Protrusive Dental Podcast

Welcome back to the third part of this EPIC series! I hope you gained more value from this than from PAID education. Dr. Devang Patel guides us through Appoint 5 of the Adhesive Full Mouth Rehabilitation - this is when things very saucey as we discuss sequencing and staging the rehab. Onions on the ready, my fellow Protruserati! This episode is sponsored by Enlighten Whitening - thanks for your support Dr Payman Langroudi and team! In this episode we also squeezed in a discussion about stressful White Patches appearing after Teeth Whitening - what causes them and how to 'treat' them! https://youtu.be/I6IB1FxY8fA Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: This is a video pearl from the Protrusive Dental Community Facebook Group on How to diagnose a Myofascial Pain that mimics 9/10 severity toothache https://vimeo.com/687007193 Head to the Protrusive Dental Community Facebook group where this video came from for more resources like this. For the Summary of Appointment Sequencing 0 - Mindset for Full mouth Dentistry 1 -  Full mouth Assessment Examination 1A - Diagnosis and Treatment Plan 2 - Patients’ Records  3 - Mock-up and Temporaries 4 - Checking Patient’s occlusion 5 -  Anterior Direct/Indirect Adhesive Composite Rehab 6 - Checking Occlusion and Taking Impression (within 4 weeks)  6A: Checking Occlusion (2 weeks after - 1st Visit) 6B: Taking Impression (2 weeks after 1st visit) 7 -  Posterior Direct/Indirect Adhesive Composite Rehab 7A: Lower Posterior Arch or Upper and Lower Right Side 7B: Upper Posterior Arch or Upper and Lower Left Side 8 - Polishing  9 - Assessing for Occlusion  10 - Maintenance or Giving Protective Appliance  The highlights of this episode are: Indirect Full Mouth Reconstruction Protocol 7:53Appointment 5: Anterior Direct Adhesive Composite Rehab 15:59 Upper and Lower Anteriors Build-up Techniques (Using Putty/Exaclear indices from wax-up) 16:41Checking of Occlusion 26:56Posterior Stabilization (Using GIC or Bis-Acryl) 28:59Appointment 6: Checking Occlusion and Taking Impression (within 4 weeks) 6A: Checking Occlusion (2 weeks after - 1st Visit) 35:496B: Taking Impression (2 weeks after 1st visit) 36:08Appointment 7: Posterior Direct Adhesive Composite Rehab 38:45 7A: Lower Posterior Arch or Upper and Lower Right Side7B: Upper Posterior Arch or Upper and Lower Left Side Appointment 8: Polishing 46:52Appointment 9: Assessing for Occlusion 47:45Appointment 10: Maintenance or Giving Protective Appliance 48:00 Join Dr. Devang Patel's Facebook Group where you can find tons of useful resources! Also, be sure to check out Dr. Devang Online Dental Courses to be able to offer a full mouth reconstruction treatment to your patients! If you enjoyed this episode, be sure to check out the first part Adhesive Full Mouth Rehabs in 11 Appointments and the second part Adhesive Full Mouth Rehabs Part 2 – Wax Up and Temporaries Click below for full episode transcript: Opening Snippet: But if you ask anyone who has seen their cases 10 years on which I have, the mentality changes a little bit. I'm very, I do not select composite resin because they are cheaper modality I tell patients that look in a long run, they will cost you the same as porcelain... Jaz's Introduction:Hello, Protruserati. I'm Jaz Gulati and Welcome back to the big one, this is going to be the big one, because we've built you up from part one, part two. And now this is part three. So if you remember, in part one, we talked about the mindset of that full mouth clinician, how to treatment plan and communicate to your patient. In part two, we looked at how to get a wax up and how that wax up might be different for an adhesive rehab, compared to a conventional rehab, and then how to actually put that temporary in the patient's mouth and let them walk away with temporari...

Dental school does not teach us everything we need to know to succeed in Dentistry (hardly surprising). There are certain procedures that we learn (just about!), but it doesn’t give us those soft skills, the people skills and a heck of a lot of basic competencies. This episode is NOT about bashing Dental Schools. It's about recognising where were were 'let down' and taking the steps to 'fix it'. There is so much we must gain from being mentored by people who’ve been there and done it before us. Dr. Paul Goodman is one of those good people in Dentistry that we need to look out for. https://youtu.be/LpOEBcmguR0 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “[There is a] lack of fundamental skills for surviving and thriving [once graduating].” Dr. Paul Goodman Check out this How to Speak By Patrick Winston as mentioned by Dr. Paul Goodman. https://www.youtube.com/watch?v=Unzc731iCUY Highlights of this episode are: Dentists’ make up for Dental School’s shortcomings 6:30Lack of Clinical Skills after Dental Schools 9:16Advice for Fresh Dentists 12:17Limited experience at Dental School 16:38Advice for Dentists in terms of finding their niche 19:59Best way to overcome Dental Schools’ shortcomings 23:55 Send an email with the subject 'Nacho gift' to Dental Nachos and they will send you back a free resource. Also, check out the Dental Nachos website! If you enjoyed this episode, you may also like 12 Rules for Dentistry – IC002 Click below for full episode transcript: Opening Snippet: And my secret to getting high case acceptance is one sentence. My secret to getting high case acceptance is one sentence Jaz's Introduction:Hello, Protruserati. I'm Jaz Gulati and welcome to this interference cast. I've got Dr. Paul Goodman from Philadelphia, USA. He runs this amazing community called Dental Nachos. Just a great resource of positivity in dentistry, and so much help and courses for dentists all over the world. It will be so obvious to you from our conversation, his enthusiasm and his great analogies and way of communicating. I'm just a huge fan of Paul Goodman. And I love the theme that we discuss, you know, how dental school let you down. Now please, please, please. I have so many colleagues are working in dental schools and I'm well connected with dental schools. Listen, we are not bashing dental schools. Okay, we are not bashing dental schools. We are merely just raising a few real world points that perhaps, perhaps in some areas of dentistry, and maybe even clinical experience that there was a little bit of a shortfall. Now it's okay. It's alright. We get it. We understand why okay? There's only so much dental school can fulfill and it takes you back to being on orthodontic clinic and one of the tutors goes to me, she goes tp me, Jaz, did you learn to drive before passing a driving test? Or after passing a driving test? And I've only recently got my license, I was like Well, I think afterwards because I still really don't know how to drive yet properly. So it's just same in dentistry, okay? Dental school will give you that certificate, will give you that license to drill. But actually how you communicate with patients, how you can formulate really good treatment plans that are appropriate, how you can get your hands skills to whether you want them to be where they need to be. That takes time, devotion, mentorship, and it is universal, that we have to learn that once we qualify. That kind of process is only enhanced and fast tracked through good mentorship and being around good people in dentistry. And let me tell you what Dr. Paul Goodman is a good person in dentistry. Let's listen to the interview. Main Interview: [Jaz]Paul Goodman, Dr. Paul Goodman from the USA from the Dental, from the nachoverse. How are you? [Paul]I'm doing awesome Jaz, really thrilled to be talking with you. I love this topic.

Articulating paper has been around for over a hundred years, and it's still the most common way we evaluate the way our patients' teeth touch or occlude. But there's so much we cannot tell by looking at those marks! We cannot tell which ones are higher force or low force, and we definitely cannot tell anything about the timing of contacts. In this episode with Dr. Robert Kerstein will enlighten you about the T-Scan! https://youtu.be/YsxjGGitJr8 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Classically on glazed ceramic, articulating paper marks will be difficult to show up. A little hack to overcome this is to get a tiny smear of vaseline on a micro-brush, paint the articulating paper and get the patient to bite together because the Vaseline has an effect on the articulating paper which allows it to stain or ink the teeth more effectively. In this episode Dr. Rob and I discussed: Traditional way of using articulating paper and its disadvantages 14:55T-scan in terms of occlusal adjustment 19:34T-scan in terms of differences in adaptive capacity 24:53Importance of patient’s feedback 28:58Treating patients with TMD through occlusal equilibration 35:45Dentists’ concern about the thickness of the T-scan 41:20Level of precision in diagnosing patients 46:50Why does T-scan seldom meantion on occlusal courses 54:18 All of the Protruserati clan get £200 OFF the T-Scan™ from Clark Dental with the code ‘protrusive‘! As promised in the episode, if you would like to read some studies/evidence base for the T Scan click here. Click here to email Dr. Rob Kerstein If you enjoyed this episode, check out Philosophy of Functional Occlusion with Riaz Yar Click below for full episode transcript: Opening Snippet: Articulating paper marks are lying to you. Now just think about it for a second, right? When you stick some articulating paper in, and you get the patient to bite together, you often get false positives. So you get these red or blue marks in areas where the teeth aren't actually touching. And you also get false negatives, areas of teeth which actually touching and you don't see a mark and I'll tell you in my Protrusive Pearl later on how to overcome that when it comes to ceramic, glazed ceramic sometimes doesn't pick up the articulating paper ink, and therefore I'll share with you a little tip on how to make it appear... Jaz's Introduction:I just want to just elaborate on this point a little bit. When we see articulating paper marks, we see small dots we see big dots. We kind of have different beliefs if you ask different dentists some will say oh, it's the bigger marks that mean that there's more force, whereas other people think No no smaller marks because pressure is force over area therefore, a smaller mark often means higher pressure. The reality of it is, is that this has been studied, and we cannot tell by looking at articulating paper marks, which ones are higher force or low force, and we definitely cannot tell which teeth are hitting first before they eventually, more or less come together. We don't know anything about the timing of those contacts, which is what this episode is all about. Hello, Protruserati I'm Jaz Gulati. Now, let me elaborate on that a little bit more still. When we're dealing with single tooth dentistry, this really isn't so important because you're just working on one tooth. And how important is that one tooth-like to be in the grand scheme of the entire occlusion of the patient. In most patients, you can get away with a lot, you know, our patients are great at adapting. But when you have an arch of temporaries, or multiple units, let's say five or six units, and you want to be able to make sure that the patient's occlusion is comfortable, and that no one restoration is taking too much load. We're relying on this articulating paper ink, but you don't know where to adjust.

I’ve had a few questions from Dentists who are interested in learning how to place fixed retainers, something I personally have found so fiddly! The whole process can be a little intimidating at first, so Dr. Raj Jabbal takes the fear out of it and makes it fun and easy. We also talked about different types of Fixed Retainers and the daily conundrums that we have when deciding on the recipe for retention. https://youtu.be/iH8oTU5gjag Check out this full episode on YouTube https://youtu.be/GkePbSVLVm8 Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Head out to my Email Newsletter for some goodies and updates from me and also for the upcoming Protrusive App! In this episode I asked Dr. Raj all about: Routine use of Fixed and Removable Retainers as part of his Specialist Plans 7:53The best type of Fixed Retainer 10:29How to avoid warpage on Braided Type of Fixed Retainer 12:21Step-by-Step on how to place a Fixed Retainer 15:14Chance of relapse on Fixed Retainer vs Removable Retainer 20:01Cephtactics Fixed Retainer Protocol 24:40 Be sure to check out the Cephtactics - Orthodontic Courses If you enjoyed this episode, you should also check out General Dentists Doing Orthodontics  Click below for full episode transcript: Opening Snippet: Do you want to see the best ever step-by-step video for how to place a fixed retainer completely stress-free? Then this is the episode where it's going to happen... Jaz' Introduction: Welcome back Protruserati to this episode on fixed retainers. We're continuing with our Ortho theme. Like I really hope you enjoy and gained so much value from that IPR techniques video like we and the team. And I say we, it was a team effort to put this video together. And it's been so great to see your comments and your feedback on Instagram, on YouTube comments, so please keep them coming if you found that video useful. In this one, I'm going to make another bold promise, okay? The video that will be part of this podcast. So if you're one of my loyal listeners, I appreciate you. If you're new to the podcast listening, thanks so much for joining from wherever you are in the world. This podcast will speak to Raj Jabbal about the different ways, the different fixed retainer types available. Is there a superior one? Is it a case that Raj Jabbal, the specialist orthodontist we speak to does he always place a fixed retainer? Or is there a place for removable retainers only. So we'll talk about the sort of daily conundrums that we have when we're deciding on the recipe for retention, which is unique to every patient, let's not forget that retention should be a unique thing based on the patient, based on the initial situation. Because initial situation, the crowded state is the most stable state. So if you're watching on YouTube, great, I will have a video step by step made by cephtactics, which is just the most beautiful video you'll ever see of someone applying a fixed retainer. It really helps make it tangible. And what I'll be doing is I'll be jumping in and out of that video and just giving you my sort of little pointers here and there. Okay, why I might disagree with some parts that video and how certain parts are just so mind blowing, and so much better than the way I used to do it. But again, if you're listening, then don't worry, I'll make sure that you'll have an easy place to click on tool. So wherever you listen, that you can jump straight to a video and watch it but you'll still gain so much more from the conversation with Dr. Raj Jabbal today. [Jaz]Before he joined the main episode, let me give you the Protrusive Dental Pearl. So you know that thing where if you only had one wish, what would that wish be? We all know that one wish should always be 'The I want unlimited wishes.' So if I had to give you just one pearl right now, it would be that I want to give you access to unlimited pearls. So how I'm going to do that?

Check out the TOC IPR Kit with the Intensiv Swingle - Protruserati Discount! Email TOC Dental for the discount IPR can be a tough gig - from the feeling of 'making it up as you go along', to the genuine threat of repetitive strain injury from using strips. Let me help you take guesswork out of it! By the end of this episode, you'll know exactly what instruments to use and have a step-by-step process in place. Why? Because I didn't learn this the easy way. I learned it the hard way, but now I'm going to share with you these different techniques to use that will definitely give you confidence and help you get high quality, efficient and SAFE IPR for your ortho cases. https://youtu.be/x6K2o9tS0GU Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: No matter how much IPR you think you have done, do some more. You probably haven't done enough. Don't believe me? Check out this paper below by Dr. Tony Weir. "You can avoid the random learning experience I had, and you'll be able to provide better IPR than I first did for my patients." Dr. Jaz Gulati In this audio-only episode (IPR Video on YouTube) I discussed: How I learned IPR 00:50IPR Strips 12:52IPR Burs 20:17IPR Perforated Discs 24:25Intensiv Swingle Review 28:12IPR Planning 35:21 Check out this paper as mentioned by Dr. Jaz Gulati: IPR-as-part-of-Invisalign®-treatment-in-10-orthodontic-practicesDownload Quantitative-comparison-of-3-enamel-stripping-devices-in-vitroDownload Thank you TOC Dental for the instruments I used. Show them your warmth and support, Protruserati! Email TOC Dental for the Discount! If you enjoyed this orthodontic episode, you may also enjoy my episode with Dr. Devaki Patel all about IPR for Dummies. Click below for full episode transcript: Opening Snippet: Five years ago, I went on a one-day short-term orthodontic course. And another course they talked about IPR. But very briefly, it wasn't covered in much detail at all. In fact, I remember them talking about, call it tooth slenderizeation, don't call it IPR call it to slenderization because it's more patient-friendly. So that was the main thing I remembered. And there we are, you know, they said, go ahead, and you can start doing orthodontic cases now and IPR is totally safe, don't worry. And by the way, use these strips... So that was my first experience about learning about IPR. I then did my first ortho case, which was my wife. Quite commonly, I think as dentist, we tend to treat a family member or our spouses first when we're learning a technique like orthodontics. I also find by the way that splints when people start doing anterior occlusal splints or whatnot, they also find somewhere to practice with their spouse, but it's a similar theme. Now, I actually remember being in Singapore, and my wife was in the chair, I was doing some IPR with strips and I was thinking, wow, this is really slow. What does the orthodontist in the practice use? Because we had an orthodontist at work there. And my nurse said, oh, yeah, he just use these discs. He makes it look really easy. I'm sure it'll be fine, Jaz. And so I started using this disc. And boy, that was an interesting experience, because I was using it and I was like, I was asking the nurse, I was asking LC. LC, am I doing this right? Is this correct? She said, No, no, no, he doesn't like this, like that, this kind of a stroke. And how about now? Am I doing it right? And say, yes, yes, you're doing it right now. So it's quite a laughable experience. When I think about it now. It's quite a dangerous way to learn IPR. But this is our reality. I find that so many dentists that start orthodontics, IPR is like learning from YouTube, winging it or from mentors. So for me, it was winging it. But then also, when I came back to the UK, I did the Invisalign course, which, by the way, again, didn't teach me much about IPR.

After the success of PDP103 Adhesive Full Mouth Rehabs in 11 Appointments, we’re here again to discuss how to plan the Wax Up, Mock up and temporaries using bis-acryl with Dr Devang Patel. https://youtu.be/GuqSkCvFWNk Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: How I communicate a high RCT risk: For ordinary patients, I would always say “YOUR tooth decay (in YOUR tooth)/ YOUR filling was very deep.” But for some patients who you feel would make trouble, I would continue to add “...if we do nothing, then your tooth will eventually be in a worse situation. And you may lose your tooth. This could be a painful process as well. If I do something, then that involves drilling your tooth decay, drilling the soft bits of your tooth away and drilling away the old filling that's leaking. Drilling is not a nice thing. So by drilling, the drill is damaging your nerve. Your nerve may die and need a Root Canal." Highlights from this episode: Appointment 2: Patients’ Records (Impressions) 11:35Patients’ Vibe as part of Assessment before planning treatment 18:29Load Testing as part of Assessment 24:22Type of toothwear to consider the type of arch reconstruction 31:48Curve of Spee as part of Assessment 36:25Guidelines regarding Re-RCT before restoring 40:40Comprehensive Evaluation among Patients 45:32Appointment 3: Mock-up and Temporaries 51:58 Check out this occlusion one-day course, hands-on and theory for the Kana Dental Academy. With amazing Speakers line-up (some of them are Protrusive Dental Podcast Alumni) If you enjoyed this episode, be sure to check out the first part Adhesive Full Mouth Rehabs in 11 Appointments and the third part Adhesive Full Mouth Rehabs Part 3  Click below for full episode transcript: Opening Snippet: It's very important for you and technician to know what type of palatal shape you want to create when they're doing wax up. And most of the technician gets it wrong, okay? Because they're trying to create natural palatal shape which we're not trying to achieve... Jaz's Introduction: Hello, Protruserati. I'm Jaz Gulati. Welcome back to another episode of Protrusive Dental Podcast. In this episode, we're going to go through how to plan your full mouth adhesive rehabilitation, including the wax up stage and actually putting the wax up into the mouth using a bis-acryl mock up and how to even send the patient home with that mock up so they can test esthetics, phonetics and function. If you're new to the podcast. Welcome, it's great to have you. This is a part 2 of 3, so you need to rewind to Episode 103. For the part one of adhesive full mouth rehab. The concept here with Dr. Devang Patel, is we're going to cover the 11 appointments, the traditionally 11 appointments from the very first time you see the patient for a comprehensive examination, all the way to reviewing them with an occlusal appliance at the end, and all the stages in between of how to get a full mouth rehab done using adhesive approach. This has been one of the most anticipated episodes ever, like the amount of DMS I get saying, Jaz when is the part two out? I really enjoyed part one. So here it is, guys, I'm so excited to share with you. And Dev. I mean, shout out to Dev for getting so much value, giving so much away to the Protruserati, it is really, really great to have educators like you who are all giving, right? That's what we want, we want to share with each other, share knowledge and improve our daily workflows. [Jaz] Now, before we get on to today's Protrusive Dental Pearl, I want to talk about emails, right? Yesterday, I sent an email and the subject was like 'Why you need to start charging more for your dentistry?' And this email has absolutely exploded. I've had huge open rates. And it was like an essay type email, but I just jam packed it with some reflections that had. So basically one of the delegates on the Splint C...

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You HAVE to check out the music video to catch the REAL vibes! Watch Fresh Prince of Appliances on YouTube https://www.youtube.com/watch?v=pJ_Czt6TDWA Singing Dentist - you ready for the collab? ;) Next cohort of SplintCourse will be open for enrolment in March. Sign up for the launch email by clicking here!

Dental Acupuncture made tangible thanks to our guest Dr David Johnson. We cover the basics of trigger points relevant to Dentistry and Temporomandibular Joint Pain, as well as the two main applications of acupuncture in for Dentists. https://youtu.be/sHGJcsIAses Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: How I communicate an Oro-Antral Communication:  I will pull up the radiograph and show it to the patient and warn them that the root of THEIR tooth is so close to the sinus. "If your roots live in your sinus then there is a chance that you will have a new party trick: when you drink water through your mouth, it could come out through your nose via the sinus", and that creates a memorable warning/consent. In this episode I asked Dr. David: What is a Trigger Point?What is the pathophysiology of a trigger point?What causes the trigger points to turn on? What are the uses of acupuncture in dentistry in terms of a gag reflex?What is the success rate of acupuncture?How does acupressure work?Implementation of acupuncture in general dental practice Please do check out Dr David Johnson's Course and Implement Acupuncture on your practice Monday morning. If you would like me to organise another course with Dr Johnson, DM me on Instagram @protrusivedental If you loved this episode, please do check out Hypnotize Your Patients with 3 Quick Techniques with Dr Jane Lelean Click below for full episode transcript: Opening Snippet: Patients with a prominent gag reflex, patients with temporomandibular joint pain of muscular origin, in relation to that is headaches, migraines, and especially headaches, we know this one yet 60% of patients who have temporomandibular joint pain are getting regular headaches, we need to start coming away from it and moving as your stunts do down onto the neck because we know that most headaches are coming from muscles of the head and the neck.. Jaz's Introduction: Hello, Protruserati. I'm Jaz Gulati, welcome back to another Protrusive Dental Podcast episode. I feel like it's been a long time since I had a PDP episode, we've had a couple of group functions, which I hope you really enjoy with Pav. Like I told Pav before I recorded those episodes, speak to me like I'm five years old, because like I said, in a recent Instagram post, I don't know very much about implants. So that's why I really enjoyed learning those basic principles from Pav and sharing them with you. And we had some great comments on YouTube asking for more of this kind of stuff, because it's a confusing gray area, which Pav made very clear. Anyway, this episode is about acupuncture, and trigger points, and two really key uses of acupuncture in dentistry, even if you don't proceed with actually implementing acupuncture into your care, then I think you're still getting a lot of value from David Johnson, Dr. David Johnson did a fantastic job to explain the benefits of acupuncture but also how you can use something called acupressure to actually suppress the gag reflex on children and adults. So do stick around for that absolute gem of advice that he gives. And I think you're able to gain even just from that. This area, you know, trigger points and acupuncture is yet another area, which is not really talked about much in dental school, especially trigger points, like the more I learned about trigger points, the more I'm like how do they not explain this in dental school? I can actually think back to patients at dental school, which were having issues around trigger points and referred pain. And we and the dental tutor and I as a student, we couldn't figure out what was going on. But now I look back and I think yes, it must have been referred pain. And it makes so much more sense to me and you find it, once you know what you're looking for, you can find it a lot more. I think on a monthly basis, I find patients who'd benefit from this.

Today we pick up where we left off on the 1st part of Group Function Episode 13 “Can I Probe This Implant?” In this episode I asked Dr Pav Khaira about bone loss around implants - what is normal and when should I worry? Another very interesting and controversial issue we tackled is how to manage implant screw loosening as a GDP? https://youtu.be/C1Y_AdDhLzU Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “If every single year you're losing one millimeter (of bone) that's obviously an issue and we need to intervene and do something,” Dr Pav Khaira In this episode we discussed: Normal bone loss for average implants 1:53Guidelines for GDPs managing loose implant screws 5:03Universal Implant Drivers? 10:45 If you liked this episode, be sure to check out the first part of this series Can I Probe This Implant? Click below for full episode transcript: Opening Snippet: Because screws become stressed and they become strained. That may be one of the reasons why it's come loose. And if you retighten a strange screw you can you can cause it to break, then you're in trouble because you may not be able to retrieve it from the implant head... Jaz' Introduction:Hello, Protruserati. I'm Jaz Gulati and welcome back to this second part of the group function. So we split it into two. On the first group function, if you haven't listened to it already, it was "Can I probe that implant?" Is it cool to probe around implants? Because there was a myth that you may scratch the implant? So is there any truth to that? Should we be concerned? That's all covered in part one. In this part two, we've got Dr. Pav Khaira, we're talking about What is the normal amount of bone loss around implant? So when I am reviewing patients who had implants placed elsewhere, potentially, and I take a peri-apical radiograph, it's been five years since they had the implant and my expecting bone loss. At what point do I get concerned? And what point should I refer? So we're gonna find that out. And another very interesting controversial issue is, how do you as a GDP manage a screw loosening? So if the implant crown is loose, is it cool for us to be going in and tightening it? What about if you don't have the right equipment? Or how to even identify which system it is. You have to stop every single driver there is? The very real world question there and I think Pav does great justice. So let's hear it from Pav, and I'll catch you in the outro. Main Interview:[Jaz] When you see a radiograph of an implant, let's say a peri-apical. And I don't know when this implant was on, I can ask the patient, the patient like a long time ago, five years ago, 10 years ago, they give me a vague answer. But anyway, am I expecting ever, is it acceptable to have threads exposed supracrestal, ie, all the threads are not in the bone, some of the threads are outside the bone, Is this acceptable? And be what amount of bone loss is normal? Because I understand that after you place an implant, after about a year, you expect to lose "some", you're probably gonna say yes, by do all this crazy voodoo magic that they don't lose any bone. But for the average implant, what is normal in terms of bone loss. [Pav]So historically, what's been considered acceptable is as a rule of thumb, bone loss down to the first thread, then about 0.2 millimeters per year, as you quite rightly said that these is, the modern techniques, the modern concepts, were really shouldn't be seeing anything at all. But you know, I see loads of patients where they come in to see me where they've had implants placed 20 years ago, okay? And I think the issue is in the absence, in the absence of any inflammatory responses, like what we've discussed about before, there's no bleeding, there's no suppuration, the implants been there 20 years, if you've got a 15-18 millimeter long implant, you've got three millimeters of thread exposed,