimes when they walk out by the office, because when they come back there, ‘So yep, Carlos, as soon as I left, I felt good.’ But so I’ve told the patient, you’re gonna feel the bullish, you’re gonna leave, you’re gonna come back. And when you come back, I’m documenting really well, where they, where they feel the where the space is and where they contracted. So let’s assume there’s no contact at all. And two weeks they come back, they may say, ‘Oh, I feel a little bit snug here.’ Let us know- [Jaz]Usually, very posterior, usually second molars, first molars, right? probably be the last ones. [Carlos]Yeah. So I feel that now what I’ll do is this is subjective, it is very pronounced because depending on the height is in a submission or missing part of the apple elicit this stole it, I may take it off. I may, I may remove it. If not just leave it alone. Okay, check the other ones, then 100 Come back, like I said, and a month from there. So it’d be two, four and eight, then you may, on the other side, pick up conflict. Why, because of the dog principle, thanks, we’ll go to the path of least resistance. The only thing that will keep you from keep coming together is what you cheek, your tongue. And I’m working in offense, sometimes not working in offense, that can that can hold that two things in place. Or there’s a study that was done a long time ago is because of somebody told me because of growth hormones, when you stop at a certain age, growth, hormones can change. But that’s besides the point. But so you might you’re monitoring the disserve equilibration that is occurring, and at the end of four, four months, four weeks, then what you’re going to do is figure out if everything is stable, do I need to add, sometimes you just leave the patient alone, my case has been this is a case insane, like half half of my cases, and so forth. They’re within two weeks by the fourth second lesson. They’re balanced. Now, what you do have to pay attention to is how far how fast were these canines? Because this is not a procedure that is that a one time dependent on the patient just that you want them. You know, nothing is more stronger than you enamel. So you have to tell Mrs. Jones, Mrs. Jones, this is not a one time deal. And you know what’s beautiful? After three or two or three or four years? You said Mrs. Jones, you know, you won this game, I’m ready, let’s let’s put some work in and you don’t have to do anything, you have to sell this. Yep. Now that’s for a certain population. [Jaz]So just just to rewind, for this group of patients, essentially, you have done utilize the dial technique, right, essentially, these patients have dialed in, there was probably a degree of further joint seating that assisted you as well, in this case, and the dial effect taking place. And then when you actually achieve those posture contacts, here’s something that’s not seldom discussed with the dance technique. And there’s a there’s a guy called Professor riazi are are one of my mentors in the UK. Carlos he’s doing some amazing research behind dog like he is doing the module. He’s doing a T scan at the time of doll placement. And then he’s following up every month and doing a new T scan a new module, and he’s seeing exactly which teeth at what interval come together what percentage like it’s amazing the level of research is going into in there so I cannot wait to turn it I know you’ll appreciate this as well. But here’s a question for you is that as the teeth are coming into contact posteriorly Are you worried about the quality of the contacts? Are you worried that okay, there is an inclined contact here or- [Carlos]You want to tell me the truth? I’m gonna be honest. No. [Jaz]Okay. Yeah. And you know what, that’s what a lot of my colleagues told me as well because then I know what to say next. You’re gonna say as long as they still have smooth anterior guidance, Kanaan initiated guidance known anterior, but the posterior the way they come to get as long as there is a contact is good enough is it would you say that’s the philosophy that you follow? [Carlos]Yes. And then and then few concern is you know, with mythology we believe in Tripodizing and so forth. Tripodizing, you know, you know, when you look at centric relation and Tripodizing that is, in an ideal, so ideal worldwide, you you can have no non interference free occlusion and a talented clinician, you know, teeth, teeth are variable, they change in anything, but what I will do and I think you had a mark one of the gnarthologist or Chow, in here a while back, but what I’ll do is I’ll put a little bit of composite at the floor at the base of the fossa. So if there’s, if I need a little compact, I’ll just add a little bit of flowable composite and that’s actually to get a little bit of stability. What I look for, when I’m working in offenses when they go left and right and remember in you know, the So when you do when you check you for non working interference don’t both have the patient know what you do is you go out and you put pressure to come back, you go out pressure, because that’s why you’re activating the masseter medial pterygoid. When you go like this- [Jaz]When you tell the patient just grind it through, right, they wouldn’t recreate what they’re maybe doing in parafunctional at their worst, so yes, get them to do it for us. And also when they get stuck, when they feel locked in you, you guide them. Yeah- [Carlos]You got to get masseter involved. Because when you clench, and grind is the masseter medial pterygoid, those are the bull dogs, those are the ones that are destructive. Those are the ones we’re trying to naturalize. When we do the interior ones, we’re trying to neutralize those things, you know, because they’re the bad. So, this scenario, that’s one. Another scenario is when I’m done with the additive procedure, a lot of times your balance, their balance is insane. Their balance. Okay, go, I’ll come back one more time and check. I’ll use this to check my diagnosis of the joint. I’ll use this to face dentistry. And other words, somebody comes in, they want an interior and I have cases in shot, I’d love to show him but why they want anterior teeth, aesthetics and so forth. Well, what I’ll do is I’ll go to the canines in centric relation, I go in and figure out that overjet, overbite, because you never believe a door like this, there’s something that is unless you’re a true class three skeletal position, but inevitably, there’s something that is pushing them forward. And is what is it like? What pushed you forward? Three things, inflammation here, inferior lateral pterygoid or the mesial incline of the upper one against the distal pushing you forward. And you just slowly work your way back, you know, through your diagnosis. And that’s what happens when you use the canine, you’re testing the joint right? You loading the joint, you test it. Testing the aesthetics and phonetics is testing the aesthetic for him. You check in the muscle, the tongue so you’re doing a lot, you’re doing a lot of work, like just confront, you know, taking care of the interior teeth, and everything. So- [Jaz]At what point do you then start restoring the laterals and incisors and the lower incisors for for aesthetic reasons? [Carlos]That’s a good question. It depends. Usually I’ll have patients because I do like this as the occlusion the aesthetics part of dentistry. And so and I do a lot of composite, direct composite even though it’s harder and everything I enjoyed. But with that said, then I’m really rock and roll with the interiors, I’ll do you know, the laterals canine. Once I have the canines, it’s up to the patient. The other thing too, is you can do face dentistry. Once you get to stabilize, you can do the top to bottom with composite, I do a lot of composites in the front, even on a class 2 Div1 railroad, I’ll build up the composite first. And then on the top, I use Emax, whatever, however you want to do it. You know, that’s, that’s a personal thing. But I’ll- [Jaz]Pick your poison. [Carlos]Exactly. I’ll use this to stabilize and do face dentistry. Because not everybody can afford a full mouth rehab, no one care but this what was beautiful about this is it gives the patient also the sense of confidence. Because especially when they come in with symptoms here and there and you stabilize him, and it’s like yeah, this is what happened the right direction. And then you can start building your relationship and do what you know, whatever you need to do with the patient and so forth. So with the additive equilibration, it gives me a I have control in helps me my diagnosis a lot. It really does. It really does and I think it’s something that’s reversible, why? Because the patient out to me as a clench and grind and so forth here start adjusting it off and everything you do have to pay attention on your recalls for the non-working interferences and so forth, you do have to pay attention and so forth. But all you do is this- [Jaz]And what are you doing when you find a non-working side interferences? Are you just adding more of steepness into the canines? Or are you happy to just adjust the non-working side interferences and if so, any guidelines to help a novice dentists when they’re adjusting those? [Carlos]Here it is, if you are novice dentist and I remember choices, what you want to be careful is make sure you have canine guidance before you make those non-working interferences remove it because what happens is you could open up a Pandora Box by start adjusting in the back without having any any stability. So- [Jaz]You got to make sure that the patient has enough potential for because there’s some patients that they don’t even have because they have an anterior open bite or severe cross bite or whatever, they don’t have the potential to have it and therefore you shouldn’t start to adjust posteriorly when you haven’t planned that, okay, what’s going to happen anteriorly. [Carlos]Right, if you’re not coupling, anterior coupling, or canine guidance, do not make any, on a class to open bites and so forth. Here’s one thing I’m going to also share with my experiences. I gave you the anterior night guard, what I’ve noticed even if you don’t do anterior night guard if you balance thing, I know you had a T-scan tube and I love that, it’s fantastic. But and the posterior, if you can balance out those that first point of contact equally, you’d be surprised how well they do it. It’s not to say you don’t mean interior guidance, please, please, please. But you know, just to get them stabilized, you’re having issues and so forth and you can’t get it, you start with with flowable composite and with this and just having bite down, like you’re not adjusted, just balancing this back from Canon back, you doing that patient, a lot, a big service. And then after that, you can start planning on you know, doing new restorative part, crowns, which what have you, but I am now I’m not afraid to tackle class two give one posterior for stabilizing them. And then also to remember, remember what the mechanics of the lower job, the key here, as long as we keep the junior how a muscle behind the canine so that means I can go to the pre molar. But as long as you’re behind this, you have a class Leverage System three, and you can use it. So, you can use that as your guidance, you can use the upper first premolar, this lower canine remember, as long as you’re using the lower canines is behind the muscle, you understand? So you can use a premolar for guidance as long as you’re using the canines, use the canine you still behind the muscles behind the canine. T 22 and put in Saturday. Remember that this is JR How is this a turbo? That’s a total Gina Holly is the most interior muscle that is similar that the pulls down. Okay. [Jaz]So what you’re saying is that as long as you’re on lower canines, you can be on upper premolars against lower canines, and a class two div one for example, because you’re still encouraging a class three lever with the muscle. Fantastic. Okay. [Carlos]Yeah. Now think about this. Remember, you know this about orthodontics? I know I’ve jumped around all over. But you know, when you take extractions and that’s why I’m not big on extracting baby teeth for ortho. Because what you do in extremely narrow and and not only you’d narrow for air space, but mechanically you put the patient at disadvantage, you move and everything closer to the muscle tissue here. That’s almost like a class two class three system. So you know, back and they don’t do it that much now, but the last thing you want to do is don’t take teeth out and bring back. No, you want to always expand. Why class three people don’t have as much problem as class one, class two? Because they’re further away from the back there. Come on. So the mechanics, that’s what it is. And if you understand that, then you open I mean, everything is just like you’re not caught in this little thing you understand the whole thing is it always is the mechanics, the mechanics, that’s all it is. [Jaz]Carlos, you’ve given us a lot of think about. I loved it. No, it’s been amazing. I’ve enjoyed this journey. Now, just on a point, before we start talking about the other side of your dentistry, the very inventive side about instruments and stuff. So I’m gonna discuss what this is about that. And tell us about some of those cool instruments and whatnot. But before we get to those, I just want to check one more thing. Last question. On those class two division ones, increased overjet and you’ve got your leaf gauge in and they might become, the public will become a little bit more class two. In that case, yes, you can maybe use upper premolars, like you said, and get some sort of class three leverage that in a way, but how do you maintain or achieve anterior coupling in those class two increased overjet cases? [Carlos]First of all, you can because by definition, you don’t have an class two, div one, the spaces so far. So to get a copy, you have to do it indirectly with plastic that’s the first thing you have to deal with plastic, either surgery ortho, bring it forward, or you have to do the plastic. Now okay, that’s the idea. And for some reason you want to go you know, for you cannot physically get you know, they’re going to look ugly. So, you just go to the canine and a night you protect them with that segmental appliance six right now, one thing about class one div one, they have a narrow angle, it’s a very narrow, they cannot tolerate stuffing in night guard, they can’t tolerate that. So, they’re very notorious for popping and clicking too. And those are the ones that you have to be very careful with, you know, class two division ones, those you have to be very careful when you go in there and doing restorative. Measure twice, cut once. And that’s for another side that you really have to be careful with those. Because you can get in trouble. They have a lot of clicking and popping, they have a lot of muscle and it’s just because they’re narrow, they’re narrow, they’re coming back, they’re back to where the muscle sources like I was telling you earlier, so you have to be very, you know, be careful with those but you can help them, you can really help him out. [Jaz]For sure. And I send you an email that if you got a chance to read this but did you get to read about the ESIPC Jig that I sent you? [Carlos]Yeah. Yes, I liked that. I did. [Jaz]So I’m gonna shout out to Dr. Gurmit Hothi another dentist, I met a BDA Study Club once and he’s been such a great person to know over the years and we email each other, I’m gonna share, I’m gonna put this in the show notes, this PDF. So what Carlos has described so brilliantly with so many different facets was the leaf gauge technique and how you can get the anterior coupling, first point of contact. So there’s that kind of revision for this episode. But a different way to do it would be to use we call the Easy Peasy jig, which is a great name, there’s a whole you know, aesthetically, whatever is a full name, I’ll get it out for you, but essentially, is using some bis-acryl material anterior, and then that becomes kind of like what the leaf gauge is doing in a way, and then that really makes you a stop, so they can then rebuild the anterior teeth. Just another way to think about it. So I’m gonna add that in the show notes. But I want to jump to Carlos, tell us about how you became so inventive. Like, where do you find the time when you’re active, your father of three, you’re very geeky dentist, how’d you invented the CaSi instrument, which by the way, I have talked about before. I talk about how much I love the CaSi instrument, I literally before I wouldn’t hold it, I used it. For a broken incisor, I love how it can, instead of using my finger, my gloved finger, I’m now using the CaSi we’ve got that you know, the blue, reduced sticking sort of surface mystic resurface and the correct contour, whether I’m building the palatal, or if I’m doing composite veneers to shape the anterior with the three planes. Amazing. And you also got some brushes that you made as well. Tell us about your instruments and stuff. [Carlos]Well, I want to talk about that. No, yeah, basically, you know, I do my own wax ups and everything and so in my lab at home, I had an epiphany with the instrument if I could, you know, create this angle, have these angles with the instrument, and so forth, you know, make my life a whole lot easier. So, that’s how I started my journey with the CaSi instruments. And then of course, Cosmedent and was very, they’re very nice to take on the instrument, and they’re the ones that they’re selling it for me and so forth. And then, you know, being on the artistic side, I was, you know, Newton, Newton fall, you have Dr. Denny, a lot of people use brushes. And so being influenced by the brushes, you know, there’s a way we can come up with a brush that is a handle that it’s not disposable. And then also with disposable tips that would, you know, could help out and so I have an handle basically, it as sturdy as you can get, you know stainless steel, and then with different tips on both angles, they’re gonna see here, it’s like, I’ll show you. So you got on both sides. And I think but for those viewers that can’t see it, you know, just the brushes. And hopefully, I’m working with Cosmedent if they go ahead and pick it up, you’ll be on the market for everyone. So but that’s our, I mean, just I’m very intrigued, I just- [Jaz]It’s great that you do that and you find the time to do that. And it takes a lot of time and effort to do these things. And I’ve got my CaSi and you very kindly sent me some more. So I’m going to start using some videos because to help dentists to see how useful that is, as well as the brushes, I’m going to have a go of them and stuff. So I really appreciate that. And I will share with everyone how I’m getting on with that. But yeah, it’s great to have the design of it. And to usually the stumbling block I had with these brushes in the past that becomes very expensive habit to use his brushes, but the way they have the autoclavable handle whatnot, and how it reaches in the back. And how you can very easily create the right angle of the cusps, as you were saying, will reduce your appointment time and occlusal adjustment stuff. So it kind of makes sense. So I’m looking forward to using that and sharing that journey with the Protruserati so thank you so much Carlos for making that possible. [Carlos]Well, first of all, thank you for you know, for the plug and everything. I appreciate that. And I hope you know people like it. But you know, I’m always I can share, I’m passionate about occlusion I think you can see as we go. And so you know if anyone has any questions that I’ll show- [Jaz]I was just gonna say because you’re so easy to chat with on Instagram and stuff like. Tell us your Instagram handle. So if someone’s doing their first case and stuff and want to send some photos maybe like, I’m sure you’d be happy to help them. [Carlos]I would I would Yes. And then with you, Jaz, I’ll send you, I have videos now to have videos with as far as I do have videos with the CaSi instruments also have with the additive equilibration start to finish. I’ll give you- [Jaz]Send us everything. I’ll put it on the Protrusive Dental Community Facebook group. I’m gonna stick it on the show notes. Please join us. Are you on Facebook, Carlos? [Carlos]I’m on Facebook, none other but on Facebook. Yes, sir. [Jaz]I’m gonna invite you to the Protrusive Dental Community come and join our little community. It’s somewhere where I don’t invite people because the problem with these big groups that invite people is that you lose control of who’s in. This is very much a club that you have to do the your own work, you have to find the link, you have to click it and then you get accepted inside. So what that breeds is a community who self select themselves. You know what, I’m so geeky. I’m going to be part of this and you will be a great addition to this. So come in Join the Protrusive Dental Community. And then you can see it’s the kind of stuff that we talk about. And we’d love to hear about your experiences and your mentorship would be very much valued on there. [Carlos]You know, I want to share because I want to make left. I love dentistry so much. It’s a great profession, you know that. And if we can make it easier for those young lads that are coming up and everything and help out that, you know, that’s to me, that’s rewarding, so [Jaz]Tell us your Instagram handle and your website, Carlos. [Carlos]Just put the Cosmedent. [Jaz]But in terms of reaching out with you, how can we reach out with you? [Carlos]On Instagram? Yeah! [Jaz]I got it @carloscanchez_casi. But yeah, join us on the Facebook as well. And it’ll be it’d be great to have you there and learn from experiences. I think a lot of my listeners are yet we’re global but lot of the UK and in the UK and also in Scandinavia, we’re already very intertwined and very experienced in DAHL, we are the leaders of DAHL in the world, right? So what you had to say, will really really catch the interest and capture the sort of different ways to approach it. So again, thanks so much for coming on today and sharing all that. It’d be amazing if they weren’t kept up, I might to break this up into two part episode. But again, thanks so much, Carlos for coming on. I really appreciate everything you did for us. [Carlos]Be blessed. Jaz’s Outro:There we have it guys, thank you so much for listening all the way to the end. So a few different unique perspectives shared there, which may be familiar to you already in terms of how you might be doing your tooth wear techniques but it’s always great to hear how other dentists around the world are managing their patients. As I said to you in the intro, I’m introducing a monthly email for free with some videos and occlusion tips to help you be a practitioner of occlusion. So why don’t you head to www.occlusion.wtf to join that free newsletter andI look forward to email you. Thanks so much again, and I’ll catch you in the next episode.

Welcome to PART 2 of composite excellence with Dr. Javier Quirós where we cover the procedural details such as the interproximal management of composites and the prevention of stains. https://youtu.be/6ESub-OVqgQ Check out this full episode on YouTube Protrusive Dental Pearl: There is a benefit of having nice tight contacts on our temporary crowns – but how can we polish our temporary crowns without ending up with open contacts? The trick is to get a Sharpie pen or indelible pencil and color in a small circle (maybe about two to three millimeters) mesial and distal of where the contact area is. Now finish and polish your temporary crown using burs/discs BUT do not touch that penciled mark. Ta da! You have just maintained the contact area. I know, why didn’t anyone tell you before?! This episode is sponsored by Enlighten who are the sole distributors of Cosmedent Products who are the ones that sell  Casi 3C instrument. This is a non-stick instrument that provides a perfect curved shape that beautifully forms the palatal contours of your incisors.  Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 7:23 Mylar Pull Technique 9:57 The 5 Ps of Composite Success 23:49 Digital Facebow Transfer Check out the upcoming courses with Dr. Javier Quirós! Be sure to watch the first part of this episode Composite Excellence Part 1 and you’ll surely love this series! Click below for full episode transcript: Jaz's Introduction: Welcome back to PART TWO of COMPOSITE EXCELLENCE with Dr. Javier Queiroz. Now usually I start the podcast by saying, 'Hello Protruserati! I'm Jaz Gulati', now I had someone messaged me the other day on the podcast page say, 'Jaz, what does it mean if you're a Protruserati? I don't get it.' So on that note, welcome to any new listeners and new watchers. It's great to have you. Jaz’s Introduction:Protruserati is a dentist who listen to his podcast, but then finds themselves scrolling and then listening back to the old podcast that they haven’t listened to before. And suddenly you’ve binged a lot of the episodes and therefore now you are a loved Protruserati. It means that you’re passionate about dentistry or you want to be passionate about dentistry and you like tangible, productive tips and pearls to help you on Monday morning. So what I like to do with the podcast and what’s evolved to become is a fun way to share. I’m hoping that most of the episodes you listen to aren’t boring and there’s a bit of humor or lightheartedness. We discuss real world dentistry or tips and themes that are really relevant and you can apply on Monday morning. So in this part two you’re in for a treat. Like if you remember the three episodes we did with Dr. Devang Patel, let’s go back and listen if you haven’t already, they were on a ADHESIVE FULL MOUTH REHABS in three episodes. So how to do from right the beginning, from zero to 11 appointments over three episodes, how to do adhesive full mouth rehabilitations? So as we got more and more towards part three, it became MORE CLINICAL, it became MORE PROCEDURAL. And to this episode is no exception. So Dr. Javier Queiroz becomes a bit more procedural in this episode into a nitty gritty. So in this episode, Dr. Queiroz covers INTERPROXIMAL MANAGEMENT OF COMPOSITES. I left you on a bit of a cliffhanger last time if you remember, sort of about isolation. Is it always necessary to use rubberdam or even split dam or OptraGate like personally? For a lot of anterior bonding, I like to use the OptraGate. For my posterior especially lowers, I will use rubberdam. Lower incisors, I’ll definitely use rubberdam. So for me it’s it’s variable and depends on the patient very much. So let’s see what Dr. Queiroz has to say about that. PREVENTING STAINS. That’s a huge one, right? So you’ll hear from him what the protocols are to prevent stains and composites and the FIVE P’S OF COMPOSITE VENEERS. This episode, once again, is kindly sponsored by Enlightened Smiles, who also are the ones that sell the CASI instrument which I talked about in part one. So in the UK, they distribute, otherwise Cosmedent products are brilliant. So if you’re in the US, you know go to Cosmedent. If you’re in UK, If you want the Cosmedent products you go to Enlighten and Enlighten who’s sponsoring this podcast. So, do show their support for supporting me. Protrusive Dental Pearl: Every episode, as you remember, I give you a Protrusive Dental Pearl and for this episode, I’ve got a really good one. I need to pay homage to Dr. Pasquale Venuti, the Don, Pasquale Venuti and Dr. Marco Maiolino These are both amazing dentists from Italy. In fact, I have a whole series with Dr. Pasquale Venuti coming very soon in a couple of episodes time, it takes a long time to edit some of these episodes. So Pasquale is brilliant, I want to do it justice. So please hang tight and wait for this epic amount of educational goodness coming your way from the Pasquale. But one of the things I learned from their vertical course online so Verti Preps online. I’ve done Verti Preps courses with three different educators now. So Andre Cardoso, Portugal, Jason Smithson, UK, and the Italians Pasquale Venuti and Marco Maiolino, you know, I am biased towards vertical operations. I still do the horizontal, and I do lots of onlays. But for a lot of crowns, I will do vertical preparation. So one thing I learned from that course, and it’s like one of those tips, I think, ‘Wait, why didn’t anyone show me this before?’ And maybe you guys already know it, I don’t know. But I’d love to share this with you. So let’s say you are making a direct temporary crown using a bis-acryl material, Luxatemp, Integrity, Protemp, you name it, right? So you fill in your putty, and then you make the temporary crown, and then you take it out and then you trim it with a soflex or diamond to make sure it sits on perfectly. Now, a lot of the time when you are polishing or adjusting the interproximal mesial or distal, let’s say single crown mesial-distal contact areas, you’re trying to make sure that you can re-insert the crown right because if you can’t get the crown back in, then you have to do some adjustment interproximally. So, you do some adjustment. And now you find that yes, the crown, your temporary crown is sitting fully, and it might be happening in the bite, etc. But now there’s an open contact mesially and distally. Now, yeah, hopefully there’s enough occlusal stability that the adjacent teeth will not tilt into the area. But we really miss out on a big benefit of having nice height contacts on temporary crowns. Because temporary crowns, well, they’re temporary, okay, and they can come away. So you know, your patient goes away for a few weeks comes back, I can hear all the cerec dentists laughing at me now. But anyway, your patient comes back. And sometimes you know that temporary crown is lost, and it’s not nice, we want our patients to keep the temporary crowns in their mouth, that’s the whole point of giving them a temporary crown. So if you have an open contact, mesial, distal or medial and distal, then you lose some retention in a way, right? When it’s nicely snug against the adjacent teeth. It is much more secure. But when you have open contacts, it’s relying so much more on the cement, on the resistance and retention form of that crown. So, how can we, this is the real tip now. How can we POLISH OUR TEMPORARY CROWNS, but at the same time, ensure we DON’T OVER POLISH and end up with open contact? So, this is gonna blow your mind. Because I was like, what the hell? Why is it so simple? Why didn’t anyone teach me this before? So, maybe it’s just me. So, when you take out your bis-acryl temporary and you just about prise it out, sometimes maybe you get a flat plastic and you bring it out. Now the first thing I would do is I will get a either a Sharpie pen or an indelible pencil and color in a small circle, maybe about 2-3 millimeters, mesial and distal, okay of where my contact area is. Where it’s contacting the mesial and the distal tooth. Now that I’ve colored that in, I’m not going to touch that, ie, I’m going to do my soflexing, diamond bearing, acrylic bearing, or however you want to polish your temporary. I will do it but I will not touch that penciled mark. So, now you’ve got a nice trimmed, polished temporary, but you’ve got a contact area that’s preserved, mesially and distally, which is brilliant, because now you’ve got a nice, tight, snug fit. That’s not overly tight, but it’s nice and smooth as well. So this is my big tip passed on from these Italian guys. Such a simple one. I hope you use it. Like please use it like next time we do a temporary crown, do it. Because it makes so much sense. And you’ll see wow, why didn’t anyone teach me before? So like I said, maybe you already know this, but I didn’t. Let’s join Dr. Javier Queiroz and I’ll catch you in the outro. Main Episode: Because it’s something that we’ve discussed on our Protrusive Dental Community Facebook group many times, which is INTERPROXIMAL MANAGEMENT. I’m a mylar pull kind of guy. And I know I didn’t see Pascal Magne in Edinburgh recently. He is a big fan of PTFE and just taking the composite right up to the PTFE. And he’s some sort of wizard like that. What is your recommendation? What is your protocol for interproximal management to prevent the composites being stacked together and getting the nice smooth flossable interproximal surfaces? [Javier]Well yes, I love that pull through technique and the pull through technique. It was taught to me by Corky Wilhite at Chicago CE, and it’s such a great technique that I use it every day. So what we do, let me show you right here. [Jaz]Show it and then you described it for the listeners as well. [Javier]Yes, I’m showing a video here real quick for those YouTube fans. You place first the incisal edges with the microhybrid. Okay, like I showed you before. And then whenever you’re going to close a gap or a diastema. Then you put a mylar strip, then you do a little sausage of composite in between your fingers. Remember, you have to have in between your fingers, the anatomy that you want to bring, if you want to bring a contact, you have to do it in your fingers before you put it in the mouth. You cannot put it in the mouth and expect to become something you have to do it in your fingers with very clean gloves and then put it in the mouth, okay, and then you put it on the mylar strip. And as you can see there in the video, you pull in lingually and then that composite will go in between each tooth, and then you take off all the any excess with your IPC thing instrument. And then you put back your mylar strip, and then you can like cure it and you’re going to get a very strong and durable contact in anterior teeth. Okay, and that’s called the Mylar Pull Technique. And they use it every day. And it gives me great, great, great results. You know, whenever you you’re getting stains in between teeth, because in your composites is because you’re not getting your composite all the way to the contact. You’re just leaving your composites shy to the contact and then you will see that line or that stain in between your teeth. And whenever you do this technique, then the composite will go all the way to the contact and it’s going to give you a much stable, color stable composite veneer. But it also is going to give you a tight contact. So you will not get food in between your teeth. I mean, that’s the best way to do it. And and it’s called the Mylar Pull Technique [Jaz]We’ve talked about it before. And I’ll add a link again to some of the videos that we’ve shared before about this technique. And yeah, our big fans want to hear what you thought about that technique? And sounds like obviously, you’re a big fan as well, yes. Now, the floor is really ours in terms of where we’re going to take the rest of this episode. Are there any key points to get great results, I know you’ve got finishing and polishing there, which is such a huge part of everything we do. What are the jems that you want to share with the Protruserati now? [Javier]Okay, so the five P’s of composite success is five P’s. The first is Patient, make sure you pick the right patient for composites. If your patient is a smoker, if your patient tells you, ‘You know, Doc, I will never get my teeth clean. I just want my veneers and get out of here.’ Then you go for porcelain don’t go for composite, you know, but if you have a patient that has great, or good oral hygiene, then you can go with composite every single day. You know, your patients that you already have in your office, they come every six months, those are your perfect patients for composite veneers, then Preparation and isolation, make sure you use a rubber dam. It’s so important to isolate, you know, it’s maybe 90% of your success is because of your isolation, then the number three- [Jaz]I just want to stop your isolation if you don’t mind, Javier. Because those who are listening may not have seen the cases you’re sharing it sounds or looks like that you are preferentially going towards split dam technique, because obviously, when you’re doing veneers all that gingival margin, it’s very difficult to actually go a normal full rubberdam. So am I right saying that you’re doing split down technique? [Javier]I do split dam technique because I don’t like to do individually and then go clamp by clamp because I sometimes get bleeding. And like I told you I’m not such an agile dentist. So I do split dam technique. And I’m showing a video here on how I do it. And it only takes me two minutes to place it. And you know what I do in the posterior then I close it with a putty in the palate so that I will get total isolation. But I have a great area where I can work with and is amazing the amount of isolation that you can get with an open or split dam technique. But as I’m showing here, you can always close the back of your palate with putty. And that gives you total isolation Jaz, and oh my god, I keep fighting you know, I keep fighting with my associates. I’m walking in the hall and I see somebody doing bonding without a rubber dam. You know, I freak out Jaz. I’m such a control freak. [Jaz]We’re the same. I can’t do any of adhesive dentistry without Dam. [Javier]You know, and I used to bite the tongue and fight the cheek. And you know, now it takes me two minutes, two minutes to place the rubber dam because we develop that practice. And those two minutes saved me like half an hour in every procedure. And I used to do a lot of porcelain inlays and the you know, the ones that I cemented without the rubberdam on, you can always see that line on the inlay, you know, a year afterwards, you know, like you have adhesion, but that’s not good adhesion, those patients that I put a rubber dam and I bond with the rubberdam you cannot even tell where the line of the inlays is that you know. You get total bonding when you have total isolation. So I definitely recommend you guys if you have to take a CE course you know Jaz, you and I have talked about before which CE courses should we take? And you know it sounds very basic, but take a course on isolation. You know I have learned so much on those courses on isolation and my dentistry has gone from mediocre or medium to top dentistry because of rubberdam techniques. [Jaz]So 100% agree and I just want to comment on one thing I just saw on your video, which I don’t do but I’m totally gonna do now is that random tissue that you put underneath rubberdam? I mean why I don’t do that? I mean this sounds like an obvious thing to do but I’m gonna start doing that, so is it just like a normal-? [Javier]It’s normal. It’s a napkin. It’s a tissue paper, Jaz. [Jaz]You just cut the corner. Cut one corner when it’s folded and then it becomes a big circle. Yeah, [Javier]Yes. I used to, there it is, there is in the screen so for those youtubers, you can see it right there. You know, I my patients, whenever I took off the rubberdam, most of them have some kind of allergy to latex. So then they have this rash on their faces. And they’re uncomfortable while I’m doing this. And I’ve been doing this for maybe 10 years I kind of napkin and then make a hole in it and then I put it underneath the rubberdam. And then when I finished, they don’t have any problems on allergies and all that. So, whenever your patients tell, ‘You know, I’m very sensitive to latex.’ This is a great technique. [Jaz]Awesome. Thank you. [Javier]Yeah, yes. [Jaz]Please to the 5 P’s. Sorry for interjecting. [Javier]Yeah, the Polymerization you know Jaz, those $75 eBay curing lights will not do for you. We’re all tempted to buy those $75 curing lights by you need a first of all, you know those expensive curing lights they have all the wavelengths that you need for every single material. Either if it’s dual cure or light cure or any material that data light. So you know VALO is a great curing light, 3M , the new one is great curing light. Bluephase by Ivoclar is a great curing light you know, all those curing lights, I’m sorry to say they’re expensive, you need to have them. At least one in your office. Why? Because then you can layer and cure for five seconds, layer and cure for five seconds and then at the end, you like your for 40 seconds per surface at the very end with this high power curing lights. And then when you polish up this veneers, you’re going to notice the difference between well-cured composite veneers and and poorly cured composite veneers. So if you have one of those or if you still have your curing lights from dental school, it’s time to upgrade. [Jaz]I’m actually a big fan of testing. I actually, now and again, I will test my light cure because I’m VALO user and I went around testing so we have the main brands, the 3M one, the VALO, which is good but if you test a cheapy like you’re on this tester I have, the wavelength and the power it is way lower and you can notice it on these tests as well. So you’re great point. Well made. [Javier]Yeah, curing lights you know is not a big deal. I also try to get rid totally of the oxygen inhibitor layer at the end. So I put some glycerin around my veneers at the very end. Once I cure in, I put some glycerin and then I cure in again, you know, and then I find out that I get less staining in between teeth. And I get less, I get better polishing because I got rid from the beginning to the oxygen inhibitor layer. Jaz, I don’t know if you if you do that or if you like to do that? [Jaz]Yep, KY jelly good old Amazon bought KY jelly. Just make sure your nurse doesn’t call it KY jelly. But yes, we use the k gel as we call it. And yeah, cure over that and definitely all those reasons, the polishing ability, the full cure is worth it. [Javier]So the number five P of composite veneers is polishing. So you have two steps. The first step is finishing and you’re going to finish your veneers first. I use a brush at the end with my microfill composite. I place it with my IPC and then I use a brush, wipe the brush, because the brush will give me a very, very close surface to what I want to achieve and you can see it here on the screen and that brush makes the tooth smooth but then I go ahead and take my ET burs, they are great carbide burs, I have nine blades and 12 blades. I go with the nine blades first and then I started with the finishing procedure which is taking care of all the lines and make sure that you give some good anatomy to those veneers when I finished my veneers- [Jaz]What speed are using this at? So you got the carbide, at what speed? [Javier]At the beginning, very low speeds. Maybe 3000 RPM, something like that very low okay. And then as much as I go I didn’t go higher and at the end I go very high high reps. So if you guys are looking at the video you can see that I already have my line angles achieved with my microfill composite and with the brush. So I tried to be very close with my anatomy with the placing and layering. So that when I finish, I only do very minimal adjustments. So I start with my Et burs and sometimes if I want to have some kind of texture I use a fine grain diamond. Okay and I use the nine blades and the 12 blades and then the last step of finishing is my course this which in the in the Flexi discs by Cosmedent is the blue one, I think on the 3M discs is the brown one, and then you start to taking off all the lines, you start getting rid of all the little holes and the things that shouldn’t be there. And at that moment, if you see a little spot you know like a little hole or sometimes you see a piece of dust, then you go ahead and take a diamond, take it out, put some bonding resin. Do not light cure the bonding resin and put some more composite on top of it and then finish polishing it because you don’t want to have those mistakes showing up at the end. Okay, this is the last step of finishing. It’s called finishing because you’re making sure that you have the right anatomy and the right texture. Once you’re done with this blue disc which is the course disc or brown disc then you go ahead and keep going the other discs, this is like polishing wood. You know if you polish wood and they tell you you know you have to use all the grids to get the right amount of shyness on your wood and you skip a step then it will not look good at the end. You have to go through every single disc to make sure that at the end, you get a beautiful beautiful glass see looking veneer which is what we want so you will not get stained and that’s what patients want because they will look shiny. And that polishing ability of the microfill composite will keep your veneers from staining. So if your patients come to your office every six months or once a year, when you look at them, they are not dull, they’re still shiny and it’s because of this procedure of taking the blue disc, then the yellow disk then the pink disk then what we use at the very end, we use a aluminum oxide paste with a buff and you go through them first at very low reps and then a very then with water at very high reps but with water because you don’t want to overheat your composite. [Jaz]How do you stop the water from splattering everywhere? [Javier]You know, I place napkins on my patients eyes and I put some glasses and yes it’s messy. It’s messy. And I tell them- [Jaz]Okay, it’s not just me. [Javier]‘I’m giving you a second shower today but it’s worth it because then you get a beautiful like I tell you surface on your composite.’ And you know what, you can control the glazing on your composite. You cannot control the glazing on your veneers, sometimes your porcelain veneers, you get that grainy looking veneer that tells you immediately that is porcelain that is not enamel. And you can control that by polishing your composite veneeras to make it look like an enamel, which sometimes if your lab technician and they didn’t do a very good job, then the texture of that ceramic will look artificial will look grainy. And that’s something that I found out that that is very hard to control. Nowadays with the new points and cups that you have for polishing ciconia and Emacs, you can get better polished ceramic than before, but it’s still harder to do than when you do composite. [Jaz]You’re relying a lot on the lab again basically. [Javier]By far easier, easier to polish than porcelain, so that those are the five P’s of composite success. Like I told you, I always do the smile design first, then the wax up, then I transfer the wax up with the matrices to my patient’s mouth. And then I layer freehand anterior to the buccal part with microfill composites and then we polish and we can go with- I use that technique every single day, Jaz. So, we can do that technique for a class four or to close a diastema. Or we can do that technique with also a full mouth rehab of 2018. So it’s something that we use every single day. And now, nowadays with digital dentistry, we first digitally design it and then print it out. And then you make your matrices on printed models as well. So like I told you, you can do it both ways either in the mouth or- [Jaz]It’s very exciting. Now before I ask you where we can learn more from you and how you can reach out more to you, I just want just touch on one thing, which you piqued my interest that you said with the digital, you’re doing the digital facebow transfer. Now please tell me about that. Because the way I do a lot of my dentistry when I’m doing digital is I record my bite at the desired OVD in the arc of centric relation, and then I rely a lot on the photos and I tell my technician, okay, lengthen this tooth by one millimeter lengthen this tooth by 1.5 millimeter, and based on the facial photos, and the side photos, so they pretty much have a digital patient, but that quite often I will not do a facebow transfer, I will get the patient in temporaries and then I’m happy to adjust that temporaries and then many months later I will then convert to ceramic based on using the TMJ as the articulator but my experience of using an actual digital facebow transfer, please tell me more about that. [Javier]Oh sure. Whenever I have a case, I do digital DSD and the DSD is just, it’s just a great way to make sure that your patient, first of all, see what they need. And also it’s a great tool for your lab technician. As you can see here, I have this app, which is called Smile Design Pro which I use it every day, you know, and it gives me the plane of occlusion and any comparison with the bi pupillary line. So that I showed this to my lab technician and this gives me my anterior tilting position of my smile compared to my patients eyes, which is the aesthetic part where you need a facebow. The functional part that you need, why you need a facebow is because you need that arc of closure Jaz and I’ve heard it on your podcast a lot of times which is so true. Every time that you’re doing posterior teeth and you don’t use a facebow you’re running the risk of day being very high. That’s why little hinge articulators are so small, so that angle is very small, it’s smaller than your head and so that you never get a high occlusion. Whenever you have a semi adjustable articulator they are exactly the same size as a head so that you get with a facebow transfer that arc of closure so you will get a good bite. Okay, so I can do it either with my I use Denar articulators just like Dr. Patel. I think Dr. Patel uses Denar [Jaz]Yes, he does. [Javier]Yes, we love Denars here. And that- [Jaz]You’re mixing digital with analog. Right. So you’re taking analog Denar Facebow, and you’ll just adding it to the printed models, right? [Javier]Yes, exactly, exactly. With my digital smile design, Jaz, okay. But if you want to, you can also use a fox plane Jaz, you can put it on your patient with some putty, and you scan that, that fox plane, and then you take it, you send that to your lab technician, you know, a scan of the Fox plane. And so they will have that with a putty matrix, so that they can see that the big problem that we have now with digital dentistry is that most lab technicians don’t know. You tell them about the plane of occlusion and they don’t understand that. And that’s where we have to educate our lab technicians so that they can take in our digital scans, but make sure that they also follow our instructions with what quite a facebow would do. [Jaz]Amazing. Javier, you answered so many big question. We could talk for days about this, right? There’s so many nuances. Where can we learn more from you? Look, I know you do some education as well. You’re just very experienced. How can we learn? All the Protruserati really enjoyed your presentation. Where can we learn with you, my friend? [Javier]Well, you know, I told you I learned a lot at school but a lot on CE. Continuing Education is the basis of every single dentist and you know, I took all the courses from Cosmedent in Chicago. It’s cosmedent.com Jaz. My Instagram account is javierquirosdds. And you can see my courses that I teach at Cosmoedent. Now, I’m so proud of being one of their instructors. I would never dream to be with such a great team of people go to cosmedent.com and go to Courses, continuing education courses and you can see the courses that I teach there. We teach a course on full mouth rehab, we teach a course on posterior restorations. And you know the one that we that we’re going to teach next is called become a cosmetic dentist with composite resin veneers, Jaz. And thank you very much for this timing. You know if you have any more questions, I’ll be more then glad to [Jaz]Amazing. Well, I think it’s great that you credited your mentors early on. And you said like, you know, you learn so much. It’s amazing to go that full circle again and then be able to give back via Cosmedent, our lovely photo there is that bud Mopper. [Javier]This is buddy Mopper with me 30 years ago, this is 1992, 1983. [Jaz]You look so baby face. [Javier]And he was, I know, he was my instructor. He was my instructor at Baylor College of Dentistry when I was taking Prosth program. And that’s where I learned how to be- [Jaz]He would have had a huge influence on you. Every guest I speak to, when you go back in their story and why they do the type of dentistry that individual dentists does, you find along the way that they were at a clinic whether dentists love complete dentures, or they were taught by this person who’s known for this thing, and then the influence just carries on. It’s like having a great teacher. It’s like having a great math teacher and then pursuing maths for the rest of your life. [Javier]Exactly! That’s another thing that I can tell young dentists that are listening. Please find a mentor. You know, Doctor Mopper is one of my mentors. Dr. #### is from Mexico is another one. And you can find so many of them. Dr. Mopper taught me he sat down with me and hold my hand. Can you believe he did that? He hold my hand to teach me how to make a tooth. And it was such a lucky break for me that 30 years later, I’m teaching and I’m trying to give back a little bit of what he taught me. [Jaz]Amazing! Well, you make your own luck and you put yourself in those positions and everything you do. So, I’ll put the link in the show notes for Cosmedent. I don’t know if you know this podcast is actually very kindly sponsored by Enlightened Smiles and they’re the sole distributors of products in the UK as well which is a great little marriage here. So, little plug for them always appreciate their support. Jaz’s Outro:There we have it guys. Thank you so much for listening all the way to the end. Listen, if you’ve found value from this episode, please thank Dr. Javier Queiroz. Check out his content. Check out his courses. But also if generally you are quite liking the Protrusive Podcast it really helps you know the podcast if you on Spotify or an apple leave a review you know it really means a lot to me I read every single one. So thank you so much for listening all the way to the end. You are a true Protruserati. I’ll catch you the next episode is Carlos Sanchez. It might be that one or it might be asked you as we’ll see how it goes for timing because my brother in law is getting married soon so times. It gets a bit busy sometimes so we’re gonna do additive equilibration with Dr. Carlos Sanchez. Will do an #AskJaz and then the big one with Pasquale Venuti, so, so, much good stuff to look forward to thank you so much, and I’ll catch you soon.

A Restorative Dentist once told me, “Composites are like being married to a supermodel….sometimes you forget how good looking they can be!” – I had the pleasure of hosting Dr. Javier Quirós who shares his vast experience with composite veneers and restorative rehabilitation with composite resin. https://youtu.be/D_ahHFXosqA Check out this full episode on YouTube Ready to learn the management of Bruxism and TMD online? Click here to enrol to SplintCourse The Protrusive Dental Pearl: Check out this Casi 3C instrument distributed in the UK by Enlighten who are the sole distributors of Cosmedent Products. This is a non-stick instrument that provides a perfect curved shape that beautifully forms the palatal contours of your incisors. Watch this video below: https://youtu.be/QDoD182j-DU “It doesn’t matter what material you choose, porcelain or composite. What matters are your beliefs, your morals, and your principles of treatment planning” Dr. Javier Quirós Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 7:32 The start of Composite Veneers 11:23 Which Type of Composite is Best? 14:07 Composite Veneers of Lower Incisors 17:39 Ceramic Rehab vs Composite Rehab 23:35 Composite Prep in terms of Occlusion 33:31 Minimum Thickness for Composites 38:26 Injection Moulding 43:44 Treating Toothwear with Composite Stay tuned for Part Two! Check out the upcoming courses with Dr. Javier Quirós! If you enjoyed this episode, you’ll surely love this Composite vs Ceramic with Dr. Chris Orr  Click below for full episode transcript: Opening Snippet: Because lower veneers, you need a lot of space if you want to do porcelain. I only do porcelain veneers on lower incisors whenever I'm raising the vertical dimension of occlusion. Because then, I can have a lot of space, Jaz. But if I don't have that space which we never do have that space, then we can do a very thin layer of composite. Jaz’s Introduction:Hello Protruserati! I’m Jaz Gulati and welcome back to another episode of Protrusive Dental Podcast. Today we’re joined by Dr. Javier Queiroz, from Costa Rica, who is one of the best dentists I know when it comes to composite resin artistry. This guy has been doing it for so long to such a high caliber. I look at his work and I think, WOW! And I want to basically piece apart his thinking process. How he uses composite? What are the best ways to get the maximum results using composite resin? And what are the sort of limits? When should you consider ceramic? Which is a theme we’ve covered before in the podcast. But it’s always great to have new perspectives. And what I gathered after recording with Dr. Queiroz is that he’s very pro composite. But he’s also someone who’s placed, thousands of units of ceramic as well. So, he can give us the lowdown on them both. Some of the main themes we cover in this part one episode, because again, it’s one of those amazing episodes, that it’s full of so much value that I had to split it into two and you guys voted for it on the Protrusive Dental Community and on App protrusive dental Instagram page. I gave you a couple of options. I gave you composite additive equilibrations, and I gave you high end cosmetic rehabilitations. So, one was like more occlusion base, one was more actually composite as the material itself, and you guys selected COMPOSITE for this round. So, after the part two, then I’ll release the one about additive equilibration with the composite. So, that’d be a really good one as well. But for this one, the kind of themes we cover in today’s episode is HOW MUCH CAN YOU LENGTHEN TEETH SAFELY WITH COMPOSITE. Which is kind of an occlusion question as well. But it gives us some guidelines to follow in terms of what substrate, what kind of composite, and planning your occlusal design and smile aesthetics. I asked Dr. Queiroz his experience on how long composite veneers are lasting. He’s been doing it for about 20 years. So, let’s hear it from him with his patient base, how long they tend to last? What kind of issues? And at what point do they happen? And we also cover the theme of what kind of case is best suited to the young dentist. So, a few years qualified and you’re starting to do more anterior composite work, perhaps you’re doing just basic restorations, or you’re gonna have some composite veneers or edge bonding. What is the ideal case to start with? Because, you want to go with baby steps, right? I mean, I’m a big believer in that, you want to go for the most complex edge to edge bite composite veneers, you want to start off with an easier low expectations, low lip line kind of thing. So, we cover that kind of basis. [Protrusive Dental Pearl]The Protrusive Dental Pearl I have for you today is a video that I’m going to play for those watching. But for those listening, you’ll easily catch on trying to say with this pearl. Which is the use of what we called the CASI 3C Instrument . There’s a couple of varieties of this, but I’ve shared this before on this podcast. It’s an instrument distributed in the UK by Enlighten who are the sole distributors of Cosmedent products and if you’re around the world and find your Cosmedent dealer, because they have this particular instrument. Now, what I love about this instrument, I’m playing a video for those watching. But those listening I’m actually building up a lateral incisor freehand. Okay, I’m not doing a wax up. I’m doing like kind of like a mini rehab here. I’ve just done a canine riser. And now I’m building up the upper lateral incisor. And instead of using my finger like I used to use my gloved finger then I used to use like a mylar strip phase. And now I use this CASI instrument because it’s got a perfect spayed-shape with a curve in it that beautifully forms the lingual or palatal contours of your incisors. So, because there’s a nonstick material, I’ve placed it up against the lateral. And I’m literally using it as my stent, my palatal stent for my composite holding in place. I’m using another one of these same instruments, but the other side of it, which is a very thin, again, beautifully curved instrument. And it’s actually designed for you to also use it with composite veneers. So, this instrument, I like it so much because it’s got that sort of three planes on it that really allows you to adapt the composite in a way that it creates those correct angles and emergence profiles that you need. So, I’m a huge fan of this instrument. So, once again, that’s the CASI instruments. These are designed by one of my buddies, Dr. Carlos Sanchez. Now interestingly, it’s Dr. Carlos Sanchez, who’s episode and we’re looking forward to next talking about additive equilibration. So, it’s nice how that one we’ve done but he designed this instrument, and I’ve been using it for a few years now since I intended the mini smile makeover course, with Dipesh Parmar because that’s where I learned how to use it and I’m just absolutely loved it. I want the world to know how much I like it. So, that’s my big tip. If you’re looking for a composite instrument, this is my favorite instrument. So, if you look in my box of instruments, I’ve got about three or four of these specific ones. Because another tip that Payman Langroudi gave me is that instead of buying eight different instruments, buy like multiple of the one instrument that you absolutely love using. So, I keep my composite protocols very simple. So, this is the main instrument I use, and it comes in sort of smaller, thinner one as well, which is great for like lower incisor and stuff. So, check out the CASI instrument. I’ll put the links in the show notes protrusive.co.uk so you can get those easily. Main Episode:And now let’s get to the main episode, and I’ll catch you in the outro. [Jaz]Dr. Javier Queiroz all the way from Costa Rica. Welcome to the Protrusive Dental Podcast. How are you my friend? [Javier]Very good! Thank you, Jaz, I’m very honored to be with you with all your listeners. [Jaz]I mean, I told you this last time we briefly met we had to reschedule this recording because there was a storm and when I say storm, most countries, you call that a storm? It was, for us it was a big deal. But for the rest of the world, they were laughing at us. But we rescheduled and speaking to you briefly then and it’s just an honor to have people, the caliber of dentists like you listen to the podcast, it just drives me like wow, I can’t believe that. So, thank you so much for your listenership and joining now the community to help and support on a pretty big topic, composite versus ceramic, which I’m really excited to delve deeper in today. But for those people who haven’t seen your wonderful work before, don’t know much about you, please introduce yourself, Dr. Javier Quiros. [Javier]Well, I’m Javier. I’m from Costa Rica and I am a restorative dentist. I also prosthodontist and I work here in Costa Rica. I teach and I’m a wet finger dentist, I see maybe from five to ten patients per day. And I do a lot of full mouth rehabs and now that I’ve Aesthetic Dentistry, and today what I would like to share with you guys is my my experience of over 20 years of teaching and private practice about which material to choose whenever it comes to cosmetic dentistry and full mouth rehabilitation. So, thank you Jaz for your kind invitation. [Jaz]Guys. We’re in for an absolute treat. I know it. I mean, just behind so those of you listening, don’t worry. I mean, have you listened to the podcast while he’s on the treadmill? So he appreciates that. You’re just listening. If you’re driving to chopping onions, he will make it very descriptive for you. But for those of you who are watching it, oh my goodness, you get to see the beautiful work that Javier does. But Javier has promised that he’s going to make it really descriptive. So, and really tangible. So, even if you’re not watching, it’s okay, you’re gonna get the real deal. So, let’s start with a big question straight off the bat. Let’s start with bigger picture before we niche down. Why is it that in the last for me, I think I really started to notice composites take a huge hit about 2013 when I was qualifying, and I started to see more and more from that point, a composite veneers going quite big? What drove those trends? And what about you as a wet fingered practicing clinician for over 20 years? At what point did you start saying, “Okay, wow, this composite stuff, it works well for veneers!” When did that shift happen for you as well? [Javier]You know Jaz, I started like everybody else, I thought my lab technician could solve my problems. And so, I just prep teeth and send that impression to my lab technician and hope that he could solve all the aesthetic problems that my patients have were having and build those smiles like I would imagine them too. But you know what, I was very disappointed when I saw that my lab technicians could not make a smile the way that I wanted to. So, I started looking at a composite veneers. And then I had an epiphany, it was that if I didn’t learn how to make teeth myself, Jaz, not my lab technician but myself, then I will never be able to do a great smile on my patients. And so, I started first doing porcelain, but then my lab technicians would do something else that I didn’t wanted it to. So, I first do them in composite then prep on top of composite and then my lab technician only had to do a very thin porcelain veneer and I would bond that in top of my composite but then I was doing the work twice. [Javier]Then I find out the wonderful material that is microfill composite, which is a very thin layer that I put on my veneers at the end, microfill composite. And that looks just like enamel, it looks just like feldspathic porcelain. And so, that was my trip. It’s been 20 years so I started with full porcelain. Then I moved to feldspathic then composite and porcelain and now I do microhybrid composite and microfill composite on top. And you know what, Jaz? Among independent dentist, I don’t rely on my lab technicians for them to build the smiles. I’m the sole responsible of how my patients look at the end of our appointment. And I’m so happy and I’m so free because of that. I have all kinds of experiences with my lab technicians. I was doing maybe one or two cases, of porcelain veneers per week. And suddenly my lab technician just doubles his fee. Or suddenly my lab technician says that he didn’t want to do any more feldspathic because he bought a CAD CAM. And now I had to prep three-quarter crowns because his CAD CAM would not read my preparations because they were too conservative. So- [Jaz]Something sounds like it was a born out of frustration, initially. [Javier]Yes. [Jaz]And then, it evolved into an artistic form for you. And then, it gave you full control. Now, you mentioned a few important things in there. Now a lot of my listeners will know about the difference between microhybrid composites and microfill. But for those who don’t, please, can you just explain the chemistry a little bit behind them. Why microfills have such beautiful possibility, like, from the one that I’m aware of in the market in the UK, is by also by Cosmedent is renamel which is just a beautiful composite. Dipesh Parmar teaches it on his two day course in the UK. And I’ve been there twice now, what a beautiful composite that shine, it has. I’m yet to find another composite to give that but that’s all behind the chemistry of it. So, if you just describe the differences in those two composites, just briefly. [Javier]Yes! So here in the screen for those in YouTube, I have microhybrid composite, which is a stronger material because he has bigger particles. So, it blocks unwanted color. It’s got great flow, it’s got the best tensile strength and is the best material for incisal edges and is very strong for posterior teeth. So, this is a slide that, if you guys are not looking at this, you can see in an SEM slide or a photograph, you can see big particles of filling material on your composite. And those big particles makes the microhybrid composite very strong, is very strong. This is compared to maybe what maybe emax or maybe something like that, very strong, but then it’s microfill composite. Microfill composite is a very small filler content material and it polishes through an enamel like it’s very translucent. And it’s got long term wear resistance because the particle is so small that whenever you get one of those fillers to pop out, the eye will not see it. So, they come back to your patients, will come back with their veneers still polished then you don’t have to polish them every time that you see them is very color stable. The only disadvantage is that it has the lowest strength of both of them. Microhybrid is stronger. So, what you have to do is first good microhybrid and then microfill composite on top of it and then you will have great results, Jaz, like the ones that you’ve seen. [Jaz]Although the only one that we, just to be complete for the geeks out there, the only one we haven’t mentioned is a nanofilled which is the best of both worlds, right? We can assume that that’s the best of both worlds and because I already want to get into the composite versus ceramic debate with you. It’s just good to know guys that these are three main groups composites and why have you described in microhybrid almost like the core ceramic if you like equivalent and the microfill like a layering ceramic in an equivalent way? Do we adopt that thinking? [Javier]To follow up on your question that nano is like a blend of both of them, Jaz, and if you want to have just one material then you can purchase nanofill but if you want the strongest, you first put microhybrid. Microhybrid is even stronger than Nano. If you want the one that polishes the best then you use microfill. Microfill polishes better than Nano. So, if you want the best results, you have to use both materials. [Jaz]I agree with you fully. But what about for lower incisors? Let’s say you’re doing a tooth wear case, and you’re doing lower incisors. Let’s say you’re doing veneering the facial and coming on to the incisal edge to build some height. Now the incisal edge and the facial of the lower incisor is the functional surface. Would you like me shy away from using microfill there? How do you manage that scenario? [Javier]Well, you know what I’ve been doing that for maybe 20 years now, composite on lower veneers. Why? Because lower veneers you need a lot of space if you want to do porcelain. I only do porcelain veneers on lower incisors whenever I’m raising the vertical dimension of occlusion. Because then I can have a lot of space, Jaz. But if I don’t have that space, which we never do have that space, then we can do a very thin layer of composite. And most of the times I still do all my microhybrid on the incisal edges. And then a layer of microfill in the front and that will not get any breakage, Jaz. And as was mentioned, microfill composite wears less fast than nano or microhybrid because of the filler is so small that works very slowly. [Javier]I don’t know if you remember Heliomolar, which was using for posteriors by Ivoclar? It was a great material for posteriors and it was a microfill composite. And the wear was less on Heliomolar than on their microhybrids because of the filler content. The same thing happens with lower incisors. And I haven’t done a porcelain veneer on lower incisors in so long. I do a lot on uppers but on lowers I stay away from porcelain. Because composite, I can make it even thinner than porcelain and it will last for years. They will be wearing away. I have seen patients that come back 10 even 20 years later with my composite veneers that they had been worn down after that. But they don’t get a disastrous come up when a portion of veneers breaks and then you have to replace the whole thing. So, they’re very long lasting and I would not recommend my colleagues to do porcelain veneers. Think porcelain veneers on lower incisors. Believe me! I’ve been through that, Jaz. [Jaz]Will you raise an interesting point about when we have a lack of space and therefore you favor composite in those scenarios? I had this notion that even for composite you need like a minimum thickness for strong and compressive but you still need a minimum thickness. But you seem to suggest that okay, perhaps we can go thinner than ceramic. So, is there a minimum thickness on the incisal edge? [Javier]Yes, you need a millimeter. You need definitely one millimeter, okay, and on incisal edge. If you get a millimeter then your veneers will last to 10 years, Jaz, for a millimeter. Of course if you have a grinder or a bruxer then you need a nightguard for those patients definitely, okay? But you will never have a composite veneer break on you. On the lower incisor, you will have it on full static porcelain. But you will never have it in composite. They will wear away years after. And then they come back and you just sandblast and add to them. But you don’t have to replace the whole thing. Which is what I love composites on lower incisors. [Jaz]Well, we touched on it already. Now let’s go to the big question of this episode, which is ceramic versus composite. Now, if you don’t mind, I just want to share a little bit of where I’m coming from. And I’d love for you to then take it away here, is that, when it comes to the debate when you’re decided that, ‘Okay, you want to go for an aesthetic enhancement, and you’re coming up to the decision between, should we go composite or should we go ceramic?’ For me, the biggest player is age. Age have a huge consideration for me and the younger the patient, the more likely I’m gonna go for composite. Pretty much all of my ceramic veneer patients have been always above 50. It’s just been my past. I want to know what you feel about that. However, some dentists suggested and the groups that I’m part of that when I posted a case they said, ‘Oh there, there isn’t much enamel. I don’t want to go ceramic. I’ll just put composite.’ And I in my head, I’m thinking well, they both are a decent dentistry. They both need good substrate; they both need good enamels. So, I kind of disagree with that. But I’d love to hear your thoughts on that. So, what is the decision making tree? What are the things that you look at when you’re deciding between a composite rehab and a ceramic rehab? [Javier]Well, the first thing is that older patients have a lot more wear on their teeth, Jaz. So, I can do composite veneers on older patients every time that I address their occlusion. If I do not address their occlusion, then I will have problems, Jaz, don’t you agree? You have to address their occlusion. Okay, so what is that we have to have functional occlusion. So, every time that I see one of those older patients with wear on their teeth, I do a wax up, Jaz. And nowadays is so much easier because you can do it in exocad, you don’t even need to wax it up yourself, you can exocad it, you know? And so, what I do on those wax ups is that I give my patients anterior guidance, and canine this occlusion Jaz. And with that, I am guaranteeing myself that those patients are going to keep their teeth and their veneers in well condition for a very long time. Believe me, if you do anterior guidance, disocclusion and canine rise, you will have functional occlusion and your veneers will last a very long time, Jaz. It’s been a long road. But believe me, if you use the right material, which is microhybrid and microfill, and you use the right occlusion, which is anterior guidance. And canine disocclusion which is brought from the wax up to the patient’s mouth with a matrix AP, a polyvinyl siloxane matrix, or a clear matrix. Then you will get the best of both worlds, you will get the advantage of an indirect restoration with the advantages of a direct one. And I get great success with that every time that I address occlusion. Don’t get me wrong. I still do a lot of porcelain, Jaz, I still do a lot of it. But I see composite as a material that has the same quality as porcelain. I don’t see it as a second-tier material, I see it as a first grade material that I can offer my patients every single day. And if you learn how to make teeth, you will definitely be able to do veneers every single day in your practice. Instead of doing once per month a case of veneers or once a week a case of veneers. I have some colleagues that say you know what, I can only do one case of veneers per week, because of my lab technician capacity to do them. What if I tell you that I do one case every single day? Because I do them myself or my colleagues here in my office do them themselves. And that is freedom. What every dentist that learns how to make teeth has the freedom to do whatever they want every single day. And not saying to the patient, ‘You know, I’m gonna call my lab to patient and see if he can have the case in two weeks.’ Two weeks with temporaries and then the temporaries fall and then the sensitivity and all those problems. You don’t have those problems with composite veneers and you will get beautiful aesthetics and very long lasting cases. I have done hundreds of cases in porcelain, like I told you I love the felts feldspathic porcelain. But then with cat cams, you don’t get that anymore, you get only very thick veneers. And when you get veneers- [Jaz]It’s a dying art. [Javier]It is a dying art. And since feldspathic is dying, composite is racing, you said it yourself at the beginning of the of the podcast. Composite is thriving because we dentists feel the need to have control to do conservative dentistry. I mean, when my lab technician told me, ‘You know what, I just bought a $200,000 CAD CAM machine and now you’re gonna have to prep on your veneers, three quarter crowns.’ I said, ‘No! I’m not gonna compromise my values. I’m not gonna do on my patients what I don’t want to be done in my mouth.’ I just go ahead and very likely prep, maybe point three or even sometimes less, Jaz. And I add my incisal edges with microhybrid composite. And then in the front with microfill composite, and they turn out beautiful. They last for a long time. Of course, I have to address occlusion, like I tell you anterior guidance, canine disocclusion, posterior support, and you have a winner. And if it’s a bruxer, and if it’s young is even easier, because you just raised the vertical dimension of occlusion, and they have tons of space. Which we can talk about that as well later on. [Jaz]For sure! I mean the immediate thing that I’m thinking already is okay, so you’re obviously a big fan of composite but you play so many porcelain as well. [Javier]Yes [Jaz]When is it nowadays that you will then consider ceramic ahead of that and then also later do want to touch on, you mentioned about the prepping. Most of the composite veneers that I see on social media are claimed to be no prep. So, they will say on the Instagram description, ‘ZERO injection! ZERO preparation!’ Very proud of it, that kind of stuff. [Javier]Yes [Jaz]But obviously putting the occlusion aside, I’d love to hear from you about, where does that no .3 millimeter come in? Is that for space reasons, or is that for other reasons? If you just go into that as well, as well as dressing, well at what point I actually go for ceramic then? [Javier]Yes, well I still go with ceramic whenever I have very destroyed teeth, Jaz. Whenever I have, class three in between each tooth and class fours and I have a lot of different colors in different teeth and then I have to mask everything and it’s just I cannot fix a smile in the morning, I go with porcelain. But if I- [Jaz]In that case, is it the crowns or the veneers? [Javier]I do both! I do crowns and I do veneers. And the other thing is that also if my patient can afford it, because if you want to do conservative dentistry, you have to have a very expensive that lab technician, that can do a .4 or .5-millimeter veneer. And I don’t know in the UK, but here in Costa Rica, the lab technicians that can do that charge as much as maybe half of my veneer fee. And so, if my patient can afford it, then I go ahead and do porcelain and if I think that is worth it, like you said, maybe patients that has very destroyed teeth, or older patients then I go with porcelain and I still do a lot of porcelain. [Javier]But I was blessed to learn how to make teeth and I’m not a very dexterous dentist. I just learned how to do it. I took a plane, I went to Chicago and took all of their courses that they see in Cosmo didn’t. And then I went to see Dr. Newton files in Brazil. And then I went to see Dr. Oz, California, California and then I learn how to make teeth and they practice and practice and practice and practice. And now I’m a free dentist, whenever I feel to call my lab technician to say, I have here a porcelain veneer case for you, I can do that. But most of the time nowadays after 20 years of practice, I tell you, I do most of them in composite. And I’m so happy and so free because of that I keep doing them and I offer them to my patients. I also have you know, I’m already 52 years old. So, I’ve been teaching this technique a lot. So, I have a lot of dentists with me that also do it. And they also have seen the value of learning how to make teeth. That also translate in posterior dentistry. I used to do a lot of inlays and onlays on Emacs. And, you know, sometimes it’s frustrating trying to make them fit, you know, the contact points and the occlusion and everything. And then I found out that I could do that directing direct technique also in posterior teeth. And so, now I make full mouth rehabs with tabletops of composite and the posteriors and tear, composite veneers racing vertical dimension in centric relation occlusion, and I gave them anterior guidance and Kennedy’s occlusion every single day. You know, I was like listening to Dr. Patel, you’re invited dentist last month about full mouth rehabilitation and he’s right, you know. If you look closely at your patients, 80% of them need a full mouth, Jaz. Because they all have wear, they all have interferences in the in the back. So, they have wear in the front. And so, if you raise them their vertcal occlusion with just a little bit of composite, and then you give them anterior guidance and cane and rice. They’ll love you for doing that because their problems are gone. Their teeth are not breaking anymore. Their muscles relax in centric occlusion. Their joints are healthier, you know, is such a beautiful time to be a dentist. Jaz, I tell you, you know, [Jaz]That’s my favorite thing. I’m always vouching for that. Now is a great time that ‘Oh! there’s so much doom and gloom’ but there’s never been a better time to be a dentist. I’m so glad you said that. [Javier]You know I have a scanner now and I look like a kid scanning all my patients. You know, I used to say, ‘No, you know you will never replace polyvinyl siloxane.’ And now I do replace it every day you know with my scanner, you know, so it’s such a great time to be dentist. It’s just a great materials that we have, the adhesive dentistry that you have to believe in. Just forget about metal. Forget about porcelain fused to metal. You know, my you know what my lab technician used to tell me? ‘Javier you have to grind, prep your teeth until you see pink so that I have a lot of space for my porcelain fused to metal.’ You know, and I used to do that, Jaz, I tell you. I’m so regretful because I would never do that, on my mother or my sister or myself. I would never do that. And I used to do it! And now, it’s very rare when I get into denting unless my patient already has crowns, already has big class for restorations. I say yummy. Now, all the time. Either if I’m working with porcelain, or even if I’m working in composite, I stay on enamel because enamel is The High Road as commonly assess. You’re working on, you’re working on a high tear place. You’re working dentin, and then it goes down. You do root canals and it’s even lower biomimetic dentistry. So, if you stay in enamel on vital teeth, you have a winner. And that’s when your cases will last 10-20 years. You know what, Jaz. I’m gonna tell you a secret here. I graduated 30 years ago as a dentist when I was 22 here in Costa Rica. And then I went to the States to do my postgraduate studies and I stayed there for five years studying and working. And so, I can see now my patients that I did some work more than 20 years ago. All those patients that I racked their teeth with crowns, they come back for implants now. All those patients that I was conservative, and I did veneers on them, they come back for more veneers. So- [Jaz]That’s a very humble of you. And that’s very good to hear. There’s no better teacher than seeing you on recalls. [Javier]You know, time is your judge. And you know I have so much enamel on my back, Jaz, that I’m regretful of doing of prepping all those teeth. I used to brag how my preps were perfect. And I used to brag how many full mouths 28 crowns I can do in a year. And now I regret all that because I know that technology was available. But I didn’t understand it until maybe, what 10 or 15 years ago, Jaz. [Jaz]Well, I think I think you’re being a bit harsh on yourself. As you know, Javier, I think, obviously advancements dentistry. You did what was right at the time, you’re practicing through the porcelain deficiency years. The whole everything was veneers, you prepped those years, and now you’ve totally embraced minimally invasive dentistry. And you’re, you know, you’re a champion of that. And you’re seeing that. So, you know, don’t worry about that everyone’s got skeletons in their closets. But it’s a very nice admission of you. So, we appreciate that. [Javier]I’m trying to be as open as I can be with you guys. Because I don’t want you guys to go through the same thing as I had been through the last 30 years. You know, which I regret doing some things. And then I find out that the golden rule is true. If you do on your patients what you would do on your mouth, then they will come back, they feel that. They’re not dumb, they know that you’re doing the best for them. And the best for them is conservative dentistry. So, I would strongly suggest either it doesn’t matter what material you guys choose, porcelain or composite. What matters is what are your belief course, your morals. And why it matters is what are your principles of treatment planning. And if your treatment plan for conservative dentistry, then it doesn’t matter if you do use acrylic, because it will work. So, there are times where you have to prep and I still prep, but there are times when you can be conservative. And so, if you see that you can be conservative, then you go ahead and be conservative, and do that every day and you’ll be a happier dentist. [Jaz]Totally agree and in my own experiences, I’m not doing so many crowns. I’m only doing crowns and I’m replacing old crowns. But even when I have to do a crown nowadays posteriorly if I’m in with the whole, then if you do much vertical preparations. But the minimal amount of tooth structure can move now to do crowns with featheredge Zirconia is absolutely amazing. But anyway, we digress, we’ve gotten a bit sick. [Javier]That’s amazing. [Jaz]I’m gonna go back into little details now because we touched on it and I know that Protruserati are hungry for this. Because you mentioned about doing a full mouth composite rehabilitation whereby you’ve got the beautiful anterior veneers with the microblade with the microfill on top and then posteriorly, you’ve got your composite tabletops. Now it other, do the rules change a bit here now? Are you aiming for more thickness of posterior composite here than on the anterior? Or is it have you found success with one millimeter still because you’re remaining in enamel? I’d love to know that. [Javier]Well, for your YouTube fans, Jaz, I would like to show you this prep,. I was so proud of doing this kind of preps Not anymore. Now I show this like showing a wreck, you know. Now I love to be conservative and I love composite resins because I can be as conservative as I can, you know. And so, let me show you for your YouTube fans, a little bit of what we can do. I’m showing here, Jaz, a patient that came into my office that had a gummy smile, you know, she told me, ‘You know, Doctor, I have a gummy smile.’ And when I look at her mouth inside, inside of her mouth, I could see a lot of wear. These are a lot of patients that they’re in their 30s. And they have a very vibrant life. And because of stress and because of grinding, they have worn down their teeth. And as you can see here in the pictures, we always ask ourselves, how much can we lengthen teeth? Should we lengthen it to the gingival or she will lengthen it to the incisal? It depends on their rest position? If the rest position they show less than three millimeters then we can lengthen them incisally. [Jaz]Javier, let’s make it really tangible because I’m loving this so far. But for those watching young dentists, some dentists are learning photography and they think they don’t know how to get a good rest photo. So, what do you say to your patient to get a good lip at rest? [Javier]That’s a great question, Jaz. You know, I’m having such a great time with you. You’re asking the right questions. You know, you just tell your patients say, “AH” they will show this picture right there that are you see, she say, “AH”. [Jaz]Amazing. That’s a great one. Another way to do it is “Emma, Emma”. And another one is just drop your jaw. So, if you just drop your lower jaw and they just open a little bit, that’s another way and they might produce slight differences, but you get near enough to ballpark. Thank you. [Javier]Exactly! And that’s just a great tool because then you’ll know that you can maybe lengthen this patient, maybe one millimeter incisally. But then when she smiles, BOOM! Look at how much gummy tissue she has, Jaz. When she has so much gum showing then you do your digital smile design. And you see that for you to have good ratio width to length ratio, you’re gonna have to lengthen those teeth. Both gingivally and incisally. So, I still use a Facebow transfer. Now with my scanner, I use a transfer that is digital, but I still use my articulators. I still do, you know, a wax up and aesthetic wax up, I still do my Lucia jig, you know, to take centric relation. And then I can take a centric relation record in the posteriors, I do an aesthetic wax up first with my mounted models. How do I do that? I literally smile design my patients. And I measure the incisal edge to the cervical and I add so that I have a good length to width ratio, which is usually 80, 75% on women. And then I do a wax up. With that wax up, I first do an aesthetic one, I do a mock up. And with that mock up, I know that I have a winner. As you guys see YouTube can see here, you can see on the left the patient before on the right the patient with the with the mock up in place. And that is going to tell us how much we’re going to lengthen the teeth. Once we have that, then we can transfer with the matrix with composite veneers on the anterior teeth. So, I usually do first the gingival surgery, okay. Wait three months to heal, I take bone out whenever I don’t have those three millimeters for your biological width. And then once you do your gingival surgery, then if you do composite veneers then you transfer it with your polyvinyl siloxane matrix [Jaz]Is this just a palatal? Is this the palatal and then your- [Javier]This is just a palatal one. [Jaz]And do tell us about your experiences or views on injection molding which also seems to be going quite a huge intake as well. [Javier]It is very very popular now. And this is another matrix. If you’re looking at it, you can do this, use this matrix for injection technique. Or you can use this one for your direct indirect technique which you only use it for your incisal edges and then you put on the front some microfill composite. So, let me show you both techniques, Jaz. I have a here for anterior teeth. You know you start with the upper anterior whenever you’re doing a full mouth, you add incisal edges and then you put microfill composite on the front and then you polish. And then you have you have your upper six veneers, you know on your wax up, you already wax up the anterior disocclusion and the canine rise. [Jaz]And again, if you don’t mind me stopping in your tracks. As you are what you’re describing it. So, just to make it really tangible for those listening as well, when have you just put the palatal putty stent so he knows exactly where he’s lengthening the teeth to. And I just want to know Javier, in your protocol, are you first putting microhybrid as your first palatal layer for strength? Or are you happy to put your microfill there for an upper incisor? [Javier]No, you always need microhybrid on your incisal edges because it’s the strongest material that you have. It’s even stronger than your nano or spherical or microfill composite. So, I would strongly recommend on incisal edges, microhybrid and then you can layer in front for your buccal aesthetics, you can layer it with your microfill composite. [Jaz]How many mil we’re talking with the microfill 0.3 and 0.5. [Javier]If you’re not changing color too much, you can do point three. If you’re changing color with point five millimeters you can go from A3 to B1. It’s amazing how much you can change the color of a tooth with such a small amount of composite. And if you have a dark tooth, you know that that has a root canal, then they you can use pink opaquer, which is an opaquer that covers grayness. So, if you have a gray or dark tooth, you use pink opaquer first and then your microfill composite. And so, every time that I have a dark tooth, I just prep a little bit more than that tooth, so that I can put an opaque composite like this pink opaquer. And then I go with my microfill. So, continuing with the full mouth, you go ahead and do the lower teeth, you take again, the matrix, you first place in the incisal edges, your microhybrid composite, and then on your buckle, your microfill composite, and then you check your occlusion to have anterior guidance and canine disocclusion. And then on posteriors, you can do the inject technique or you can do also direct indirect technique. What I usually do is that it on posteriors, I use a clear matrix, which I heat up microhybrid composite with a composite heater, and then I put it on my matrix and then I take it to the mouth and light cure it, I do it at a tooth at a time. But those are great, great onlays that you can do with microhybrid composite, and a clear matrix. This material- [Jaz]Like Memosil or Exaclear [Javier]Memosil from Kulzer’s great. This one is called RSVP by Cosmedent, or Zhermack. I don’t know if you know Zhermack materials, they have a great material, a clear matrix material like this one, which is great. I use tints so that my my anatomy shows and it looks better, you know, like brown tint or oprah. And so, you can go with teeth that are flat and worn down to have a great onlay just with microhybrid composite. And then you can check your occlusion, make sure that you have points in the back. And whenever they’re going to protrusive movements, they will have lines in the front, anterior guidance, and canine rise is so important. I cannot stress that as much. So, you can do a full mouth rehab, Jaz, with composite and you know, on those young patients, 30 something, 40 something that they don’t want crowns and that you know, I get them all the time. You know, you’re the third dentist and I’ve been offered 28 crowns, and they don’t want that because their teeth are still. They still have maybe 50, 70% of their tooth structure and without prepping you can open that vertical dimension of occlusion and you can full mouth rehab a patient without taking off an ounce of enamel. And that’s what’s valuable about dentistry nowadays. You can give your patients function and aesthetics without being a grinder. [Jaz]I mean, the etiology is also important I think there’s a difference between a primary erosive case and a primary attritive case. The forces, I mean, for a lower risk patient lower headache for dentists you want to be treating that primary erosive case because the functional demands that there may be lower than the primary attritive. So, that primary attritive patient will be producing higher forces and although we do our material selection, and we believe in the composites and we get the right thickness, minimum thickness, the correct type of composite ie microhybrid. Just like you said the beginning, some patients, whatever they did their own teeth will put the same high forces through the resin and therefore an occlusal appliance, you know, you can do all the beautiful excursions and canine initiated exclusion. But some patients with the large masseters and history of destructive forces need an appliance I think. [Javier]Oh! Definitely they need to have a nightguard. But another thing that I found out, Jaz, is that I used to do a lot of gold, metal, a lot of Zirconia. And then I found out that it’s not that you need to put something stronger than their own teeth in their mouth, you have to put something that is he has this exactly the same strength as their enamel and dentin. And you know what? In Zirconia is very, very tough on teeth very tough on occlusions, like that. And then I don’t see broken restorations, I see broken teeth that I need to extract, you know, after putting very tough materials on patient’s mouth. So, nowadays, I think about, what is material that will live with my patients for a long time and that will not harm their teeth? Put in something so strong, that they will break their own teeth. And I don’t know, if you’ve noticed that we used to prep so much teeth and maybe porcelain fused to metal, and then your restoration will last for a long time. But what breaks? It’s the tooth inside, and especially if they need a root canal. [Javier]So nowadays, you know, whenever I’m treatment planning for a full mouth. And I see some teeth that already have root canals or already has, they have root cavities, root decay, those teeth, you better replace them with implants before you go ahead and try to be a hero. If you want, I mean, your restorations, Jaz, are gonna last a long time. Even if you do them and porcelain or composite or Zirconia or gold, what will not last a long time are those teeth that are already very badly broken, or badly used, you know, like with root canals or deep cavities in between teeth, you know. So those teeth, you might as well treatment plan them for implants before you go ahead and try to be a hero. But if those teeth are healthy, don’t grind them down. You just add to them whenever you need, you can do that. I do a lot of those cases, whenever I have maybe 20-30% of enamel loss because of wear, either because of acid in their mouth, because they bulimic, or because they drink a lot of cola. And those cases, you just clean everything up, you use a rubber dam, and you microetch them with a sandblaster and then you can bond to them very, very successfully. Of course, you always have to refer those patients to the gastroenterologist so that they take care of their stomach problems, or to the psychiatric, if they have bulimia, you know, that’s a very common problem here. So, you have to first, be a doctor and look at them in the eye and said, ‘You know, I can fix your teeth, but you first have to solve your problem. And you have a bulimia problem. So, you have to solve that because if the teeth that God who is the Mighty One, gave you they worn down, of course the veneers that are going to place are gonna go away as well. Because the problem that you have comes from your stomach or comes from your brain, and you need to get help.’ And those are things that we can help our patients so you know what, I have some patients that they come back from the doctor and say, ‘You know what, Doctor, I had this, I have this huge ulcer that I didn’t know. And now I’m gonna have to go into surgery and it was showing in my mouth’, you know, or ‘Doctor, you know, I’ve been going to the to the psychotherapist and you know, I have stopped with the bulimia problems that I had, and I’m very grateful so now I’m ready to fix my teeth.’ And so, it’s like I told you before, Jaz, its a beautiful profession. it’s a great time to be a dentist. You know, you know I wish to have three kids, you met my past. I wish the three of them were dentists, one of them doesn’t want to be a dentist. It’s okay. But I recommend them everyday to be a dentist because we can help so much people hear anything anywhere in the world with dentistry. You know, we are doctors of the mouth. And this is such a great time to help people that they are stressed and they’re wearing away their teeth with either chemicals or forces that are in the wrong time and the wrong position. [Jaz]Very well said. And I echo all those sentiments. I’m gonna go into again, Geek mode now. Before for a general discussion, and the geek in me is going to ask you a question that the Protruserati are definitely hungry for because something that we’ve discussed on our protrusive dental committee Facebook group many times, which is interproximal management. I’m a mylar pull kind of guy. And I know Pascal Magne in Edinburgh recently, he is a big fan of PTFE. And just taking the composite right up to the PTFE. And he’s some sort of wizard like that. What is your recommendation? What is your protocol for interproximal management to prevent the composites being stuck together and getting the nice smooth flossible interproximal surfaces? Jaz’s Outro:There we have it guys at my friend Dr. Javier Queiroz. Amazing composites, you must check out his work. I put all the links in the show notes so you can check out the courses he does, and the kind of cases that he’s presented. Of course, the YouTube people do get a little bit more advantage. But I made sure that any parts that aren’t clear to my audio listeners who are the original Protruserati, I will always make sure that your listening experience is not hampered in any way. So, make sure that anything that was too visual, I took it out and I just stuck it on the video elements only. Do join us next time for part two with Dr. Javier Queiroz. We will discuss the interproximal management. I left you on a bit of a cliffhanger there. We also discuss isolation techniques for composite veneers. How to prevent those dreaded stains? And what are the five Ps of composite veneers. And hey, thanks so much for listening all the way to the end. If you’re one of my listeners who always listens all the way to the end. Thank you! If you haven’t already joined splint course, do consider joining. it’s actually as a podcast as well because I realized that in our busy lifestyles, where do we make time for laptop education, right? Because that’s the kind of course it is on demand online course. So, to make it more accessible, I’ve also got it as a podcast and then use a video as a reference. So, if you haven’t checked out already, check out www.splintcourse.com and enroll today. I’ll catch you the next episode guys. Thanks so much!

What happens when conservative care fails? What if you have prescribed patient education and the ‘best’ occlusal appliance and none of it is working? That’s where surgery MAY be indicated for certain diagnoses. Listen or Watch my podcast with Professor Andrew Sidebottom Maxillofacial surgeon (who is limited to the management of TMJDs) to help us make timely and appropriate referrals to provide the best possible outcome for our patients. https://youtu.be/7m30jvUPlMA Need to Read it? Check out the Full Episode Transcript below! Ready to learn the management of Bruxism and TMD online? Click here to enrol to SplintCourse Protrusive Dental Pearl: Head over to the Protrusive Dental Community Facebook group where I posted an 8-minute walk-through video on how to screen which patients are at risk for getting a bite change or AOB after an occlusal appliance and how you can minimize that risk. The highlights of this episode: 12:47 Why you need to provide Conservative Care first 15:57 TMD is a Spectrum 19:21 Early Surgical Intervention? 21:42 Acute disc displacement without reduction 26:40 Imaging used when managing TMD patients 35:10 Pain Management 41:03 Arthroscopic procedure for TMD 50:29 How much does TMJ Surgery cost in the UK? 53:22 Successful management of temporomandibular disorders Check out these studies as mentioned on the podcast. Orofacial Pain Prospective Evaluation and Risk Assessment StudyDownload A Real-Time screening tool to aid management of Post-Traumatic Stress Disorder in facial traumaDownload Temporomandibular-joints-in-asymptomatic-and-symptomatic-nonpatient-volunteers-prospective-15-year-follow-up-clinical-and-MR-imaging-studyDownload Also check out Prof. Andrew Sidebottom’s website for more information and download leaflets. Check out the Tubules Congress in Heathrow October 2022 If you enjoyed this episode, check out Stay away from TMD! [SPLINTEMBER]  Click below for full episode transcript: Opening Snippet: So I think understanding TMD is about understanding that it's a spectrum of care from joint related right down to muscular related, and patients are somewhere in the middle of that. Probably about 90% of the patients I see down at that muscular end as you say. Jaz’s Introduction:What happens to our TMD patients when conservative care fails? Like you’ve done your patient education, you’ve given him the best occlusal appliance, you’ve worked alongside your TMJ physiotherapist, you’ve been through exercises, and you’ve even counseled them about the importance of recognizing awake bruxism, a huge player, and all this stuff isn’t working. What happens next? Well, depending on your diagnosis, the next step for some patients will be see a maxillofacial surgeon, but not any old maxillofacial surgeon, you ideally want to send someone who’s got an interest in TMJ and TMD. So I’ve got today a private physician, private maxillofacial surgeon in the UK, who exclusively treats TMD. So what this guy doesn’t know about surgery and TMJ. And what happens in the latter parts once conservative care fails, how the referrals manage, when should we refer these patients, which patients are suitable for referral to Maxfax, once conservative care fails. Let me give you a clue, if your primary diagnosis is muscular, then really, you know, really need to go and exhaust conservative care and the physio and by the way, most TMDS are of a muscular nature that myalgia and myofascial pain and there’s no real scope for surgery when it comes to muscles that are upset. That’s when we really to give the best conservative care we can and involve a pain specialist sometimes potentially Botox and lots more which we will discuss. Now if you want to learn more about occlusal appliances, bruxism as a GDP as a restorative dentists who wants to just not be afraid of doing a TMJ exam when the patient comes into an emergency slot and they’re complaining of pain from their jaw, or they got like a facial pain and you take a step back and think Whoa, I have no idea what I’m doing here. Then I’ve set up a course just for you. You guys know that my flagship course is splint course so it’s www.splintcourse.com I’ve just relaunched it, got hundreds of very happy delegates all over the world. And we’re continually, it’s like a school family, little community on Facebook. We have these monthly meetups on Zoom, but the entire course is online on demand. Dentists from Singapore, Estonia, Ghana recently as well, India all over the world, UK, loads from the UK and US have joined the course and now are implementing knowledge that they can help their patients with bruxism management and TMD and relaxing the muscles and just doing a good examination of the joints and muscles. I initially set this course up because I was so confused many years ago about which splint do you give when? How do you give a really good Michigan splint? How to actually adjust a soft splint? So it’s got some sort of occlusion, right? And a lot of times soft splints we’ve been guilty of just you know, grab and go and just give it to the patient and let them leave and claim your 12 days or, or whatever it might be. But actually, there’s a little trick that you can do to get some occlusion on your splint. Now I cover all of this in a lot of depth with clinical lectures and visual animations, PDF downloads, you name it, I really, really made something I’m super proud of. And that’s going to help you save time, be less stressed, and actually be able to charge appropriately for your appliances with confidence. But don’t take my word for it. Have a listen to Aoife Egen, one of my lovely Splinycourse delegates. I admire Aoife so much because she demonstrates that it’s all about implementation. Knowledge is nothing about implementation. So I congratulate Aoife for applying the knowledge from splint course. Have a listen to her experiences [Aoife]My experience with undergraduate and postgraduate was very similar and in both cases, and I felt it was lacking. So when I started Jaz’s splint course and I was going through all the modules, I just found it such a welcome shift in thinking. And I was really, really delighted to have come across it because I felt that it was the first time I was finally going to be able to really apply and yet kind of actually use all of the information was very logical compared to the theory based approach that I had experienced before that. So I started this course in December I think and so I kind of went got through all of the information by about I think the end of January. And then as it happened, I was going coming back from maternity leave at that stage. So in the last six weeks or so, I’ve applied so much of the principles from Jaz’s course already, and it’s just been great, you know, just immediately, my diagnosis has been better. Even something as simple as, you know, before, I had always just written like, you know, as part of my notes, extra oral examination, TMJ, and then a note about it. But now I actually understand what it means to if there’s a click or, you know, I just have found my notes are more detailed. And I’m not just kind of noting it, and then doing nothing about it. But I’m actually kind of acting on my diagnosis a little bit more. Sorry. All right. I just hope Jaz hears this now [Jaz]Ladies, I heard you loud and clear. I love to hear that. That’s fantastic. Thank you so much Aoife. Now, the biggest excuse I hear from colleagues, they message me in terms of time, Jaz, I’d love to do your course. But I don’t have the time, I can’t find time in my busy life, to sit in front of a laptop. And watch these videos as fascinating and engaging as you make it Jaz. I don’t have the time. But you made the time to listen to this podcast. And I realized this afterwards, when some of my delegates were not making as much progress I want you to do well, I want you to make progress. So then I decided to put the make the course as a podcast as well, because then a lot of people can while they’re commuting, make time for education. And therefore now a new feature of the course is that you can download the mp3 of the modules. And listen while you drive, or on the train or chopping onions or whatever. And you gain most of the knowledge like that you reference it with some of the videos you have the course ebook, and all the PDF forms and gives you a new way of learning through the medium of podcast. So that’s right up your street, head on over to splintcourse.com and enroll today. Before we joined Professor Andrew Sidebottom, the maxillofacial surgeon, we talking to you today, I’ve got your Protrusive Dental Pearl And this is a video I posted on the Protrusive Dental Community. So if you’re not part of the Protrusive Dental Community on Facebook, search it up, join. It’s a lovely little community, very helpful. I’m proud of it I one of my colleagues, Maria posted a case whereby she gave full coverage appliance, upper and lower, full coverage like a retainer and a full coverage appliance to a patient and she developed anterior open bite. And so this happens right? So it’s not just a small appliances and over eruption and that kind of stuff. And I’ve talked about it before, but a patient now has an AOB. So inspired by that problem, I saw an opportunity to make an educational videos, eight minute video made to ship to walk you through with a patient life patient there exactly how to screen which patients are at risk for getting a bite change or AOB after an occlusal appliance and how you can minimize that risk. So it’s a free eight minute video you can watch, I pinned it to the top as a featured content on the Protrusive Dental Community. So you could check that out as your Protrusive Dental Pearl. Otherwise, I hope you enjoyed this podcast. I’ll catch you in the outro. Main Interview: [Jaz] Professor Andrew Sidebottom. Welcome to the Protrusive Dental Podcast. How are you? [Andrew]I’m good. Thanks, Jaz. How are you? [Jaz]I’m great. I just came back from Porto on holiday we took 16 dentists to learn vertical preparations with George Andre Cardoso in Portugal, which was amazing. And we’re feeling a little bit tired. I’ve got a few ulcers. I’ve lost my voice a little bit, typical. But hey, I’m good. I heard about your weekend before hit recording, very family orientated which was nice. Like how do maxfacts people? How do you get time to have a life? Serious question like you guys must be so so busy. Well, how do you manage it? [Andrew]So I mean, I think I stepped down from my NHS work 18 months ago and just do private work now which has given me an extra day a week. But yeah, it was chaos before and doing a one in four on call was was hard work. But yeah, I’m enjoying life a bit more now. [Jaz]I’m so glad to hear that and please give us a flavor and I want to know as well. With going private MFS like you do you have your own niche within MFS and what are the types of surgeries that you have niched into? [Andrew]Okay, so, as an NHS consultant for 20 years, I developed a practice in TMD and facial deformity. I became one of the go-to people for TMJ problems from other IMFs around the UK and Europe. And the the facial deformity side of it fits in nicely. In addition, all of us kind of Do wisdom teeth and dentoalveolar work as well and I still love doing the basic dentoalveolar surgery. I just like getting my hands wet. So that’s great doing that. And so my private work, probably about 60% Is TMD-based. And then 40% is general Maxfacts and facial cosmetic surgery. [Jaz]I’m so excited to have the chat now. They told me the background terms of how much work could you do with TMDS right on my street I am sure I’m gonna learn so much from you and we are all asked you got a platform of GDP is it all over the world who tend to listen to Protrusive Dental Podcast because they’re a little bit geeky. They want to a bit more, they like the nitty gritty details. And they have an interest in some way in occlusion or TMD. Or that’s why they started listen to this, that’s why they clicked on this episode. So let’s scratch that itch for so many listening. So first, just tell us where you work. Tell us where you work. And how did you get into that niche of TMD. Because most dentists I speak to want to stay as far away from it as possible. [Andrew]And I think that’s true of most maxfax surgeons as well. We, what did I? How did I get into it? I kind of got into it almost not quite by default. But I at dental school, I went to a very interesting lecture by a chap called Richard Juniper, who at the time was a consultant in Oxford, and specializes in TMJ. And I was really intrigued by his kind of anatomical understanding of how the joint works and their relationship with the lateral pterygoid to the disc and the head of the condyle. And then went off to do my SHO jobs ended up in Birmingham with a chap called Bernie Speculand, who was one of the first guys in the UK doing TMJ replacement and TMJ surgeries. Liverpool as a senior SHO, none of the consultants was interested in TMD. So I got dumped with all of that work by the seniors, and thought I ought to start learning about it, went back to med school, married an orthopedic surgeon. And by default, therefore, you’ve got to know a little bit about joints. And went through did my higher surgical training in Liverpool with a guy called John Cooper who again was interested in TMD and came to Nottingham and just that was part of one of my areas of interest, along with facial deformity, cranial facial surgery, and just develop the TMJ stuff along those lines and set up a specialist clinic literally in my first week in 2001. As a max fact surgeon in Nottingham, and having the time to spend with the patients at the first visit, when they get referred to secondary care is the key to management of these patients is spending time with them. [Jaz]That is brilliant. I love your story and how one stem from another and the fact that you married orthopedic surgeon, I think gives you an edge for sure. It totally gives you an edge. I love that. The kind of themes we’re exploring today, if we were to achieve two things on this episode is one to gain insight what happens when us, dentists have really exhausted conservative care, and they come to you? And what are the types of diagnoses that lend themselves to a better prognosis? What kind of surgeries do you do? I mean, in this short time, we can only cover so much I know you’re coming to visit us on the live of Splint Course, which I’m really excited for you to meet the delegates who have taken a real interest in the conservative management TMD. So really excited to see you in May and June for that. But the first question is, what do you think? What is the level of care that you want general dentist to have carried out before that patient is referred to you? Because and please do tell me what percentage of referrals that come up come to you sort of bounce back and say actually, there’s no indication for surgery? And then do you sometimes just take over and do the job that perhaps you feel that our colleagues should have done? [Andrew]Yeah, so one of my roles at the moment is as the East Midlands advisor for NHS England, Oral Surgery, so I’m the emcee and lead for oral surgery. And one of the things that we’ve done is send out a missive to all the dentists in the region about what they should be doing for patients in primary care for the initial management of TMD. The guys in Darby audited the referrals before and after that, and found very little change in practice. And that roundabout 80% of patients had a basic rest, anti inflammatories bite splint protocol, before they came into hospital. The Royal College of Surgeons guide suggests that patients should have a six months of conservative treatment prior to referral in. I don’t agree with that. I think that misses some of the patients that will benefit from early surgery, particularly younger patients with an acute severe restriction of opening. So I think a basic rest, anti inflammatories, reassurance that the majority of patients even that we see in secondary care, don’t go on to need surgery. And reassurance that clicking is something which about a third of the population have any way and most people with clicking don’t get problems. So don’t worry about the noises that are coming from your joint. We don’t worry about noises in our knees and hips and shoulders. So we shouldn’t worry as much about TMJ noises as some people stress and basically to just give that reassurance that you know, the biggest thing I would advise everyone not to say is never tell a patient they’ve got arthritis because as soon as you say that they assume they’re going to need a joint replacement, [Jaz]Especially if they started googling it. [Andrew]Absolutely, yeah. [Jaz]Which they do. TMD patients I’ve had, which eventually watch my dental podcast, which is, can you believe it, they didn’t know, my podcasts are meant for dentists. And they search these terms, which only a dentist would ever search, right? And then they end up with me and they come, and then I’ve seen a few of them. That’s kind of like how I’ve also made a sub interest in TMD. But my mission was always to be really good with conservative care, because I can treat so many of my patients with really good conservative care. And one thing maybe we’ll touch on is giving an occlusal appliance with intent based on diagnosis. And with that comes, you know, one important consideration that yes, you know, you shouldn’t say arthritis and stuff to your patient, because they’re worried, but loads of these patients, their diagnosis is in the muscular region. And correct me if I’m wrong, but you know, they don’t, there’s gonna be no indication for surgery for somebody that’s muscular, that definitely needs rest. So just please expand on what percentage of referrals that you get are perhaps muscular, and they’re not, you know, osteoarthritic or intracapsular, that you feel as though hang on a minute, we need to just go back and break things down, go back to basics and apply conservative care. [Andrew]Yeah. So I think understanding TMD is about understanding that it’s a spectrum of care from joint related right down to muscularated. And patients are somewhere in the middle of that, probably about 90% of the patients I see down at that muscular end, as you say. So of the patients that get referred to us in secondary care around about it. The easiest thing to think of with TMD management in secondary care, which I tell all my trainees is it’s an 80% disease. So 80% of the patients we see in secondary care, get better with conservative measures. 80% of patients who go on to have arthroscopy get better with that, of those 80%, 10% don’t need further intervention, despite not getting better with arthroscopy, because it becomes very clear that they haven’t got the joint related pathology. Of the remaining 10% that go into open surgery, 80% of those get better. And of those that don’t, when they’ve got significant pathology in the joint that go on to joint replacement, you look at that. And of those 100 patients who have come in initially to secondary care, probably one will go on to open surgery. And about point one will go on to need a joint replacement, so very few. So as a surgeon, Maxfax surgeons aren’t interested in it, because you don’t operate on the majority of your patients. [Jaz]That’s an interesting take, cctually. If it was more surgical lead, maybe Maxfax would have more of an interest in it. But you know, we agree that there’s so much general dentists can do with good conservative care, perhaps teaming up with a local physiotherapist and following a hierarchy of things, where we’re both well acquainted with Kreena Panchal, who again, will also be there in the dates of May and June on the live version. So it will be great to actually put our heads together and see how can we help our GDPs give better conservative care, and that’s essentially what it’s about. And with that Prof, I want you to say, there’s a rule that one of my mentors taught me about PDQ. And just as you said, with the clicking, and lots of patients get concerned and worried. And you should just reassure them a clicking is normal, PDQ. So it’s only really an issue in any real diagnoses within TMD, which is an umbrella term, if it gives a patient’s pain. If PD means let’s say dysfunction, okay, so they’re not able to chew properly or quality of life. If it doesn’t satisfy any of those three, then really, there’s there’s no reason to actually intervene at all, not even with conservative care. Really, if it’s not giving any of those. When any of those three happen, then of course, conservative care. And if that fails, which 20% time it may do, but to be fair, I think if we only had a group of patients who had muscular symptoms only, and you gave them really good conservative care, and we can get into heated debate, maybe but not just give them a soft splint. Okay, well, we’ll talk about that towards the end, then I think we will go beyond 80%. And some of the literature says that, but the general lecture 70-90% patients will get better, even just without an appliance, just giving them some advice and rest, a physio, no appliance will do well, and we know that. What are the kind of cases that you think dentists should and it’s really interesting mentioned should be referring to you without conservative care first, because you feel as though okay, this patient is just going to be worse off in six months with conservative care, and they actually need early surgical intervention. Can you describe those type of cases? So the diagnoses. [Andrew]So it’s a term that I’d be amazed if any of your listeners come across, which is called Anchored disc phenomenon. And basically what that is, is with repeated compression of the joint and one of the things that we’re increasingly aware of is that TMD is related to repeated compression, micro trauma of the joint from clenching or grinding, usually clenching rather than grinding. And to put it in a simple term, they squeeze out the fluid of the joint. So if you wash out the engine oil, the engine ceases. And what happens with the joint is that you lose the glide component. So your initial rotation of about two, two and a half centimeters in the lower joint space continues, the upper joint space loses its viscosity, it loses its lubrication and sticks. And so the disc is stuck against the fossa, you don’t get the glide. So they stick it round about 25 millimeters. And anyone with that onset suddenly, so they getting on fine, suddenly they come in, I can only on my mouth two fingers or less, needs urgent referral, because those are the ones that do extremely well with an early washout and early arthrocentesis. And do extremely badly if you delay and delay and delay. So those patients who are delayed beyond one year, their outcomes are about 50% success. Whereas those that are treated, within three months, you’re looking at about 95% success. [Jaz]Wow. And we and these patients are different from that patient in their 40s or 50s, who’s always had clicking, clicking, clicking, and then sometimes they get the the lock, which they can fix. And then eventually they get down to two fingers. And we suspect a disc displacement without reduction. So the disc is not able to come back on the condyle, the condyle cannot translate as well. And that’s a different beast to the kind where they get like you described more sudden. And that makes sense. Now, when it comes to patients who have intracapsular disorders, and they have that disc displacement, locked or the closed lock, and the jaw deviates towards, or deflects to one side even and they cannot open, they’re in pain, acute pain. Why do you see the success in conservative care in there, because this is where I give reduced prognosis to my patients, I can still help a lot of patients. And actually funnily enough soft splint, the bite raising can help those patients to recapture and then various things. But the longer that’s happened, the worst prognosis? Is any evidence that early surgical intervention in those kinds of cases can help or what would you advise general dentists to do in those acute disc displacements without reduction? [Pav]Yeah, so I think a lot of this is dependent on understanding the basic kind of pathophysiology of what’s going on. So what you’ve got with this displacement is that you’ve got compression of the joint. And if you compress the joint often enough, it starts getting thin, and the retrodiscal tissue stretch, and then the disc slips forward. So when you open, you go past the back end of the disc, and then you get the click as it relocates in position, the click can also occur, because the retrodiscal tissues thicken, in adaptation to the increased load. And that can also click over those. So those are the ones that you can get click click, sometimes. The reason you get a lock isn’t that the kind of old fashioned thought processes of the disc is just stuck there in front of the joint, what actually is probably happening is that you’re getting to a certain point on the retrodiscal tissues, the tissues are so inflamed and uncomfortable that the muscles Stop it, and they go into spasm and they stop you moving forward. So that’s either spasm of the lateral pterygoid, on the front end of the disc, or spasm of the opening muscles, the masseter temporalis, which literally, because it’s painful, it stops you’re moving, it’s like a limp. You don’t on purpose limp when you’ve sprained your ankle. And it’s the same with your TMJ, your body knows that it’s going to be painful, and it suddenly says, I’m not going to move there. And then your jaw deviates over towards the side where the pathology is. And you get that restricted opening. So trying to release the muscle spasm, trying to offload the joint with your splint is going to help that patient in the initial phases, and probably will get significant number of those patients improved with good splint therapy, good rest and avoidance of that whilst you’re waiting for a referral onwards. But yeah, don’t hesitate to get the splint in there and kind of offload the joint really. [Jaz]Do you think that kind of patients should be also going down the conservative care for six months before referring to someone like you perhaps or is that warrant a referral to you to start also being involved in that patient’s care? [Pav]So I think the problem you’ve got in Maxfax is that there’s only about a dozen of me around the country. And there are about 300 Odd maxillofacial surgeons who aren’t comfortable providing early arthroscopy, arthrocentesis and therefore, what will happen is that they’ll get referred in. The patient will be seen by often a junior member of staff who will say, Oh, yeah, these need conservative treatment, or they’ve been having conservative treatment, or let’s give it a bit longer, and they get delayed in the system. So it’s about knowing who to work with as much as how to get that process going. And, you know, I’m not being demeaning to my colleagues, some of them are brilliant cancer surgeons and what have you, and I wouldn’t want to touch that side of things. But similarly, it’s an awareness that you’ve got your own limitations of what you’re comfortable with, then it’s probably worth referring into somebody who does have, most regions will have one or two surgeons who have an interest in TMD management. And it’s really about finding out who that is in your area, and working with them to kind of get those patients referred into their clinic. At the moment in the NHS, it’s a disaster regardless, because I don’t know what it’s like for you guys down there. But at the moment, for a routine referral in East Midlands, it’s like 40 weeks Wait, and TMD will be a routine referral. So you know, you’ll have a 40 week wait, and by that stage, they’ve missed the boat. [Jaz]Agreed. And this yeah, like I said, similar here, and just on the idea of getting finding someone who’s local to who can assist you, as a general dentist, with those complex intracapsular locked as acute, but I think we still need to apply conservative care that might be just a little bit different. And we’ll talk about that when we come to the live courses, obviously. And that may help patients a lot while they wait, especially if you get that lateral pterygoid to calm down, because I like to lateral pterygoid to calm down and a lot of those cases will get better. And just like you said, the beginning, it’s everything that’s a spectrum, there’s no purely intracapsular, probably less purely intracapsular, there’s always a degree of muscular involvement as well. And one of my favorite analogies for the relationship between the condyle and disc is that the disc is like a bar of soap. And with the compression that bar of soap can slip. And obviously that’s a very simplified way of thinking about it. There’s lots more anatomical changes that can happen. But essentially, yes, when someone gets restricted opening and your suspect a disc displacement without reduction, my Inkling is to help out. But I’m also thinking about imaging. So let’s talk a little bit about imaging of those patients who either conservative care has failed, good conservative care has failed. Or they have disc displacement without reduction before even surgery, what kind of imaging Are you providing for these patients? [Andrew]So I’m probably a little controversial in my views on imaging. I very rarely will get an MRI. The reason being that the MRI scanners we have in this country, first of all, the majority of 1.5 Tesla. And so the views aren’t that great. The radiologists are few and far between who are good at interpreting them. And when you look at the best series in the world, from the likes of the ninth People’s Hospital, Jiuyuan unit in China, even there, the accuracy of diagnosing a disc tear is about 50%. And so if you base your surgical intervention on your MRI 50% of the time, you’re going to be wrong. An audit that we’ve done and not seen as similarly done a similar audit in Oxford, and colleagues in America have audited their practice. When you do an arthroscopy and you find a disc tear, a lot of colleagues would say, Oh, you need to take the disc out. My feeling is based on an audit of 115 patients that we’ve presented, but haven’t published yet. 50% of them get better with a disc tear. And that’s its own disc tear, which can’t heal itself because it’s avascular. So if you then said, Okay, well, I’m gonna base a surgical discectomy on an MRI scan 50% of the time, it’s got the diagnosis wrong, and 50% of the time, you’d have got better with just an arthroscopy. So, you know, 75% of your patients, you’ve taken the disc out unnecessarily. And that sort of data correlates with a couple of studies in the literature from Sweden, a chap called Anders Holmlund did a lot of work on diskectomy and found that following arthroscopy, if you did a diskectomy, about 50% of patients got better. Whereas if you didn’t do a diskectomy, if you didn’t do arthroscopy, 80% 85% of patients get better with a discectomy, so that means 35% of patients probably would have got better with arthroscopy alone, so it kind of correlates with all that. So that’s why I’m not a huge believer in MRI. MRI, in theory, if you take a good history, and do a good clinical examination, the MRI will only confirm what you clinically know. [Jaz]I’m glad we’re in the same viewpoint actually because I find as a GDP who’s got an interest in this difficult for my patients to accept having an MRI and going to London to have it. There’s a few people I know who do it but they’re few and far between. And a lot of time with my history and knowledge of anatomy, you can get, you can suss out the diagnosis. So I agree with you on that. I’m sure there’ll be times where something’s just not quite right. And you will need to take some form of imaging. I recently had one of my delegates on Splint course in our Facebook group, he posted a case where acute pain on the right, limited opening with a deflection so we’re discussing, okay, we suspect disc displacement without reduction on the right side, but it’s quite sudden onset. Can we explore? So he referred on and they did take an image now I’ll have to check out I’ll put this in the show notes. Exactly what type of imaging it was because I don’t want to get it wrong. We know that MRIs are good for looking at the disc and soft tissues, we know that CBCT’s are better for for hard tissues, but they did diagnose a right side condylar fracture, which was fascinating. And they were they were surprised in the report that they wrote. So yeah, those kinds of things yet, when the when something’s really unusual, then I’m sure you guys are would do that. But for many cases, it may not change your management, is it is that fair to say that with your differential diagnosis about imaging, it may not change your management with the presence of an MRI? [Andrew]I think the other thing that you need to understand about an MRI, have you ever, if you’ve ever had an MRI, you will understand [Jaz]For my shoulder? I have Yes. [Andrew]So it takes about 30 minutes. How do you lie still for 30 minutes, with your jaw, it’s and then you’re trying to open a jaw into a bite block, which is an unnatural movement, you’re not going to move past a point that might be painful. So if you had a painful click, you’re going to stop before you get the pain because you’re not going to hold your mouth for three minutes with that pain in that painful position. So you will often get an over diagnosis of limited disc reduction from the MRI, not because the radiologist has got it wrong, but because of the unnatural surroundings that you have with an MRI, you know, and everyone that says oh, well, you get a dynamic MRI. A dynamic MRI doesn’t show a joint moving like that. It shows a joint in that position for three minutes, then that position, it’s then that position for three minutes. And then they combine it to make it look as though he’s moving. And even with that, it’s not natural. So you’ve got to take your clinical diagnosis, your clinical diagnostic skills, to the level that you’re thinking, Okay, what’s going on inside that joint and you’ve got it in your brain, what movements are happening, and then you can use your MRI to confirm that. So one classic, I remember I got asked to go over and treat a Saudi in Saudi Arabia. And this girl was the daughter of the hospital owner, multibillionaire and the MRI showed an anchored disc. The MRI showed a disc displacement without reduction. And they said, Oh, I think she needs a discectomy and they had various people say that I said, Okay, well, no, we’re going to do an arthroscopy. So I did an arthroscopy on table mouth opening went from 20 to 44 millimeters post op, three months mouth opening 45 millimeters pain free, disc relocated on the MRI. That’s an anchored disc phenomenon. But what the scanner show is that the disc was stuck in front of the joint. So you’ve got to listen to what the patient’s saying. Listen to your experience and work through that and think, Okay, what could be causing this and the anchored disc phenomenon is it tends to be under 30s. I’ve always been aware of these younger patients with acute severe restriction. Yeah, the majority of kind of teenagers, it’s myofascial pain, been caught out a few times with new diagnosis of rheumatoid arthritis or inflammatory arthritis. A few others that you get this acute severe anchored disc phenomenon, but a lot of patients under 30 is muscular. But those acute severe restrictions is going to be an anchored disc before it’s going to be a disc displacement without reduction. [Jaz]Well, that’s a really great insight. And just to add to an MRI study that was done, they and I’ll put the exact reference in the show notes, you’re probably familiar with this study where they had symptomatic patients, and they took an MRI, but they had asymptomatic patient patients, and it took an MRI of the joints. And they found that a quarter of maybe even a third a quarter to a third of these asymptomatic group have a disc displacement with reduction and had a pathology. And then about a third of the patients with symptoms had no pathology on the MRI. And what it also goes to show is that we very much need to respect the biopsychosocial model of disease and just because those patients had a MRI diagnosis of disc displacement with reduction, they had some sort of pathology per se. It didn’t correlate to pain and What physical abnormalities or pathophysiology or problems, they don’t always manifest as pain because pain is very complex beast. Do you work with other specialists when it comes to pain management? Because I imagine that’s a big part of what you do. Please tell us more about your reflections on the relationship between an actual disc injury or positive finding or lack of and pain. [Andrew]Yeah. So I think the first link you were saying about working with a physiotherapist, the more treatments I’ve carried out, the more I’ve worked with physiotherapists. So I’ve got now about six or seven physios that I work with around the country. All of them are pretty much specialists, TMJ physios, you can access them through the acptmd.com website. And Kreena who is on the course is one of those and I work very closely with Kreena, I’ve got three around Nottingham that I work with and one now in Lincolnshire, a couple in Sheffield, and one other in London. So these guys are fantastic. And they’re also good at emailing you back and saying, Andrew, I’ve done what I can, please can you put a bit of Botox into this muscle, because I think that’s something which is very good at breaking the cycle. The other thing with Botox is that it’s very badly taught to dentists by and large. So it’s injected suit, too superficially. It’s injected in the wrong places, it risks damage to the zygomaticus muscle, which runs from the front of zygoma, to the corner of the mouth, because one of the areas of major muscle spasm is the upper anterior masseter, just here. And if you try to inject that, it will leak into the zygomaticus, which is just next to it. And you’ll end up with a patient that can’t smile for four months. And so they won’t thank you for that. So when you’re injecting with Botox, you’ve got to find where your muscle spasm is. And what say to all of my juniors is muscle spasm. Teaching patients where muscle spasms, you get them to feel the muscle firmly. And if they can feel a speed bump, they go over the muscle spasm and it’s uncomfortable. And that is one of the keys to where the physio works is massaging that area of speed bump and running your finger over that speed bump for a minute, four times a day. It stretches the muscle. It helps improve the blood supply and it releases endorphins so that they get pain relief. Similarly, you look at muscle relaxant medications low dose, tricyclic meds, which a number of my colleagues are very quick to jump patients onto those meds. I think you’ve got to look at less invasive ways of doing it first, you know that they are quite difficult drugs to manage. And if you’re not used to using them, then really they should be managed by either the GP who are quite used to using them for a lot of things now, or a pain specialist. And I will try either low dose amitriptyline, nortriptyline or gabapentin, pregabalin. And if those aren’t working at that stage, I send them to my pain management team. And I have about three pain management consultants that I work with, that are very used to what I do. And similarly, they bounce patients back and say, Andy, could you put some Botox in this patient? I think that will help. In addition to what we’re doing in the medical management side of things, I think it’s very easy to just FOB patients off with muscle relaxant meds, when actually, it they need a more holistic approach to management. [Jaz]And with your pain management team, as well as cognitive behavioral therapy, what other modes of sort of intervention are available from the pain management side. [Andrew]So I think you’ve got to consider with these patients, I, in a lot of my lectures, I draw three circles interlinked. And there’s this internal derangement, there’s osteoarthritis, and there’s myofascial pain, and then there’s a double arrow feeding into all of that same psychology. Because if a patient has anxiety or depression, they’re more likely to clench and they’re more likely to feel pain. If a patient has pain, they’re more likely to become anxious, depressed, and clench their teeth. So it’s a two way cycle that you’ve got to look at. So you, there’s the occasional patients, I treat two consultant psychiatrists. It’s always interesting having that feedback with them about you know, you do realize that you need to see psychological management techniques and saying, Yeah, we do these things and blah, blah, blah. But yes, you’ve got to interact with psychologists with CBT therapists with psychiatrists on occasion and Kathy Fan from Kings produce a very nice paper where they have developed a tool, which works out all the patients that come into their TMD clinic get put onto this tool, and it says, This patient is high risk of anxiety, high risk of depression. And then they link in with their psychiatric team to manage that side of the problem as well. And then on top of all that, you’ve got the medical problems. So you’ve got the fibromyalgias, the inflammatory arthritis, which you’re linking in with the rheumatologists. So, it over the 20 years of working, I’ve worked with more and more colleagues and more and more colleagues work with me and it was beautiful working relationship in the end. I’m sorry, I left [Jaz]And that’s what it’s all about, you know, multidisciplinary care. So the definitely was all about and I’ll put reference again to the OPPERA study, which talks about all those other comorbidities. And I’ll put that in the link as well, because we discussed that with an episode with Kreena a long while ago. So we’ve talked a little bit about the kinds of cases that should be seen little bit sooner, the importance of conservative care, and you gave us some success rates. I love the 80-80-80 sort of rule if you have, Pareto principle comes to mind. When you talk about arthroscopy, please describe to general dentists, What is an arthroscopic procedure for with regards to TMD. What are you actually doing? And what is the sort of prognostic features or what are the features that will suggest okay, this patient has a good prognosis or a bad prognosis from an arthroscopy? [Andrew]Okay, so, arthroscopy is usually carried out under general anaesthetic. Patients don’t need antibiotic prophylaxis, orthopedic surgeons have not been using antibiotics for years and years and years for knee arthroscopy. The scopes we use, by and large, a 1.9 millimeter diameter and 30 degree angled, the scope I use now is a disposable 1.2 millimeter. And on viewing scope called an on point. It’s smaller, it’s easier to get into the joint, it theoretically causes less damage. But the risk is that sometimes you don’t quite get into the anterior recess, the majority of pathology, you see, an arthroscopy is in the posterior portion, or the mid zone of the disc. Arthroscopy realistically, unless you’ve got a disc test, you’re only going to see the upper joint space. So you will miss low joint space pathology. But you basically descend the joint, you then put in the telescope, and then you look around the joint, and you try and work out what’s going on, the commonest thing you’ll see is that this folding of the retrodiscal tissues because they’re stretched. And so when you open the mouth, you’ll see this kind of little wave formation flatten out as you move the scope through the joint. And then the next thing you’re going to see is, is there any inflammation on that tissue? Does it creep up onto the avascular disc, which is called creeping synovitis? And is there a hole in the disc, and you’ll see that a chronic tear has a nice rounded edge. And acute tear is a bit more jagged. And probably an acute tear is more likely to heal, and the patient get better than a chronic tear. Because what happens with a chronic terror is you get adaptation. You know what we’re doing as surgeons is facilitating the patient to get better. So if you like we’re helping God to get the better. We’re not God. You know, I know they say, you know, what’s the difference between God and the surgeon. God doesn’t think he’s a surgeon. But basically, what we’re doing or what we should be doing as surgeons is helping the patient’s body to heal itself. And so what you get from an arthroscopy then, and level one arthroscopy is literally putting the scope through the joint, looking around the joint and flushing it out, under pressure. You need to do it under pressure, because it distended the joint, you need to flush out enough fluid. So you need 200 mils plus a fluid to get rid of the inflammatory mediators or those free radicals. And what that 200 mils starts doing is getting rid of the free radicals in the lower joint space as well by diffusion through the retrodiscal tissues. That’s work that direct net San has looked at from Israel, that shows that less than 200mils. 200 mils is that kind of key 99.9% of all free radicals have got rid of. 100 mils, you’re looking at about 97%. 50 mils is around about 50-60%. So you really need to be flushing through a lot of fluid. The pressure distends the joint and breaks down adhesions in the joint that are forming. And it also what happens what you see with an anchored disc is like little fibrillation is where the joint surfaces have been stuck together and then pulled apart. And the way you can imagine that is if you put two surfaces of glass together with a thin layer of fluid and then you pull it apart. You can see those little strands forming. So that’s what you would see with an anchored disc phenomenon. Level two arthroscopy and there’s realistically only one person in the UK that It does this frequently, is putting a separate scope in and taking biopsies and freeing up tissues. Level three is putting three bits in and hiking the disc back. Now state that there is no good evidence that level two and level three given added advantage of a level one is categorically in the literature, there is no evidence that added procedures arthroscopically give any advantage. There is likewise no evidence that open disc plication, putting the disc back into position gives a long term relief of symptoms over and above dealing with any other pathology in the joint. So disc plication in the 70s and 80s was a common procedure. What happened was that five, six years later, the patient got clicking again, you did another disc plication, five, six years later, it comes back again, by that stage, the fact that you’ve opened a joint two or three times, you’ve got a degenerate joint. And so disc plication went out largely as a procedure through the 90s. There’s still people who will do it regularly. And state they get good outcomes from it. My own view is that I do it probably about 5% of my cases, I’ll do a dislocation. This is with open surgery. Of those, only about 50% of them get better. Whereas everything else I do, which is deal with, if there’s damage to the eminence, if there’s damage to the disc, if there’s damage to the condyle, I’ll deal with all of those at the same time. My success rate with doing that is 80%, bizarrely, as opposed to if you just do an emenectomy, your success rates about 60% If you just do a discectomy, your success rates about 60%. So if you address all the pathology in the joint with open surgery, then you’ll get a better success rate. But if you do disc plication, you probably won’t. And it possibly is because you’ve got the diagnosis wrong. [Jaz]I mean, that’s I’m sure there must be like there is dentists, difference in opinions amongst all surgeons. And this is where we need more evidence in our profession to know about these, you know, long term success rates, but very good insight now when it comes to arthroscopy, as you mentioned, and then you place fluid inside to distend the joint is that then classified as an arthrocentesis. So IE arthroscopy is the exploration. Is that an arthrocentesis? Fair term to say that that’s the flushing of the joint? [Andrew]Yeah, so arthrocentesis, by definition is putting two needles into a joint. And that can be one needle with two lumens. But two needles into a joint, and flushing the joint fluid through under pressure with a volume of fluid. Arthroscopy is exactly the same type of that, but one of those needles is an arthroscope. [Jaz]Got it. And those patients who have a acute disc displacement without reduction, who maybe is in their 40s or 50s. And conservative care is not working, they’ve come to you. Is arthrocentesis or arthroscopy the next step for those patients largely and then if so, is it again, an 80% success rate? So unlock them. [Andrew]Yeah. So when I’ve looked at my outcomes, you know, I’ve got now a series of roundabout 2500 patients where I’ve got the prospective data of an even when you look at that group, and you classify them according to Wilke stage and Wilkes is still, it’s the only classification system we have. But it’s controversial. There doesn’t seem to be a very clear correlation statistically, that a patient with a Wilkes V, which is a severely damaged joint or deranged joint does significantly better or worse than a patient with a Wilkes II. The trend is that Wilkes II does better than Wilkes V, but Wilkes V is like a disc tear. And so 50% of my patients with a disc tear get better. Whereas if they don’t have a disc tear, and this is again, a study, which we’ve looked at 596 arthroscopys, their risk of or the success, if you’ve got disc pathology, means that about nine I think it was 9% went on to needing open surgery. Whereas if there was no disc pathology is about 2% [Jaz]That I’m gonna have to boil that down again, and look at all these percentages because they’re very fascinate because essentially, it’s about helping our patients. I think the first port call is to get them there, right help with you, or someone who’s experienced with that. And then these Micro sort of diagnoses that are made with surgical interventions, it’s about getting the right treatment because I’m sure you know, like you said, every surgery is unique that you do and Every patient is unique and you will not just do one thing you’ll address all the things in there. That’s what I was thinking in my head. Okay, these percentages as a general dentists, I mean, if you don’t mind me asking and this can be off the record if you want me to, as and when we send patients to colleagues like yourselves who are very experienced in this and this is exactly what we want we you know, I think we want to send, I mean in my group of hundreds of delegates, right, we are desperate for people who can help with this at the next level when conservative care has failed because because my group of dentists are really good at conservative care. So I’m actually really glad to have found you as someone to recommend who has experienced in this what are the kinds of things that we say to our patients terms of budgeting and fees because you know, this is something that you know, with NHS is massive waiting lists and whatnot and you don’t know you’re gonna get I’d love for them to be seen by us, more complex cases who conservative cares failed, what kind of because I want to set my patient up. I don’t want them to come to you and say I can’t afford this. How’s it work with insurance as you charge and and what other kind of fee structures? [Andrew]So most of the private health care insurance companies cover all of the stuff to do with TMD. So a lot of my patients Bupa or AXA. AXA are a problem for me because I’m not fee assured with them but Bupa, Aviva WPA, vitality, etc. All of their fees are covered. Some companies you’ll have an excess to pay, some companies don’t cover the surgeons fees. So for me AXA cut the fees that they pay by 40%, five years ago. And I didn’t want to accept that fee cut, but that’s my choice. Other surgeons will accept their fee rates so. But if you’re privately insured, it is covered by and large, and the surgeon should tell you, if you’re likely to have an excess to pay. You can find out who they’re insured by on the PHIN site, which is a government site which all surgeons have to submit their data on to and it says what they’re doing and what they have. The problem with the PHIN is that there isn’t a strict code for TMJ arthroscopy until recently. So on that site, I do a lot of ankle arthroscopy and a lot, a lot of knee arthroscopy, because it’s been coded as that. That’s changing. And, you know, hopefully it will become more apparent, but self pay, again, it varies between regions, so you will pay a lot more London prices, in Nottingham, for a unilateral TMJ arthroscopy, it’s around 3000 pounds, bilateral about four and a half. And it’s usually a day case procedure. So you come in, [Jaz]That includes the anesthetist fees? [Andrew]Everything in. Every cents. [Jaz]That’s retty good. That’s what I think that’s pretty good. I’m sure the figures are much meatier in Australia in the States. [Andrew]Yeah. They are. [Jaz]Okay, that’s a really good insight to have, you know, because sometimes patient unsought, to give them a ballpark figure that’s really useful. Prof. Thanks so much for that. And [Andrew]Consultation fees will be on the PHIN site as well, of course. You know, Mr. Sidebottom charges 200 pounds for his consultation, or Mr. Evans charges, 250 pounds for his consultation and whatever. [Jaz]Got it, got it. And then that’s really useful information for us, general dentists listening to this. Last thing to ask you generally is, obviously I’m really looking forward to meeting you in the flesh in May and June to do the live lectures and you get to meet the delegates who are passionate about treating the TMD patients in general practice with good conservative care. And maybe even you’re slowly inching with more complex intracapsular cases as they develop the practice which would be a great help to you I’m sure you’re desperate for dentists who are good at providing conservative care. So I look forward to meeting you live and geeking out all about that. And you get to see what we teach the dentist as well. What is the main message you want to send out to general dentists or general dentists when it comes to the successful management of temporomandibular disorders? [Andrew]Okay. Without swearing don’t believe a lot of the BS that there isn’t the internet. Simple management measures are largely beneficial for the majority of patients. So on my website, andrewsidebottom.co.uk, there’s a free to download information leaflet which I recommend all my patients download, which covers pretty much what I tell them in the initial appointment, which is, you know, first of all, it’s not likely to progress the surgery is not likely to develop to arthritis. The majority of patients can get better with simple conservative measures. This is what how, what’s happening, this is what causes a click. The only things realistically we should be treating in secondary care are patients with persistent pain restriction, or locking and locking is kind of gets stuck as you open or you get stuck as you close. And that is happening relatively frequently. So I wouldn’t tackle anyone with just a clicky joint, I don’t want to know, they should just be told, yeah, you’ve got to clicky joint, that’s fine. So 30% of the population, the vast majority of people don’t develop problems with that. But you are slightly more prone to develop problems because of it. But just because you’ve got it doesn’t mean that you’re going to have problems. [Jaz]Yeah. Are you more in demand after the pandemic, in the sense that do you think there is because of the stress and the change and the lifestyle changes and the work from home and you name it? Do you feel as though in your practice these are resurfacing now? [Andrew]Yeah, I think everyone has seen an increase in TMD type issues. Because as you say, of the clenching and what have used the stresses of it all. Obviously, my viewpoint is somewhat skewed, because I’m dealing next door to a trust, which has a 40 week wait. So before the pandemic, 10% of my patients were self pay. Now, about 50-60% of my patients are self pay, because they don’t want to wait for two weeks to get a diagnosis. The other interesting thing, which is just an anecdotal aside, I’ve seen more facial cosmetic surgery in the last year than I have done in the last eight years. [Jaz]Is that you mean like facial cosmetic surgery gone wrong. [Andrew]Zoom faces. No. Looking at their face on Zoom and thinking, Oh, my chin looks a bit fat, my chin looks flat, what my wrinkles [Jaz]Indeed the zoom, boom. Thank you so much, Prof, for giving up your time to come on the podcast. I really appreciate I think we covered a lot of ground today. But like I said, I look forward to meeting you. And going a little bit further for those dentists who are already a little bit inclined towards this. This will also help them but we’re gonna go a little bit meatier and a little bit get again to the nitty gritty. So thank you so much for giving up your time today. [Andrew]Not all, cheers. Jaz’s Outro:There we have it, guys. A interesting perspective there about what happens if conservative care fails. What about those complex intracapsular issues. Thankfully, they’re not as common as muscular. Muscular issues are far more common, which is why the splint course can help so many of you who are looking to delve into a world of TMD, but you don’t want to go limited to TMD. That’s what I do. I’m a restorative dentist. I like to do my rehabs and stuff. I like doing Invisalign. But I’m confident when it comes to TMD consultations, and I refer the really complex ones which are intracapsular on because their success rate is lower in those cases. So I’m very good at screening about success and how it can help the majority and majorities patients just need a bit of TLC, education, physio and a splint. That’s it. Now if you’re looking for a live in person version of this, it will take like three days for it to happen. But if you want a one day introductory live course, I’ll be teaching with Kreena Panchal, our physiotherapist at the Dentinal Tubules Congress in October 2022, later this year in Heathrow. So if you don’t learn more about that go to protrusive.co.uk/congress that’s /congress. That will take you to a page more about our course how to do a TMD examination, how to palpate the muscles, how to come up with a differential diagnosis and how to work alongside your physio and which occlusal appliances to consider when, that’s what we’re covering throughout that day and the Tubules Congress if you’ve never been to it, it’s electrifying. Such a great atmosphere of dentists, the energy is just through the roof, you’ve got the best educators, you got the best parties. So wherever you’re on the world gonna come to Heathrow London in October, join the Congress. It’ll be amazing to see you and if you want to book onto my workshop, it’s seven places left only so check out protrusive.co.uk/congress. I’ll catch you in the next episode, guys. Thank you so much.