Protrusive Dental Podcast

Be proactive. Be the master of your destiny. We have another non-clinical topic all about ‘making your own luck’ in Dentistry and in life including landing your dream associate position with Dr. Rupert Monkhouse, the removable prosthodontic wizard from Suction Lower Complete Dentures – Improve your Removable Prosthodontics   https://youtu.be/7AODxoWKwTs Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! “I made my own luck by thinking, you know what, I AM going to go for this. It’s the same as rocking up to somewhere like the BACD conference or the ITI conference, or Tubules” Dr. Rupert Monkhouse The highlights of this episode: How Dr. Rupert landed his ideal associate position 7:04 How Dr. Rupert managed to work full time 13:12 Advice for a young dentists looking for their ideal associate position 18:43 Dr. Rupert’s journey of development in finding his niche 31:22 Don’t forget to check out The Impression Club and also Dr. Rupert Monkhouse’s Instagram If you loved this episode, you will like How to Find An Associate Position in 4 Mins Flat  Click below for full episode transcript: “Opening [Rupert] Well, I think from my sort of perspective doing those Saturdays the reason why she asked me to do those Saturdays is because especially when none of our associates want to do Saturdays, they’re all that was, they’re all that little bit older or they’ve you know, they’ve got their two kids or whatever, they don’t want to do Saturdays. And that’s true of a lot of private practices. They don’t want to do Saturdays. They also don’t want to do Wednesdays or whatever. So whenever people ask me, I always say go and find, go and research 5, 10 practices in your area that look fantastic. And just go to them say look, do you want someone to work on a Saturday because probably they do. Jaz’s Introduction:Hello, Protruserati! I’m Jaz Gulati and welcome back to this interference cast, where we take a slight non clinical ditto it’s with our friend Dr. Rupert Monkhouse from #impressionclub. Listen, if you don’t follow this guy on Instagram, you are missing out. This guy is like making removable prosthodontics sexy again, and you may remember him way back in episode 73, where we discuss lower complete suction dentures, right? So this guy is a wizard, you need to check him out. And today we talk about something a little bit different. Rupert actually works quite close to me. So we met up and I like to hear stories of how he got his first or not his first associate position. But where is that at the moment, a beautiful practice. And it very much covers this theme, which is a question I get a lot of how do I go about getting my first associate position. And just if you scroll down on Apple or Spotify or wherever you’re listening, if you’re watching on YouTube, I did an episode recently how to get an associate position in four minutes. Okay, so if you haven’t seen that, please check it out. But essentially, this is a story of how I got my first associate position, his story of how Rupert got his first associate position. And how the relevant theme here is to be proactive. Nothing will happen if you’re reactive. So if you’re reactive, you wait for things to happen, and then you will respond. Whereas when you’re proactive, you are forcing change, you are a force to be reckoned with. You are actually a master of your own ship. You’re in charge of your own destinies, does that makes sense? This is what it’s all about. So the message and the lessons from this episode will hopefully inspire you to change the way you look at the world and look at dentistry and look at your career options to hopefully put yourself in a better position going forward. Let’s catch the main interview with Rupert and I’ll catch you in the outro. Main Interview: [Jaz] Rupert #impressionclub Monkhouse. Welcome back to the Protrusive Dental Podcast, my friend how are you? [Rupert]I’m good, Jaz. Cheers for how many back or a year on from the first time? [Jaz]Yeah, must be a year how fast time flies. If you haven’t listened to Rupert’s episode on suction lower complete dentures, you must listen to it. It is something that is so useful for anyone who’s looking to improve their overall complete dentures, but we focused on a very tricky area, a lower complete denture, and Rupert did such a great job of that. So do check that one out. Today is a slightly different theme. Me and Rupert had a little meetup, at a Turkish restaurant in Pangbourne. It was great Turkish food. So if you’re in that neck of the woods, go to that place near Rupert’s, wherever Rupert works. Where wouldn’t near Woodbridge house. It’s called Le’ Da? La’De? What’s it called? [Rupert]La’De. Yeah. [Jaz]Wow, phenomenal. Donna was amazing. And so we were talking and Rupert told me the story of how he got his first ever associate position as that wow, this story is needs to be heard. And there’s some lessons that we can extrapolate from this story. So Rupert, my friend, first, just introduce yourself to those who didn’t listen to that episode. And to probably like the two people business podcast who don’t already follow you on Instagram. Just tell us a little about yourself, what you’re about. And then we’ll go from there and lead to your story, my friend. [Rupert]Yes. So my name is Rupert. As Jaz said, I was on talking about some complete dentures last time. So I’m a general dentist, I qualified from Kings five years ago now. And my main area of interest is removable prosthodontics or prosthodontics overall, and I share lots of that on Instagram, or my page Dentist Rupert. And since doing our episode a year ago on here, that gave me the kick and the confidence to launch my own sort of platform that I’ve been thinking about for a while called impression club live. Impression Club was a sort of bit where people were sharing impressions and then it just sort of spiraled into, essentially it’s another dental podcast, people come on Instagram, it’s a live chat, more like a FaceTime kind of thing and become are a bit of everything and now there’s a newsletter and a website and all sorts so it’s yeah, it’s going a bit crazy in the years since I’ve had you on but you are the catalyst man you inspired me to do so. I owe you that. [Jaz]Well, you’re taking it in a beautiful direction. I love what you’re doing. So please guys, check out impressionclub.co.uk there’s a big gold subscribe button and a beautiful photography of a denture, that’s a denture I believe. Lovely photo of that, you know Rupert’s photography is also just phenomenal, his case documentation so follow Rupert on Instagram. Check out the website impressionclub.co.uk, register for a newsletter and check out the podcast on Spotify, on Apple. It’s an all the main platforms. So if you like protrusive you will love impression club. [Rupert]Very, very kind man. And that yeah, that was cool when we were chatting the other week about it and it wasn’t quite my first position. Ideal, my actual first position NHS beat me by about two months. But yeah, essentially I mean, it’s the position that I’m in now you mentioned it earlier, when we met it would be house. So coming out of Kings, I went up to FD in hole, I didn’t do very well. [Jaz]I want to just build some context here. I just want to build a bit of context, because people need to know the kind of practice that Rupert house is, it’s in a beautiful area. It’s a fantastic private practice. Your principal is this all singing all dancing prosthodontist. Who does these amazing big cases, he has a freaking modjaw. Okay, so if you guys don’t know what a modjaw is, like, it’s like the, it’s the closest thing that you can use to basically get a motion tracking of the TMJ of the jaw. And again, Rupert covered this in one of his Instagram lives. So if you want to see it in action, check out one of his Instagram lives. But the kind of kit this practice has is beautiful. I had a you know, you very kindly gave me a little tour. What a great vibe of the practice that you have. So this isn’t your average practice, this a beautiful practice that any dentist would love to work in. So the the crux of it is we are, you know, dentists are messaging me saying there’s a lack of opportunities. How do I get this all singing all dancing practice position? So this is where I’ve just built some context. So how did Rupert at such a young age, get the position? The story will actually blow your mind. [Rupert]Yes, I mean, I was. It all started when I went up to my FD. So I finished at Kings when FD went up to Hull East Riding of Yorkshire because I did very, very badly in national recruitment. And I thought it was the end of the world and all of that, but actually had the best time, the best year and I think that also comes into the theme of the story overall. So I ended up there and actually, I’ve landed in a fantastic practice. I mean, we talked about it in our episode of completes and it had that lab and they let me do what I wanted and things like that. And the deanery for Yorkshire row, I think it was in a pretty much earlier first sort of month saying we’ve got these two tickets for an FGDP study day. Down in Birmingham on I don’t know what it was Friday, the 10th of November or whatever. And I’m from Worcester down the road. So I was like, yeah, why not? I’ll apply for that. If I win that I can go home on Thursday night, see the folks, pop down on Birmingham on the Friday, come back for the weekends. Great, I’ll do that. So I applied for those tickets. And I won those tickets and went off down to Birmingham. And at the time, I was really interested in pediatrics. I like the bookends of General Dentistry. And I’ve got the dentures and the pediatrics. Because again, my practice are there had a charity, it runs a charity that I still do some work with other COVID curtailed it a bit called teeth team where you go into schools and they supply brushes and that is supervised brushing and then you go in twice a year and do a DMFT and all that kind of stuff. So I was really enjoying peds and wanted to go down that avenue, maybe special interest or whatever. And the, it was a holistic dentistry put the mouth back in the body kind of FGDP day. And there was a guy doing peds and he was actually the consultant from Leeds and I’d had the study day with him three weeks ago or whatever. And I chatted to him at the time. And I wanted to go and chat to him a bit more having thought about it and said, You know what, I want to explore this and maybe look at, you know, a masters or something like that, but it was one of those, you know, hour and a half talks. And then there’s a 30 minute coffee break. And I sort of sat there going, oh, there’s a bit of a queue, I don’t really want to go and then I got sort of 10 minutes to go and I thought you know what, I need to just go and do this. So I went up and stood in the queue and started chatting to him. You know, I’m enjoying this, you know, we chatted a few weeks ago. I want to explore it. And then this woman just as they do Yeah, not a lot of time left in the queue sort of just joined in the conversation. And the three of us were just chatting away and her point was the, his presentation have been mainly about pediatrics high needs being in low socio economic areas. And as you mentioned with the area Ruperthouse, it’s a pretty well off area and she went well actually she did all the pediatrics it would bring so much I see a lot of kids from, you know, not low socioeconomic status and they still have a high dental need. So maybe it’s not exactly right. But we got chatting. And then it was you know, Avi Banerjee is coming on to talk about composite everyone take your seats to do. And as we’re walking back to our seats, she said, Where do you work? And I said, hold, and she said, Do you want to move to Reading? And I laughed it off, and sat down and listened to Avi and whoever else came on after, I think Ian Chappell did some perio after or something. That’s fantastic. And then yes, three, four hours later, at the end of the day, she tracked me down at my table, the other end of the room and said, No, seriously, do you want to move to Reading and I said, Well, I’m an FD. So I’m looking for a job in September. This was November of FDs. I’ve been graduated two months at this point. And I said, Well, I’ll be looking for a job in September. So great. Here’s my card. And now a bit more context. She’s from New Zealand, her and her husband, Nick, from New Zealand, so all private dentistry there. Nick, he always loves to tell me that when they moved here, they moved to Earls Court as all New Zealanders do apparently. And he worked in the NHS for a day and gave him his notice and left as soon as he could and was like, no, no. So they been in private practice for 15 years. So they have no real context of what an FD was that it meant I was probably 23, which I was and all that kind of stuff. But she just liked our spoke to this consultant, essentially. And yeah, gave me a card and we started chatting a little bit. [Jaz]That’s the key thing to pick there. Of all the things, she just like the way you spoke, like, what did he even say? Like, what was it just that you’re polite? You’re polite young English man, or, you know, what was it? [Rupert]Yeah, I think probably just that I just spoke to a consultant well, and I don’t know, maybe I can’t remember what we talked about in the I knew it was roughly it was about wanting to do special interest. But I don’t know, just the way I spoke to this consultant. And I think, looking at it now. Not wanting to jump ahead, but essentially, as I transition through, she retired last year, and I became full time in her position, basically, because I think she saw herself in me and nurtured me over the three years to then take over her list. So I think that was partly it. She just sort of, we just sort of clicked and that was it. But that was the November and then she actually called me I think it was on holiday, I think I was in Italy. She called me that summer at the end of my FD and she was in Italy as well with a big group of dentists out there. I can’t remember what it was. But there’s quite a few famous Dentists there. Slaney was out there and things and I think it was about mentorship. And that email, got in her head. And she called me and said, Do you want to come and do some Saturdays? And at the time I was in my first full job which was in or I just taken a job in Fulham down the road from where I live now, ironically, and a big NHS practice. I was doing five days a week and alternate Saturdays and I sort of looked at when I haven’t really but go on, then I’ll do my other alternate Saturday mornings in Pangbourne as well. Because I just thought you know what, this is it. [Jaz]At this time. Let’s just pause it. So at the time you committed to working every Saturday, basically, because you’re already doing Saturday practice. So you pretty much committed to working every Saturday, which no one, no young dentist wants to do really no one, forget young dentists, any dentists just wants to redo that. But you saw an opportunity here. And I think is great that, you know, that came upon you or to all dissect that a little bit later. But you know, how that came to you, what lessons we can draw from it and how we can now apply some of that magic to people listening watching. You put yourself in a position where you’re going to be overworking in a way, how did that make you feel? And how that, What about you know any relationships you’re in at the time? It just put a strain all this you know, working as a dentist, six days a week? It’s a tough gig. [Rupert]Yeah, absolutely. It was. And when I look back at it now, I’m just like, that was crazy. But it’s got me into the position that I’m in. I mean, the good bit was is that I was living as I still do in Fulham. And it was, as we were chatting before we started recording, you know, it’s a 10 minute walk to the practice. And it was pretty reasonable nine to five hours and following and things like that the odd 12 to late or 2 too late or whatever, but on a Monday but even on that Saturday, I was working eight until 12 or one o’clock, 12:30 I think it was I’d be home by one o’clock it wasn’t that big whereas tracking out to reading on a saturday, won’t get back until half three, four o’clock. That was, it was those days that were the sacrifice not The Saturdays in Fulham. But there was that benefit that I saw of doing it and and it was great to one year out or not. We had literally straight out of FD I started I think the November then I started that so two months after finishing FD, I started doing the Saturdays and To be in that kind of environment, albeit with none of the other specialists and things there, because it was a Saturday, it was still being in that environment, having that patient base. And having the sort of support of that team around you was definitely, it was just a massive plus. [Jaz]Did you find that you were crapping yourself a little bit? Did you have imposter syndrome? Did you feel like, Oh, my goodness, am I really about to do this? Tell us about those kinds of thoughts. If you had them. We know what were you thinking? [Rupert]I still have them. I think no one. No one doesn’t have those thoughts, man, I think, yeah, it was the nice thing was that when I went into the position of Sarah is very good. And just said, You know what, just treat people the way that I know you will, and it will come and there’s nothing in terms of the work. And this is again, the really great bit about Woodborough, or a place low would prefer young clinicians because we’ve got endo, pros, perio, Oral Surgery, ortho, we’ve got pretty much every specialty oral-med and peds ironically, you know, we’ve got a registered specialist and everything else that actually you can just sit there and go, You know what, I just want to do posterior composites, that’s all I want to do, I’m going to get good at it, I’m going to do it. And now we’ve got Celine now. So I don’t have to do those either. If I don’t want to, you don’t have to do anything you don’t feel comfortable with. Because you can just turn and she said just use the line a little bit. This is a you know, it’s not a cheap practice. We’ve got someone here who’s even better than me, you might as well pay them a little bit more. And do it with them, you know, because they’ll do a fantastic job. They love doing this. It’s like anterior composite bonding stuff. We’ve got, you know, couples who love doing it and just go you know what, I’m gonna sit there stressing out over it. He’s gonna love it and spend all day polishing them guarantee him like, so there was nothing, there was no pressure to do anything. And a lot of that early Saturdays was a few nice family checkups, few emergencies, which you know, you can never really go wrong with an emergency and extirpation, they’re always going to be grateful that you’ve seen them on a Saturday and all that. So it was, that was a nice way to do it. I think if I’d gone into like a full list on a Monday, Tuesday, Wednesday, that would have been a lot trickier. And maybe in a practice where you don’t have that support. And it’s just, you know, you mentioned again about Nick, and it’s not that often that Nick will do a full course of the treatment, they’ll see the endodontist, they’ll see the periodontist, yeah, that’s just the ethos of the practices, whoever’s the best person to do that, the treatment, they’ll see. So it’s, there’s no expectation that you’re going to have to go in and get a massive OPG and a do a full mouth rehab, you just haven’t got to do it. That’s not the way it works, which helps. [Jaz]That’s great. And so I want to find out more about when that sort of initial encounter happened with your soon to be principal, at that talk at the FGDP, what lesson can we quickly sort of pass on to those listening and watching or I think that it’s a lesson of and you know, to the simple mind, you can take a step back and say, You know what, you know, some might say Rupert got lucky. And you could say that I think there’s always an element luck, like you know, who you get married to at the end is based on a little bit of luck being in the right place at the right time. So there’s always a little bit of that, but it’s more, I’m a big fan of you make your own luck. So the fact that you applied for those tickets, the fact that you stood up, and you were thinking, Oh, should I go? Should I not? But you did. You went there, and you conduct yourself the way you, you know, you’re a charming man. And, you know, that shone through and first impressions are everything, not just with dentures, but in life in general. So I think that has a lot to do with it and being proactive. What kind of advice do you give to our younger colleagues listening? I know, we’re both fairly young as well. But for some people who are just looking for that ideal associate position that hasn’t come along yet. What kind of advice could you give to someone listening and wanting that inspiration that wanting that? [Rupert]Well, I think from from my sort of perspective, doing those Saturdays the reason why she asked me to do those Saturdays is because especially when none of our associates wanna do Saturdays, they’re all that way. They’re a little bit older, or they all they’ve you know, they’ve got their two kids or whatever, they don’t want to do Saturdays. And that’s true of a lot of private practices. They don’t want to do Saturdays. They also don’t do Wednesdays, or whatever. So whenever people ask me, I always say, Go and finds go and research 5, 10 practices in your area that look fantastic. And just go to them say, Look, do you want someone to work on a Saturday? Because probably they do. And then they’ll want to take that, they want to take that on, but 100% So yeah, I definitely got lucky. But yeah, I made my own luck by thinking you know what, I’m going to go for this. It’s the same as rocking up to somewhere like the BACD conference or the ITI conference, or Tubules or whatever it is, you know, put you go out into these environments and we always Say that cliche of like dentistry is a really small world. And it is. And if you look at the bubble of the online dentistry, it’s an even smaller world. And so but those are also the circles of people that tend to go to PhDs and things like that. So go off to these events, because one, it’s good for you from a CPD perspective and social and get out of your little box surgery and meet other people. But yeah, it’s a small world. So make sure you’re one representing yourself well, because good news travels just as or if not slower than bad news travels. And yeah, put yourself out there and just have a look around. [Jaz]I totally agree. I think to add to that, I think don’t be shy. And to use the old cliche, your network is your net worth. So that amount of CPD sessions section 63, this column here, this freebie ones and evening in London, the amount of those I went to, was insane during my FD. And so at the time, my girlfriend at the time, now wife, she was studying in Liverpool, and so I didn’t have to worry about seeing until the weekend. So I had the free reign, during the week to go to as many of these events I could and even the weekends if I did as many free courses, cheap courses, I keep my hands on I would any opportunity to network I would. But more than that working, I just was there to learn and what happens that you’d like just like you said, you strike up these conversations, you find that you get a bit of luck, you find yourself somewhere at the right place at the right time. And things happen. But if you don’t put yourself out there, if you’re going to be too reserved, or you know, it makes life very comfortable, like just oh, you know, I sit here, my mates, my FD mates, I’m not going to go in, you know, to meet someone new today, then you know, where is where are those opportunities gonna come from. So one thing I want to add here is a story of when I got my job at Richmond, so for those of you know, I worked at Richmond with a guy called Hap Gil, amazing dentists, like he creates some brilliant laboratories you don’t even imagine, great inspiration and lovely practice by the river, we called it the Richmond Riviera. And so it’s a great place. And you know, I would have bitten someone’s hand off if they had that opportunity came to me earlier, basically. So it was a practice that anyone would love to work out. And so eventually I got the job after I came back from Singapore. But even like that was in 2017. But six years before that, in 2011, I was just tweeting because at the time I was on Twitter a lot. I’m not anymore. I haven’t got time for Twitter, but time I was tweeting out just striking conversations. And there’s one of these conversations I struck up happened to be this all singing all dancing, I use that term a lot today, dentist in Richmond, who I developed a relationship with online, and then one thing led to another, we just stayed in touch. So that is probably a more new age, Instagram generation social media generation example of how things can eventually work out for you. Would you say? [Rupert]No, absolutely. And, you know, moving down the track of that journey a little bit more. I mean, I did those Saturdays and then I think it was about a year later. So 2019 I think again, November, I don’t know why everything happens to me in November, I started doing Wednesdays, I started doing Wednesdays and just working with Nick. So they it was sort of service when this will be really good. You know, come in and just shadow Nick, you enjoy Pros come and shadow Nick on a Wednesday, it’s his consultation day he’ll do, he’ll fit the odd implant crown, fit the odds, you know, set of crowns but no surgery or things like that, that just come on in and shatter that. And I was like, well, I need to drop a day and my NHS and all that. And they were obviously very supportive with that and essentially just sort of sorted that. And then I spent what would end up being six months with, obviously, then COVID came in 2020 But I did six months of doing those mornings, and then my Saturdays started to get full. So then I started seeing patients on the Wednesday afternoon as well and then eventually became all Wednesdays. And then just as lockdown happened I left my NHS job to start a part time job in Worcester, where I’m from, and that was through Instagram. So that was the Tom Crawford Clark’s practice, it’s his family’s practice. And he just put on Instagram lichaam story, we’re looking for an associate. And again, just sort of when you know what I’m gonna go for that, couple of phone calls later shoot down to Worcester and have a meeting and ended up going to work there. And unfortunately, had to leave that place after a year because then Sarah said, You know what, you know, when I said I was going to retire at the end of 2023 I think she said, it’s gonna be like next week. So I had to finish that quickly. And literally, I think she said, I’m gonna I think end of 2020 End of 2022. And then she just turned around, I think as a lot of people did sort of COVID wise and just when that I don’t really, I’m not sure I think yeah, and again, it was sort of stuck between doing the business and doing the running the practice and doing dentistry and all that stuff. And I think I’d earned my stripes or whatever by then and got the opportunity to then go in and replace a fully which, looking all the way back to it became the sort of master plan I guess, I was going to be molded into this replacement. But yeah, that other job came through Instagram and I’ve got Yeah, people who get it through not maybe not dental Twitter anymore. I know that’s still a thing that’s a bit more political, isn’t it? But yeah, definitely Instagrams are good places to keep an eye on the ground. And again, if people know you through whether it’s personality, your work through your digital portfolio, it’s, an easy foots in the door, isn’t it? [Jaz]Great point and term of use the term digital portfolio because nowadays, more and more dentists, especially young dentist, new qualified, they’re journeying, they’re journaling their dental progress on the Instagram. And I’ve known plenty of colleagues who’ve gotten their jobs because someone just messaged him saying, Hey, I like your work. I like your composites, come and work for me. Because they see that okay, if this dentist is taking time to a photograph, so meticulously their work, and B) the hardest step is B, which is share it to the world. The first time you post the cases. I mean, you’ve been doing this for a while now. But if you remember the first time I, gosh, I remember the first time I posted a case, I was shitting myself, man, I was like, Oh my God, what’s the world gonna think and whatnot. So to put yourself out, there is a big step. And when you get comfortable, and you see that the world hasn’t exploded by you posting case, then you start posting a few more, and then it’s okay to take some criticism and you learn and stuff and that’s okay. But I think that shows that okay, I’m meticulous, I like to document, you take a lot of zoomed in shots and you show it to someone that you know what I care about little details, I care about my, what I’m doing, I care about how I roll the marginal ridge and all those little things. So attention to detail really shines through. So that’s the digital portfolio. But just to take a step back, there is still a role of the classic way IE, one of the other jobs I got very early on as a DCT in hospital, I wanted a Saturday job. So I didn’t deskill. So then I just rocked up at my local practice. Even though they weren’t hiring, I just gave my CV, dressed up smart on a Saturday, had a polite conversation with the receptionist, and lo and behold, also in November, but also in November. Okay, I need a new associate, you know, come and get a job. So there are those traditional way as well do it. And I think your advice just do, in case someone missed it. Your advice of the top 10 practice that you want to work for in your vicinity, go out there. And if that job, advert doesn’t exist, doesn’t matter, you make your argument compelling. You say I’m willing to work Saturdays, I’m willing to do this, I’m hungry for knowledge, I’m hungry to learn. This is me, I’m smiling. Look at me, I can, you know, I’d love to work for you kind of thing. So that is going to be a great way to help a lot of people I think. [Rupert]Yeah, I think absolutely. And yeah, it just shows your, as you say, the photography stuff, as you say is important. But yeah, putting yourself out there and willing to learn and even just things saying, can I come and shadow every other Tuesday or something, you know, because it’s easy when you’ve just come you’re early on your career, you worry more about your earnings and things like that. But doing a bit of shadowing like that is going to be so so valuable. And think even my sessions with Nick those mornings and I got essentially salaried to be there and things like that. And the which was which was of course helped it but I took so much away from just being in that environment. Because even on my, say my Saturdays it was me and a hygienist that kind of thing I wouldn’t necessarily see as much of, you know, how the specialists or the more experienced dentists would be with the patients and how they put things across and even sitting there watching Nick put a plan together and do a letter and suddenly you’re seeing four or five page you make it clears or whatever. You know, really extensive thinking and putting it across like that, that learning things like that is so so valuable as well. And again, it just shows that you’re willing to get in there and be a part of it. But I think Well the biggest piece of advice clearly is be on your A game in November because everything happens. So we’ve got one seven, eight months to get on point for November. [Jaz]Very good. Very good. Now, you reminded me of something had a chat with our Paul Goodman recently, episode at the time of recording this hasn’t been published yet. But he is the head of dental nachos. And he, you know, made a really good point that when you ask someone, if you can shadow them, that person who’s allowing you to come to your clinic is doing you a huge favor like enormous favor. When I have a dentist shadow me. I’m going to be slower. It’s gonna take me more time. I love it personally, but it does take me more time, more effort to make sure that I have things a bit more structured and I’ve checked my diary in advanced to make sure that that dentist is well cared for and the team can look after them as well. So we, you know, when a dentist allows you to shadow them they’re doing your massive favor. So A) don’t be afraid of rejection, ask if you can shadow and B) if the dentist doesn’t reply or you get a no, don’t take that to heart, okay? It’s a big deal to let someone come into your clinic, come into your space, come into your surgery to let you do that. So definitely asked, but don’t be disheartened if you get some no’s not everyone is comfortable with, you know, with their dentistry being watched. I know some great dentists who still, to this day will not allow anyone to shout at them because it’s not comfortable. And that’s fine. That’s cool, let’s make this make peace with that. But still get your message out there that I am hungry for, to watch someone and definitely find those opportunities. Even if you have to take on a sacrifice a day sacrifice and pay any way you can to to get that experience is invaluable. Shadowing for me as a young dentist is great. And I still am looking for opportunities to shadow now and again. And I love it. [Rupert]Yeah, 100%, I took so much fun. And I was already in the practice at that point. But it definitely helped me integrate or transition even better into that role of private practice, or high end sort of specialist referral private practice. And yet you get so much more out of it than that alternate Wednesday or whatever it is that you lose from your other work. See, I think definitely worth doing. [Jaz]My final question for you, Rupert is in your journey, how long did it take for you to come to a point to feel confident to be like, You know what, I’m cool to be associated as the dentist who loves dentures, and I’m proud of the dentures and here’s my photos of my impressions, because you know what, I’m proud of my impressions and they look good. And they are, Rupert they’re amazing. So how long did it take you and all how can you, it doesn’t matter how long it takes anymore it’s more about reaching that stage. So on that journey of development, how can dentists listen to this, expedite the development in a way to find their niche and then be proud of that niche and be able to share that niche because like I said, most people are afraid to show their work. So takes a lot of steps, sacrifice and hard work to get to a stage where you have now created a niche and like you know, everyone knows you’re awesome. A lot of things, but especially dentures like you are known for it. So how do you get known for something? How do you become comfortable in your skin to be able to do that? [Rupert]Yeah, I think it’s funny one, really, in terms of the social media stuff, I never did it with any intention of becoming the denture guy. I literally, I made the account. And the way this is said was we sort of cruise over, we almost got onto the star when I was doing the six days kind of thing. And there was a point where I was really, really struggling in practice and things like that, in terms of just the blasting of NHS and things like that. It just wasn’t for me. And I’d have these bits where you start to follow a bit more on Instagram, and we talked about it in our other episode, I do a lot of landscape photography and all that kind of stuff. And my normal Instagram was getting filled up with, you know, George, the dentist doing remarkable things or whatever. And I was some days, I don’t want to look at this. So I’m gonna make another Instagram, I’m going to make Dentist Rupert, just so that I can unfollow it all from this and follow it on that. And if I don’t want to look at teeth that day, I can switch over and I can look at lovely pictures of the mountains in China or whatever it is. And that’s what I did. And then there was the odd story, posted the odd story picture of an impression or whatever. And then impression club became a thing. Someone else tagged it first. I didn’t come up with it. Someone else tagged it. And I thought I’m having that that’s good. And, yeah, it just started a little bit like that. And then I did it stories first, dip a toe in the water, right? Because they disappear after a while, so it’s fine. And it got some traction. And people wanted to ask us some questions as Okay, people one are interested because you don’t think that someone’s going to care about primary impression of a edentulous patient or something. And they respect my opinion and want to know, so I thought you know what Go on, then, as you say still first case is terrifying, right? But it was yeah, that was sort of it really, I thought you know, people actually do care and people want to hear about it. So I’m going to I’m going to go for it. And it started off slowly. And a lot of the pictures were horrendous. And then you go and do Manish Patel’s course and learn how to take them properly. And shout out to Focus as everyone does. And yeah, I think you just take it like that. But the weird thing is I always think I did the, you know, the drill podcast of the day if you’ve heard that on the two chaps, 40 episodes, kings and they were asking me about running a successful dental social media account. I said like I had no intention of doing it. I think the weird thing is people that you go out and got Want to be an Instagram dentist. So I don’t really know about that, because it just sort of again happened by accident probably in November. And I think yeah, it’s just start steady, have some stuff banged up and just do it because you enjoy it. Like, it makes me enjoy my work more. I think the even though I get, you know, get a lot of questions do you have all the time for the live sessions and the podcasts and all this, it’s probably the same for yourself. That’s actually my favorite part of the week. I love so much, my Tuesday nights when I get to call up some epic dentists from wherever, and have a chat with him for an hour about teeth. Because we’re both the same. We’re both a bit geeky, really and enjoy teeth, maybe a little bit too much. But yeah, I just it feels my passion for it. I’ve had the passion in the first place, but it just feels in and keep driving it on. So I think you’re doing it for the right reasons is really important as well. [Jaz]I totally agree. And I think just to remind everyone, the way this podcast started was I, I mean, the whole overarching theme is sharing because I was driving to Oxford, back to London, to Oxford to London. And every time I was driving, I was speaking to a new dentist, telling them about my experiences in Singapore as a dentist, and therefore it got very laborious. And eventually I was like, How can I record it on a voice recording and just put it out there? Oh, there’s these things called podcast exists. So essentially, I was sharing my experiences. And then I was sharing some other people’s experiences. And then that’s how it grew. And in your case, you are sharing your impressions, you were sharing your enjoyment of dentistry. And so the lesson here is share. I’m not saying give up density and become a content creator or anything, I’m saying just share. And if nothing comes up, it doesn’t matter. Do it because you love to share, and you will help someone else who may be a few steps behind what you’re sharing to figure out oh, if I just now start using polyf as my temporary cement for my temporary onlays I might get better success, then I then they’re not and then you little nuggets, you know, not everyone knows what you know, and you have to be comfortable if that that even though you, the listener right now, the watcher right now, even though you feel as though you don’t know everything, no one knows everything, you can still contribute to our community of learning. And therefore, the answer is Share, share, share, don’t be afraid to share. [Rupert]And that’s the beauty of doing it on Instagram really is that everyone’s there for the same reasons. We’re all just sitting there trying to get little tidbits and some people want to sit there and absorb it all. Like that’s what I was doing at the start just absorbing it all, that’s fine. And as you say, we’ve all going to have something and we’re all going to have a tip that someone else maybe doesn’t do or not even maybe a new tip, we maybe just say it differently, and other people that resonates with people in different way and things like that. So it’s even just so how you put it out and put it across which is important. And the funny thing with your story and I remember you talked about that with how the podcast started, it’s exactly the same as how the live session started. Because I’d get lots of DMS and I’d get the same few DMS. So I thought you know what, I’m gonna make some videos and I may as well do them on a live with my technician and we’ll run through five different cases and answer them all it’s an FAQ. So yeah, I think just go with it and just share, if people are asking you the same stuff it’s probably means that people want to listen to it right. [Jaz]Amazing. So right, Rupert, it’s been a pleasure as always You’re very welcome. Protruserati and alumni of this podcast, guys, please check out impression club, just his Instagram account, but also the podcast. The newsletter is full of absolute gems, as we say. So Rupert, my friend, thank you for making time for this. Thanks for sharing your journey. Again, back to sharing. Thank you for sharing your journey. I’m sure that will help a lot of people [Rupert]Cheers both. Thanks again for having me on. And I’ll catch you soon. Jaz’s Outro:There we have it guys. Hope you enjoy that chat with Rupert Monkhouse. Listen if you found this to be inspiring or uplifting, or there was a nugget in there, which you really thought yes, you know, I needed to hear that today. Then please can you say your thanks by going on iTunes, or Apple and Spotify and giving me a rating of your choice? You know, ideally five if you thought so. But please do rate the show. That’s how other people, other dentists around the world can find out about Protrusive so we can share the love, share the love with everyone. Anyway, I’ll catch you in the next episode. Be a clinical one. I’m not gonna tell you what it is. I’m gonna keep it a surprise, but it’s one I promised quite a while ago and I’ve been you know, holding it as like a trump card for that way. I’ve got a little trump card on my pocket and I’m about to take it out. So catch the next episode, same time, same place. Thanks so much

Hi Protruserati! Welcome to the first episode of #AskJaz. This segment is all about sharing some gems I have learned from my mentors – I will address a combination of the questions YOU have sent in over the last few weeks. https://youtu.be/qMEGcs1XP4A Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! In this episode, I answered some of these questions: Inlay that kept coming out 3:15 Stable Income vs Risks 5:18 Mentorship 6:36 Injection Moulding Mistake 7:38 Step by Step PDF Infographic. Click here If you loved this episode, be sure to check out the first episode of the ‘Occlusal Adjustment’ How To Plan Your CPD/CE to Maximise Learning  Click below for full episode transcript: Opening Snippet: Welcome to the first-ever AskJaz, I'm doing it live, okay, Because I am literally so strapped for time right now, tomorrow is my holiday, I'm going to Dubai on a family holiday... Jaz’s Introduction: Man, I have never needed a holiday so badly. So for those of you who know me, you’ll know what I’m like, for those of you who don’t know me so well, I only really switch off when I’m abroad. It’s just a funny thing about me. So if I’m not playing my son, or if I’m not chopping onions, or if I’m not writing a treatment plan letter, or doing some admin or doing the podcast stuff, or the courses stuff, I literally don’t switch off. So this pandemic has been very difficult for me in a way that I’ve been desperate for an opportunity to switch off. So that’s coming next week. But I want to explore this concept of AskJaz, because I’m no like, you know that I’m No expert. There are so many people who know so much more and do great work and I admire what they do. For me, it’s just sharing. And the reason why I think that’s important is because when I started to share some years ago, so the specific example is when I worked in Singapore, and then I came back to the UK. And then what we found is that, like, I was on the phone to a different dentist every single day on my commute, to from Oxford and to back to London. And I was telling them the same story. They’re asking me the same questions. Hey, what’s it like in Singapore? How much do you earn? What’s the language like? Are there any exams that you have to pass to be able to practice in Singapore and that kind of stuff? So I decided to share and I made a podcast called Protrusive Dental Podcast, you may have heard of it. And I thought it was just a great thing to be able to do to free up time for me that was amazing, It was a selfish reason why I created the podcast, okay, if I can now just make this and the next episode was like, USA, one of my friends was going to USA she’s studying there. Okay, how can we now help people who might be considering the USA and then Episode 4 (I meant Ep 5, my bad!) was Australia. So the way it developed initially was like, I was kind of like this immigration agent for dentists, right? But then I started to be myself, I started to share my geeky things. I’m a massive geek when it comes to dentistry, as you guys know, so I think it’s so important to share. And one of the questions instantly I had in was about a dentist who was so nervous to share and post his cases on social media. And I said, Listen, if you can post your cases on social media, you will develop so fast, so quick, and so much that it’s going to be, it’s going to bring about great, great vibes, great energy when someone shares. So part of the Ask Jaz is although I felt like a massive imposter syndrome, so you know, ask me, I’m the expert, nothing like that at all. I’m just literally here to share. So let me share with you some questions that we’ve had over the past few weeks, obviously, on YouTube, we had that question about the bonding protocol. He said, Saline but he meant Silane. And so I shared that to the Protrusive Dental Community Facebook group, if you’re not part of it, do join it. And on that group, there were some great comments, I tagged some people who I really admire why no have really studied in depth all about the bonding protocol. And what’s the best way to get highest bond strengths? So they chipped in so German shout out to you, my friend. There’s some great content. So if you’re looking for some bonding tips, and optimizing your bond strength to ceramic, that’s already covered on the Protrusive Dental Community, just go straight there. So the next question I had was from a buddy I’m not gonna I’m trying not to name people without asking their permission first and at the time when people ask this I didn’t think of asked, so I’m not going to name people but you know who you are. So one of my buddies whom I actually went to Dental school with, he told me about an inlay that kept coming out. So an inlay I think, as a premolar that kept coming out maybe three times. And so he said, Okay, what do I do now? How do I manage this inlay that’s coming up? So funny thing about inlay is that when I was at a really great lecture in Singapore, I can’t for the life of me, I cannot remember the name of the speaker. He was a Swiss speaker in Singapore at the Singapore Dental Conference and I have to find his name. And he shared this hilarious thing about inlays. He described inlays as RobinHood dentistry. You are stealing from the rich and you’re giving to yourself, you’re stealing from the rich and you’re giving to the dentist so it’s RobinHood dentistry. Because inlays, he kind of saw as an obsolete thing. So he did not practice inlays and he thought that it was kind of very few niche scenarios where it’s appropriate. Actually, the episode we did with Chris Orr 30 something, I actually asked him about, okay, well, is there a place for inlays in dentistry? And he literally said, So Chris Orr, someone we all love and respect so much in dentistry, Chris Orr literally said that the only time you do an inlay is if he’s kind of running out of time and he’s prepping a whole quadrant. And instead of doing an MO composite, he’ll just impress the entire quadrant of indirects. And then he was asked for an inlay in that area basically. So there’s no major reason of doing an inlay usually. So what I said to my buddy, was that okay, the patient doesn’t care about the inlay. The patient doesn’t want an inlay. The patient wants a tooth. Do your composites for that, you know, my composites don’t fall out, okay? So then why don’t you just clean up the tooth and place a composite? Is said Yeah, you’re right, actually that the patient doesn’t care, the patient just wants their tooth. So that was how we dealt with that. I thought that that’s something worth sharing about where inlays stand in dentistry. And the advice I gave. Another question I had was, some advice I gave to one of my colleagues on telegram about how there’s a job position. So he’s looking for an associate position, by the way, that app is coming out soon, it’s going to have like a jobs board. But he’s looking for an associate position. And I sent him a link to an associate position, which was advertising for someone to build their own list, and it had all the bells and whistles and toys. But the downside is there’s no initial stable income, you have to do the hard work to build your list. So he said to me, I need a stable income, though, this is the issue. And I said, Look, sometimes you have to take a pay cut, sometimes you have to take a pay cut to, in the pursuit of something much bigger. So for example, when people are starting a brand new practice, okay, from what I read, it’s very unlikely that that practice will be highly profitable until about year two, this is from reading, I’ve zero experience of owning a practice or zero desire to own a practice. But this one I read, it takes some time to get the level where you’re making profit. So when you’re making, when starting to practice, or when you’re doing a master’s program, okay? You’re not only are you paying the fees for the master’s program, you’re also taking a hit in terms of loss of earnings. So that’s another consideration there. So sometimes you have to take a pay cut, to be able to grow. So that’s the advice I gave there. Someone asked about, where do you find a mentor for implants, and I kind of gave a couple of suggestions that I knew of in London. But I think whenever you are considering, okay, I need a mentor. There’s no harm in just literally reaching out whether it’s by email, facebook, instagram for you, like you’ve all heard of this thing that there’s six degrees of separation between you and anyone else in the world. When it comes to dentistry, it’s probably like two degrees of separation between you and any other dentists in the world. And nowadays, you can message pretty much any dentist like if I were to message Marcus, Professor Marcus Black, who I admire so much on the work he’s done with the Zirconia and Ceramics, like he replies to me, I message him on Instagram, I get some advice for him. So you can reach anyone, and then you can build that relationship of mentorship. So I always say, there’s never been a better time to be a dentist than right now. So mentors are everywhere, you just got to keep an eye out. Next one was, which is the best way to prevent contact sticking tooth to each other. I forgot the context of this one. So Uzman I’ll get back to you on that. Okay, last one, then. My buddy was doing an injection molding case. And he was absolutely horrified, because he managed to stick loads of teeth together. So injection molding, obviously, you get like the clear stent like exaclear or Memosil, I think people prefer exaclear, because it’s a bit clearer. So exaclear’s a GC product, super clear. And one top tip is to make sure it’s got enough thickness, and therefore it have enough rigidity. So when you’re using that kind of stuff, make sure it’s it’s thick enough so that it doesn’t flex as you’re placing it back on the teeth. So when it comes to injection molding, one of my buddies, he went on, like two courses, not on injection molding, but on treating tooth wear. So he found this tooth wear case and decided that okay, I’m going to use the injection molding technique, which was briefly described on the course. And he found that he had an absolute nightmare. Despite using PTFE, he found that the composite went everywhere, and it stuck to everywhere. So I delve deeper with this dentist. I said, Okay, can you just describe your protocol to me, and I was kind of shocked that although he’d been on this couple of courses, no one had mentioned to him that nowadays, there’s only one really sensible way to do injection molding, in my opinion, okay? I’m no expert in injection molding, but in my opinion, there’s only one the sensible way to approach it. And that’s by using an every other tooth model. So what does that mean? So imagine you have the pre op, upper model, or someone with worn teeth. So imagine these worn teeth of a model. And then you get the technician to digitally wax it up, okay? And print that model. So now you have the pre op model and the post op model. And you can do that the trial and the mock up to get the patient’s approval and check the cant and the aesthetics and phonetics and that’s all fine. But on the day of the injection molding, the clever thing is that you can tell the technician on the digital plan to Okay, let’s say we’re doing upper canine to upper canine, every second tooth, right click, Remove, so remove the digital wax up. So let’s say you have an upper right canine which is digitally waxed up and the upper right lateral which is original tooth, it’s not waxed up, then the upper Central is digitally waxed up then the other Central is not waxed up. So this causes every other tooth scan and when you print that lesson every other tooth model. So the first thing you will do for injection molding is create a memosil or exaclear stent for that every other tooth model now can you see where I’m going here? When you put that exaclear stent on the worn teeth, it’s going to hug the every other worn teeth so nicely that you’re going to really minimize how much excess you get. Because if you use just the exaclear of the final model, that composite’s just going to go everywhere, it’s going to stick everything together. So by using this every other tooth model, the first sort of stent you put on, will be waxing up every second tooth. And then the other alternative tooth, the exaclear will be hugging the teeth so nicely, so tightly, that it’s really going to minimize the excess. This makes it really quick, really easy. It’s definitely worth the extra expense of having a second model, you know, that cost minimal in terms of how much you can be charging for a patient. Then once you’ve done that, and you’ve tidied it up, and there’s just a little bit of excess to clean, now you can use the final sort of every tooth being waxed up. And essentially, you have another stop now, whereby you’re going to really minimize how much excess you have because you already have composite on the adjacent teeth. And yes, of course you have to use your PTFE and make sure that you’re not overzealous with your injection molding, you’re not placing too much of the resin. So it was a real shock that this dentist had about how much he had to sort of clean up. So he had to put the patient back in, start again, do a lot of it freehand. So a real waste but a real valuable lesson learned. Jaz’s Outro: Anyway guys, thanks so much for joining me. If you follow me on social media, you probably hopefully see some nice holiday snaps. I’ll catch you next week, same time, same place. appreciate you listening so much. Thank you

Psst! Hurry, www.splintcourse.com Enrolment ends Thursday night! No matter what kind of Dentist you are and what niche you are in, chances are that you will encounter TMD acute pain patients. This practical episode with TMJ Physiotherapist Krina Panchal is going to equip you with 3 simple exercises you can confidently prescribe your patients and WHY they are effective. https://youtu.be/fNay0J6NlS4 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Handing Composite for a Class 4 Restoration: When you’re restoring a Class IV on incisors you will need to decide how to manage the interproximal area. In the ‘immediate’ technique (called Immediate because you will manage this straight after the palatal wall build up) you can use some form of an interproximal matrix (posterior sectional matrix used vertically, for example). The tip here is to roll the composite between your gloved fingers first, roll it into a sausage, then you will then place that ‘sausage’ into the interproximal area. This will help you get a better interproximal shape. Inspired by Dr Dipesh Parmar from Mini Smile Makeover course. In this episode we discussed: How Physios assess their TMD patients 13:46 Joint Exercise (Rotation) 15:03 Muscle Exercise 19:25 Tongue Scrape Exercise 26:13 Advice for Patients who are in Pain 29:43 Bucket Analogy 32:10 If you enjoyed this episode, check out another episode from Dr. Krina Panchal TMJ Physiotherapy – When to Refer and How They Can Help  Contact Krina Panchal Click below for full episode transcript: Opening Snippet: Hello, Protruserati. I'm Jaz Gulati and welcome back to your favorite dental podcast. In this episode you will learn how to prescribe three really simple, really easy but super effective exercises to all your TMD patients Jaz’s Introduction:The thing I discussed with TMD Physio Kreena Panchal today is that as dentists, we don’t really get taught exercises that well what the indications, how to do it, how many seconds to hold it for, because usually we ourselves learn it from Googling, finding a PDF, and following the images and just giving the patient the leaflet or a brochure and so that yeah, just do these exercises, you’ll be fine. But from this episode, we’re gonna make it super clear, super tangible. So you can start implementing this right away. Before we join Kreena, some important announcements that by time you’re listening to this, if you’re one of my listeners who listens on the day the podcast comes out, my superfans, the real Protruserati, thank you so much. There are just two days left to join Splint Course online, if you want to learn how to manage bruxism and TMD in practice now, the exciting announcement I have to add to that is that by the end of next week, the splint course will be available as a podcast. So it’s designed for the busy people who are commuting who don’t have time to watch the videos just yet. Therefore, even when you’re commuting, like you listen to this podcast, I’m going to let you consume the course, entire 13 plus hours as a podcast. And then all you have to do is refer back to the ebook, and refer back to the videos for the little clinical bits here and there. But you will absorb so much more just from driving and listening. So if that’s been, if you’re on the fence about it, because you’re gonna struggle to find the time but you always find time to listen to podcasts, then this is done for you so that you can access that information. And then you can drastically reduce the screen time you need to be able to get the knowledge that you need to start making splints on Monday morning. Now some of you email me saying Jaz, when are you going to bring the splint course as a live course because the online course really isn’t for me, well, good news and bad news, okay? Good news is that the live day is coming, okay? So me and Karina and a maxillofacial surgeon, we’re gonna do a live day. We’ll talk more about that later on the towards the end of the episode about what we’re gonna do, we’re gonna teach you, but the prerequisite is that you need to be a splint course delegate alumni, because if we did cover all the theory and the hands on that we want to as part of the splint course and I wanted you to really walk away with all the confidence that I know my delegates can get that it would be a three day course, that’s three days of lots of earnings, accommodation, etc. Therefore, I only want to do a one day hands on with a physio, myself and the maxillofacial surgeon to supplement the theory. It will be a little bit of a refresher as well. And there’s a beauty about live courses that sometimes you know, you really grasp concepts well when you’re there palpating, the origin the masseter where you are perhaps palpating in the wrong place all that time. So there’s so much to be gained from a supplement. But unless I did it into a whole three to four day course, it’s unrealistic to make it happen. So it’s a supplement only available to those splint course delegates, it’s just 200 pounds. Obviously, it’s in the UK. So I apologize to all my international delegates. But that’s another reason why the main course is still the online course. The most exotic delegate we’ve had so far in this cohort of splint course is from Ghana. So thank you, the Dentist from Ghana joining us from Africa. I think you’re the third African dentist to join the splint course. It’s great to have you. So because the Splint Course is international, it needs to be online. And I’m so proud of it. In fact, have a listen to the way that one of my delegates, Marwa was able to apply the splint course is gonna blow your mind, okay? Listen to how she was able to apply it. [Marwa]Yeah, it’s going really well. So I work. Half my week, I’m an associate just in general practice and half the week I work in maxfacts. So I’m actually applying what you’ve taught me in Maxfacst a lot. [Jaz]Amazing. Oh, Maxfacts need people who can.. [Marwa]They need it. [Jaz]Who can really think outside the soft splint [Marwa]Yeah, oh my gosh, like very, very guilty of just giving soft splints to everybody. And like, I used to have a sense of dread because like, no one wants to see these TMD patients they get given to the most junior person on clinic which was me for a very long time. I used to dread it if the dentist really tried a soft splint because like, oh my gosh, what are we going to do? I can’t.. [Jaz]You have no weapon anymore. [Marwa]I know and I’d be panicking and then conservative I eat you know nonsteroidals and just you know, see you in six months knowing they’ll never be seen again, unfortunately or not for at least two years just because of the backlog in the terrible system that we work in. So now I’ve got Yeah, got my own little clinic going and people are referring to me within the hospital because I’ve been made [Jaz]I’m so happy for you. Amazing. Oh, and what kind of, Have you found any failures there? Have you learned from any of these failures? In terms of diagnosis and stuff? I think you weren’t here earlier but what we were talking about the new form, the TMD evaluation form and one thing that I hadn’t really mentioned much on the course because not so common is people with masseter atrophies not hypertrophy, atrophy and the mistake I used to make in the past is okay this patient grinds let me try and ampsa and see if that helps them, these patients wouldn’t respond. Because obviously the whole point of ampsa is to dial down the muscles but with atrophy, you actually want to dial them up and I’ve learned a few things over time. So I’m gonna make some a bonus modules for you. But have you had, what kind of success or failures have you had so far? [Marwa]And so I guess last week, I just I had a fantastic successor, a lady that has been around everywhere she actually had ortho thinking it would solve her problem. It didn’t. And she was just fed up and she’d been see private specialists I think, trying to remember her if she had Botox or not, I think she potentially had tried Botox once but yeah, hadn’t reacted well to it, didn’t benefit her. And she was wearing like upper lower essix and I basically just converted one of them into an ampsa and essix with it, with the discluding element of splint. Sorry. And yeah, she literally came back three weeks later and was like, my pain has gone and she was just incredibly grateful and yeah, she’d been around ever so that was probably my biggest success because it’s one of those that literally has been to everyone, has been the orthodontist, has been to see other specialists, has been see other consultants, has had Botox I think privately and then little old me thanks to spplint course. And thanks for everything you’ve done [Jaz]Oh No, nothing. Oh, you did all the implementation. Honestly. It’s all I’m so so so happy to hear that. Well done [Marwa]Yeah, I’m trying to get the other team members on board and the consultants. The consultants when I presented this idea to them, obviously, they’re very old school, very much soft splint for everyone. And then when I said to them, you know, I’m learning about this, can I do this? I got two out of four of them on board, and another one came on board, and now he’s referring his patients to me, so they’ve got no interest in it. So but I’m very fortunate that I’ve got access to kind of MRIs I found a physiotherapist via ACP TMD, as you recommended, I can refer patients to on the NHS. There’s not too far from where I work. So I’ve been working with her as well. [Jaz]The Protrusive Dental Pearl I have for you today is a composite one, I know what you’re thinking, What are you doing Jaz? You’re mixing TMD and composites. But hey, guys, we’re generally dentists, right? We love this, we live and breathe this stuff. So my tip for you is this. Let’s say you’re doing a class four restoration in composite, and you’re going to be managing the interproximal area. Now, there’s so many different ways to manage it, now if you’re gonna be using the immediate way of managing. So it’s immediate and delay, and this is what Dipesh Palmer tips on the mini smile maker course, there’s immediate is okay, when you build your palatal wall, you are now immediately going to manage the interproximal area, the delayed would be you build the palatal wall, and then you start doing your veneering and whatnot. And then right at the end, you will manage the interproximal area however that may be. To manage it immediately. It usually will involve you using some form of an interproximal matrix for your class four, so sometimes we like to use a posterior sectional matrix vertically, right? You put us a posterior like SB 100, for example, or Tor VM. And there are some bespoke ones out there for those indications anyway, but you put it in vertically, instead of the horizontal way that you normally use it. And now you’re gonna place your composite to create that contact area, okay contact, so it’s not contact point, it’s a contact area. Now, the main tip here is I’ve been guilty in the past of just squirting with my capsule, the composite into that interproximal area, and then getting my burnisher on my brush and just sculpting it. But it’s not the best way, the better way would be actually. And I used to be really against this because I thought oh, you’re contaminating the composite, as long as you use a clean gloves it’s okay, so I’ve been taught. So you would take the composite on your fingers, first your gloved fingers, and you will roll it into a sausage, you will then place that sausage into the interproximal area as part of this immediate technique. The main tip here is how you handle the composite. And the reason that it’s a good idea to handle it in that way is that you’ve kind of halfway there and to get in the right shape for the interproximal, you want a nice curved area. So by putting something that’s already pre curved into a sausage in that area, it reduces the amount of work that you need to do with the instruments to get to adapt neatly to the interproximal surface. So that’s the main tip there. Use the composite in between your gloved finger, roll it as a sausage and put it there when you’re doing an immediate technique for class four. Anyway, let’s join Kreena and I’ll check you out in the outro. Main Interview: [Jaz] Kreena Panchal, Welcome back to the Protrusive Dental Podcast. How are you? [Kreena]Good. How are you? [Jaz]Amazing. I mean I say amazing. But we’re both parents. So we are exhausted. We are struggling, your little one is having a fever. My little one is with my parents because we’re afraid to send him to nursery in case he catches something before our holiday. So this is the sort of manic life that we live but I’m so grateful that you have time to speak again to the Protruserati. So guys if you haven’t listened to Episode 63 Please go back and listen because in that episode with Kreena, we discussed about the role that physiotherapist can have to help our TMD patients. What is it that you guys actually do? You mentioned a lot about Research, the opera study, for example, you mentioned, we went in a lot of detail into that. But today we’re gonna go a little bit more about exercises, the three main exercises, people, can dentists can listen to today, and have more faith, that they’re educating their patients better. Before we get to that, for those who haven’t yet listened to Episode 63, just introduce yourself, and tell us about why you love what you do. [Kreena]So I’m a specialist TMD physiotherapist. And I think I love working with TMD patients because they are so complex, no sort of rule or protocol fits all. There’s a lot of investigative work, I have the luxury of time. So I spend a lot of time with my patients, and therefore I’m able to do the investigation. So I just like how tricky they are to be honest. And so many different modalities need to come in for the treatment to work for the patient and how I’m able to work with so many different professionals and learn from them as well. So yeah, I really enjoy working with TMJ patients [Jaz]Where do you work? So obviously, lots of dentist message me all the time saying, Okay, well, who do I refer to? A lot of them have already listened to our episode. So they already know you and they refer to you and whatnot, but just give everyone a flavor of where you work. And then how potentially, if they’re not in your locale, how they can get some help from a local physio, maybe? [Kreena]Sure So, and I work in Mayfair in central London. And I also work in Gerrards cross, just outside of London, but I also do virtual appointments as well. To help, I’m able to assess them and give them exercises or teach them how to manage their own condition. Otherwise, you can go on the acptmd.co.uk website, under their menu, if you go on to find a practitioner, you’ll be able to find a local physio, who has training in TMD. From the physio hospitals out in up north, and there you say that can be your physio that you refer to and I would encourage you to get to know that person, maybe just have a quick phone call, see how the work, see how you can work together, so you’re both on the same page. And you’ll get referrals both ways. [Jaz]That’s so true. You know, the physios that help these patients with musculoskeletal issues which involve TMD can then refer to you where appropriate for an occlusal appliace for their mastication, restorative works, it definitely works two ways. And when I first found out about that website some years ago, I was working in Oxford at the time, and I found someone locally, we went out for coffee, I met this nice Greek man, unfortunately, he went back because of the pandemic, but the message here is connect, have a coffee, share the treatment principles, and then there’s definitely a mutual sort of relationship you can have in terms of referrals, and ultimately the patient’s benefit. So I would definitely encourage everyone to do that. Now Kreena, you are going to talk about some exercises. And the reason I wanted to bring you on to talk about exercise is because a bit like physios who in their training, they don’t get actually taught about TMD, which is when you first told me that that was fascinating. And you know, you’ve been around the world to learn from the best people, which I admire you so much, and I refer my patients to you. But when it comes to TMD, we know that there’s a mixed experience, even for dentists and the knowledge and information that we get at dental school, but exercises for sure we’re not very well taught. And in fact, most dentists will learn exercises by Googling them, finding a PDF, and then reading that information and then conveying it to their patient in front of them. So can you talk about what are the maybe two or three main exercises that you prescribe to your patients? What is the indication, the benefit for them? And how can I obviously lots of audio listeners here, but there’s video as well? How can you sort of describe it to them so that we can get better results for our patients? [Kreena]Sure. So when physios are assessing patients, you’re checking for their movement, their strength, their coordination, and then how all of those three link to their function. Okay? So the initial exercises that we give, are quite simple because first we want to assess their suitability with the exercise, the last thing you want to do is give them something and then everything flares up. So your assessment is key in there, if they’re already flat or so 10 out of 10 pain on the slightest touch, then, you know, you want to give really simple exercises initially. And it’s important to give them something because they don’t have confidence with on how to move, how to chew, how to function at all. So we need to initiate that movement and therefore start with them feeling confident that they can use their jaws, all of a sudden the discs gonna slip or they’re going to lock. So the first exercise is my joint exercise. And this exercise is where really simple, you can give it to everyone, even if there are 10 out of 10 acute flare up in their jaw joint, and super painful, I can’t do anything they’re talking with their lips, that sort of thing. They’re already on soft food diet, this is the first exercise to start with. So this is where we are doing pure rotation of the condylar head. Now, even though it seems like such a simple movement, when you are only rotating the condylar head, you are lubricating the condylar head, and therefore you’re getting lots of blood flow into that area. One of the reasons why whilst they’ve got pain there, but they will also have some inflammation there, and we need to be able to flush all of that out. So if they are not moving their jaw joints at all, specifically rotation, they are not getting fresh blood into that area, and that pain will persist and increase. So it’s really important that we initiate movement. [Jaz]And that’s a great thing. And also, I love this approach, you’re taking the Hey, everyone suitable for this exercise, because the classic mistake that a dentist might make, and I’ve made this mistake before is you see those images on that PDF with the exercises. And you just throw everything at that patient, like a, you know, spray and pray kind of thing. So it’s really good to start with this. And it very much follows a paradigm of motion is lotion. Because with movement, we are, the patient’s definitely worried to move it but that is contributing to their problem. That is, you know, the muscles are designed to move. So when they’re restricting their movement, that is not an optimum position biomechanically, so please tell us about the exercise. [Kreena]Yeah, so while you’re basically going to do is you describe it like this, you put your hand, if you do it with me, you will then know exactly how to do it. So you put your index fingers on the lateral poles of that your Condyle. And what you’re going to do is put your tongue onto the roof of your mouth. And that tongue, the tip of your tongue will not come away from the roof of your mouth at all. So we’re going to open and close our mouth, and we’re going to do it six times. But we are not going to do Snap, snap snap like a crocodile, we are going to count to about four for opening and count to four for closing. And ideally, and I insist, usually with patients that they do in front of a mirror, because they may have some deviations. And they don’t even know that they have it. Okay? So this is also an exercise to help you initiate and be aware of what normal movement is. Okay? So and so like I said, you do it six times, and you would do that then six times a day. [Jaz]Sure. And with the finger being at the lateral poles just in front of the ear. The rationale for that is that you don’t want to feel the condylar head, because that’s when it starts to translate. So that’s something you want to tell your patient that hey, if you’re feeling the bulge, you’re opening too big, right? So the tongue is one safety mechanism. The other one is for them to feel their finger that hey, they shouldn’t really be able to feel the condyle come out. And with them looking in the mirror, what do you say to when they have a deviation you tell them, Look, don’t worry about just yet? Or do you actually tell them to try and like some physios I’ve spoken to actually get the patient to sort of resist against that deviation? Where do you lie on that? [Kreena]I do give that exercise but later. So if this is my just the first go-to, get them moving, if they’re scared. And yeah, just basically, I would add the resistance in maybe next time I see them, if they come back and say, pain has reduced, the feel more confident they’re not talking with just lips, then I would then start adding the resistance in after but yeah, it’s really important that they are aware of what alignment. There are we. [Jaz]So this exercise indications any patient especially in pain, acute pain, chronic pain, this is going to help all your patients, which is great and get some moving fantastic. There’s no obviously contraindications to this at the very first sort of beginning. That’s a fairly easy one that we can all all of us dentists, we can prescribe this very much. So any more they want to add to this one or can we move to another one now? Maybe at a different level and a different approach. [Kreena]We can move to the next one. So the next one is my go-to muscle exercise. Because this exercise is basically an isometric strengthening exercise. And another name for it would be rhythmic stabilization as well. And the reason why I use this for my muscular patients is because their muscles may be in a lot of spasm. So if you go on to do really aggressive strengthening based exercises, it could flare them up again. So again, I’m assessing how irritable are there because because you know, you can do one thing for one patient, and he works beautifully, and you do the 10% of that thing for another and they’re in 10 out of 10 pain. So it’s really important to assess and you want them to trust you. So that I find that the first exercise and this one that I’m giving you, but 99% of my patients, there aren’t any flare ups, okay? So with this exercise, because we’re doing the isometric strengthening with it, what it will do is it will decrease the pain at the muscle that we are trying to strengthen, it will increase the range of movement of that muscle, but it also increases the blood supply within that muscle. And therefore we can flush out the lactic acid that’s built up there, which is usually the reason why they are complaining of the tension, at least that they are feeling, okay? But not only for muscular pain, but also if they’re presenting with just clicks or and just pops, you know, that is their only complaint, then this exercise is great for them too, because it stabilizes the joint. Because when it comes to isometric strengthening, you are contracting the muscle whilst the joint is fixed, the joint is not moving. So that means that we can strengthen the muscles around that joint and that stabilizes the joint capsule more and makes the muscles stronger so that you’re not clicking and popping constantly out of place and therefore is really good for hypermobile patients as well, which are usually the clicking and pop type patients because they over recruit their muscles in order to compensate for their increase in laxity of their ligaments. [Jaz]So remember guys, it was hyper because H-Y-P-E-R. So whenever someone says hyper or hypo, people always listen to it as such quick speed they sometimes misses a hypermobility, think of Ehlers Danlos as classic or other variety patients, these are the ones who often get quite open locks as well. And they are pretty much statistically known to have more disc intracapsular issues. So it’s great that you mentioned that but also on the theme of stabilizing, one of the tests that I like to do my patients I’m trying to figure out is this a joint issue, or a muscle issue is a stabilization test before you come on to the exercise. But let’s take a step back in diagnosis is I will hold and grasp their mandible, so the teeth are together, they’re pressing the teeth together, I’m keeping that mandible sharp so behind them, I’m actually bracing their mandible up against the maxilla. So teeth are now in maximum intercuspal position. And I’m getting the patient now to try and grind their teeth and try and protrude their teeth, all the muscles are firing, but I’m not allowing their jaw to move and henceforth, the condyle is not moving, the muscles are firing. And therefore if they have pain, or any issues here, it’s more indicative of a muscular issue than a joint issue because your condyle wasn’t moving. So that’s one thing there. So how are we going to use this principle here in the form of exercise? Please go ahead and describe it to us, Kreena. [Kreena]Sure, so I’ll explain it to you the way you would explain it to a patient, okay? So what you’re going to do is get your thumb placing on the bony part of your chin, you’re going to oppose opening of your mouth, okay? And the amount of resistance you’re going to put into that opposing force is about 50% ish of your maximum force. So it feels very light, you hold that for six seconds. Once those six seconds is over, you move over to one side of your chin, take your chin towards your finger. And then you oppose that movement again, hold it for six seconds, and you move to the other side and go over to the side again towards your finger. Oppose that resistance. And again, hold it for six seconds, and then you’re back into the middle. [Jaz]Just to make it really tangible, Kreena for those listening who are not getting the benefit of watching on YouTube because they’re in car mode or the chopping onions mode or whatever, it is, essentially, when you get the patient to grind left and right, you’re resisting that movement. Basically, you’re using the finger to stop them so they cannot grind in that direction. [Kreena]Yeah, so you’re you’re basically resisting opening and both lateral excursive movements, right? And you’re holding each one for six seconds. And then you would do that whole thing six times in one setting. And then you do that six times a day. [Jaz]Henceforth the name six by six. [Kreena]Exactly. So this is also good for those patients who are constantly playing and see checking something or wants to see how what their clicks like today or tell them to stop doing all of those things and do this exercise. instead. [Jaz]We had that patient recently on the the splint course support group. You mentioned that exact thing. That’s sometimes patients are keep testing about their click. And then it was actually the Protrusive Dental Community this one and Lakshmi, she was talking about the patient who on opening was, extreme opening was getting more pain in click. But I tend to think that okay, that’s more of an issue that there could be some hypermobility. And it could be like an open lock, as in the condyle can becoming beyond the eminence, so that patient just needs the advise to stop checking your click and stop opening so big because what part of the history was that when the patient yawns, that’s where an issue when it’s an issue. So if we don’t go as far as that range of motion, it’s going to improve and get better. And also by strengthening the muscles, you’re improving the future prognosis of it. [Kreena]Yes, exactly. Yeah, so this muscular exercise is a really good sort of go-to. And to be honest, if we’re looking at just the first session, then I would give the first exercise like I mentioned, and or the muscle exercise that I’ve mentioned. And I’ve the reason why it’s an or is because if I’m seeing that the patient is in acute pain, doesn’t really want to do much, then we stick to the first exercise, if the patient is presenting with always about, you know, five out of 10 pain, you know, in the background, then give them both [Jaz]Amazing. Now, can I be really cheeky Kreena and ask you for a third exercise, not that we’re going to be replacing physios because you guys are so important. And we need to be working as a team. But I think when we are prescribing exercise, you want to have more competence in that. And I don’t know, please tell me which exercise you were going to prescribe. But if it could be that the tongue scrape that we discussed in our recent monthly grind, because I find that, one of the most common emergencies that we see it as dentist is a spasm of the lateral pterygoid, in particular, and to stretch it, I think will really help the dentist. Is it okay, if we’re going that direction, but just out of curiosity, was there a different exercise that you were considering? [Kreena]Yeah, I was toying between that one and doing trigger point release. So I didn’t. [Jaz]I think trigger point release’s a bit more advanced. So let’s go for something that a dentist can apply really easily, advise our patients, and will help in a lot of emergency visits. So let’s talk about the tongue scrape. [Kreena]Sure. So the tongue scrape exercise is purely for the lateral pterygoid. And the way that we are basically stretching the lateral pterygoid. And because it’s such a small muscle, it’s quite tricky to feel you may feel I don’t really know what I’m doing here. But maybe if you’re in some pain, then you would be able to feel the stretch on your lateral pterygoid. If you don’t have a tight lateral pterygoid, you may not feel anything at all. So the way that you do it, is again, tip of your tongue, when you’re going to do is take it all the way back towards your throat as far back as you can, whilst your mouth is closed, okay? So that’s the first starting point, the number two is what you’re going to do is keep the tip of your tongue third back as possible, and then open. Okay? And close. But again, it’s not snap, snap snap, you need to do it really slowly. And to hold it for four and then close for four [Jaz]How much are we opening here? [Kreena]Until your tip of your tongue starts coming forward. If it starts coming a little bit forward, then stop that opening. Okay? so it’s very small opening and closing, because your tip of the tongue will probably start coming forward quite quickly. [Jaz]It’s definitely I mean, this is definitely within the rotation. And it’s not opening very much at all. And, you know, I’ve got a big slide. So I’ve got a very large horizontal slide so I can feel myself becoming more and more class two. Whereas with other people who don’t have as big of a slide as I do, they will not feel their jaw moving so far, posteriorly. But the whole point is that the lateral pterygoid is being stretched, because what you know, and this often confuses people who aren’t so into their anatomy, because the lateral pterygoid, the inferior lateral attaches to the condyle head and then the neck of it. So that brings the condyle forward ie protrudes. So we’re trying to do the opposite of contraction, we’re trying to lengthen and stretch hence why the direction we’re going is backwards just to cement that in the dentist head. [Kreena]Yeah, exactly. So yeah, so this will help reduce the spasm there. And this exercise again because you’re doing it in rotation. So say if you are presented with that acute pain patient, they are locked. You’ve given them the rotation exercise already. This is a nice one to give alongside that because it will help relax that lateral pterygoid and therefore release the disc hopefully as well. [Jaz]What do you advise on pain? Because I often tell my patients that okay, you know, no pain no gain some I’m okay with you experiencing a little bit of discomfort. I usually say six out of 10 but anything more than that, then maybe don’t go as far back or ease into it. Any guidelines that you give your patients? I’d love to hear. [Kreena]Sure, I’ll have two guidelines. Again, it’s about go back to the acute pain 10 out of 10 patients, those ones, and I don’t want them to feel much pain at all. And because they just they’re going to flare up and they’re going to catastrophize it potentially. So for those my guidelines is I don’t want it to be uncomfortable or painful at all. For those who are the five out of 10, muscular little bit of click that sort of thing, then yeah, around five, six out of 10 pain is fine. Anything more than that, then you need to back off. Also, I want their exercises to feel more stretchy, uncomfortable, rather than pain. So yeah, I usually phrase it like that. I’d say pain is bad at this stage. And it needs to be stretchy, uncomfortable. [Jaz]Great. I mean, I had a 19 year old patient recently who presented with some posterior open bites and acute pain, and my diagnosis was okay, there’s a degree of lateral pterygoid spasm here. There’s lots of, you know, malocclusion issues as well, I don’t want to go into a sponsor that debate versus malocclusion and TMD, that kind of stuff. But essentially I gave an Aqualiser sprint which we covered in the splint course and also in one of the monthly grinds, if you’re splint course delegate you go in you watch when the monthly grinds we talked about specifically that this patient and lateral pterygoid spasm basically made her a loom video of me showing the exercise and I showed it doing the tongue scrape as well as describing it with a tongue. I showed it with a ice cream stick like you know Magnum wooden stick and get them to sort of grind back onto that using that stick. And that’s a good thing to do as well and hold that position. And we’re able to within three weeks, correct her pain by 80% and get her occlusion back to normal look just confirming our diagnosis because sometimes our diagnosis is based on history and anatomy is our best guess. And sometimes, you know, there could be something more intracapsular going on, which becomes more apparent because although you’re doing all these muscle things, and then you’re doing everything to remove everything out the bucket. And I think what we’re does bucket come from? So this is where we’re going to have next Kreena, tell us about your bucket analogy, you came onto one of our Splint course monthly grind support sessions recently, and everyone loved your bucket analogy. So as a final piece here, can you please tell everyone about what is it? What would you refer? What do you mean by this bucket and how we can use that to assist our patients? [Kreena]So as we all know, the first session with a TMD patient is tricky, because there are so many things they are throwing at us. And we’re trying to work how rich, which ones are the top three contributing factors, causing factors. And we’re doing that through our medical examination, of course. But it’s also important to listen to what the things that they are saying, because usually those other things are aggravating them, right? It’s not just what they present with clinically. So my bucket analogy is basically, I gather all this information, and I’m looking at basically their sleep, their posture, their desk space, their stressors, that person that’s irritating them at work every single day, they happen to have a child that doesn’t sleep. So alongside the clinical assessment that I’ve made, and I’m thinking, well, this is the reason why I say they are clenching, say they are nail biting, I’ll put that into my bucket, then I’ll put in all the things that I’ve just said the sleep, the person, this kid irritating them, the child does not sleep at all that into the bucket and tell them that you’ve got all of these things are in your bucket, and they are contributing to the symptoms that you have. Now as physiotherapist or say, as a dentist, I can give you this to help with this. But you still have so many more things in this bucket that we are still contributing. So what can you do? Or what can, who can we refer you to, to help you with some of these things? And that way, ends up being a 50-50 relationship where I will do what I can from a physiotherapy point of view. Now what are you going to do to help yourself? Because this isn’t something that’s going to go away overnight, or I do six sessions of physiotherapy and all of a sudden you’re cured. And unless we take these things out of the bucket, we’re not going to be able to manage this condition for the long term, and it may come back again. So if we want to do manage it for the long term, then really let’s work on maybe we need to add some CBT and maybe you need to share the sleeping with your partner when you’ve got a kid that doesn’t sleep through the night. You know, all of these sorts of things. Lots of conversations need to be had. So when I say it like that, I find that other patients understand that it’s not just I grind my teeth, and if I could just stop grinding my teeth everything would get better. It’s not as simple as that. [Jaz]That’s why I love this analogy so much, because it’s useful to us as dentists. But when we’re communicating to our patients, there’s not just an occlusal appliance that’s going to help, there’s so much more to it. In all those things that you mentioned, it could even be cognitive behavioral therapy, as you said, so many different facets to it, including physiotherapy, and therefore it gets the patient on board that okay, although me as a dentist, I’m giving you some education, some exercises to some degree, I’m giving you an appliance. These are 3 of the 11 factors that we found in your bucket. So why don’t we look at the remaining eight things in your bucket and work with that, and the patients all be on board. And, you know, with conservative care and occlusal appliances, so many studies after studies after studies, and the range of successes from like 75 to 90% is around about 80% is the you know, to pull out the generic figure. But there’s still those 20% of patients that will need more, they will need more. And then sometimes they get more and more complex. And then when chronic pain enters a situation, that just becomes a whole new level, what would you say? [Kreena]Yeah, exactly. And it’s also it’s taking away that blame factor as well is that I got the splint or I did the physiotherapy and it hasn’t worked. But if in the first session, you’ve already explained the bucket, then they already are aware, they’re the ones are first come to you say okay, fine, I’ve had about three sessions, it’s not working, maybe it is the stress that you mentioned, maybe I do need to go and have some CBT. And so that you don’t need to then have that conversation, you’re not going to get blamed, they’re not angry or disappointed. They just know they need to move on to the next thing. And it’s just more, it’s a nicer relationship to have with your patient, rather than I’ve paid all this money and it hasn’t worked and then you’re stuck with what do you do next, you don’t need to be stuck, because you’ve got the bucket [Jaz]Kreena, I mean, that was absolutely brilliant. I know that dentists all over the world now will be able to help their TMD patients so much more. So thanks again for coming on adding so much value. But I think very excited to announce that we will be doing a live hands on day for TMD. And this is something that I think is going to help a lot of people above and beyond the online course. Because there’s so much more you can gain from actually hands on elements. So what kind of things are we hoping to cover on our live hands on day? [Kreena]So of course, we’ll do things like an anatomy. But I think it’s really important that we actually get hands on. So there’s one thing looking at a video of it. But there’s one thing actually feeling what a tight muscle feels like, palpating lateral part of a condyle when it’s inflamed, hopefully there’s some TMD patients there, they usually are find someone. And also to help calibrate the muscles, we’ll be looking at what a trigger point feels like. So I happy to go around and show everyone where their trigger points are, what it feels like, how we refers. And hopefully if we do it all together, everyone will be able to feel each other’s trigger points as well as everyone can describe where their referral patterns are, as well. [Jaz]I think the key word there for me is calibrate, you know, because to calibrate Okay, are we all doing the muscle exam correctly? Are we all putting the right amount of pressure? I get loaded and still asked me, Can you just make it really clear about the leaf gauge? Are we using leaf gauges? I’ll be making chairside splints on we’re gonna make some on each other. And I’ll show you how it’s done. We’ll pick someone we’ll go through the nuances of what the challenges, why that patient or that dentist that’s attending will be suitable for chairside appliance and why someone’s malocclusion will you be better with an indirect appliance. So we’re going to go over all that. But just to reiterate that actually, this is not a replacement for the online course, the online course is the foundations. And that’s why we’re pricing it as a very low, it’s just 200 pounds for to come along. But you should be a alumni of the splint course, because we assume then you’ve already taken some of that information on board, you’re already a little bit, you know, clued up about diagnosis and stuff. So this is just to fill in the little cracks in the voids, and give you that sort of confidence that when you’re clinically palpating your patients on Monday morning, you’re going to be better. So the dates for that is going to be eighth of May, and 19 to June. And I will email you probably in a couple of weeks to give the opportunity, going to be keep it quite small group sizes. So I’m sorry if anyone gets left behind. But this is the sort of there’ll be more opportunities in the future. But it’s about taking that one step further and adding a clinical day, a hands on day to what you’ve already developed through Splint course. So it’ll be great to have you there. We’re also getting a maxillofacial surgeon to come along, to talk about okay, at what point do we need to refer for surgery? And what is it that the surgeons actually do? I mean, I’ve got a really cool video on arthrocentesis I need to add on Splint Course still, but to find out what does that actually mean? What are the success rates? So that’s where the Maxfacts comes in. Anything you want to add to that, Kreena? [Kreena]No, I think just expect it to be incredibly hands on. Because like Jaz said, it’s not about listening to the theory of it, you would have already have done that, it’s going to be getting hands on and being really confident with how to diagnose a patient, and therefore knowing exactly what to then do when it comes to treatment as well. Whether it’s referring to a physio or whether is the which exercises are you going to give them and I know we’ve already mentioned my two or three go-to exercises. But those are the basics, there’s a lot more to add to that I will give Yes, I will give that rotation exercise but there’s a lot more that I tell the patient are more exercises, I also gives the patient a lot of advice as well. So you will get all of that information if you attend this practical day. [Jaz]Amazing. And I’m going to put your website as always in the show notes. So those patients or those dentists are looking to get an opinion from you, or refer a patient for your for virtual checkup or a real examination. Amazing, we can get that happened. So I’ll put that on the show notes. Kreena, thank you so much for coming on again, and just blessing us with so much information. I am so grateful to be a friend of yours and to have you in my circle. Thank you so much for adding so much value. [Kreena]Thank you. It’s been a pleasure as always. Jaz’s Outro:There we have it guys. Thanks for listening all the way to the end. If now is a time to add splint course to your list of courses that you’ve done, because you want to learn more about bruxism, occlusal appliances, which splint, when. Head on over to splintcourse.com. Hopefully you’re making time for enrollment. If not, don’t worry, there’ll be opportunities in the future. And for those who are already on to splint course and you’re waiting for the live dates and booking links, whatnot, don’t worry, I’m going to email them to you soon. So again, thanks so much for joining me all the way to the end. Now please do excuse me, if I am less responsive over the next week, because I’m finally going on a family vacation. So three years later, obviously pandemic and whatnot. And my son has never been on a long haul flight. And so we’re so excited. When last time I went to South of France, but I almost died. I had like some crazy thing in my throat and I had to like get this emergency flight back and almost lost my airway. And I don’t want to go into that. But I’m hoping for no health mishaps on this holiday. And so it’s our first proper holiday, we’re going to Dubai. So if I’m a little less responsive, please forgive me. I have always tried to make sure there’s an episode every week and there still will be even though I’m on holiday. There will still be an AskJaz episode coming soon. So I’m excited to share that one with you. Anyway, I’ll catch you soon guys. Thanks so much as always listening all the way to the end

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 7:53 Appointment 5: Anterior Direct Adhesive Composite Rehab 15:59 Upper and Lower Anteriors Build-up Techniques (Using Putty/Exaclear indices from wax-up) 16:41 Checking of Occlusion 26:56 Posterior Stabilization (Using GIC or Bis-Acryl) 28:59 Appointment 6: Checking Occlusion and Taking Impression (within 4 weeks)  6A: Checking Occlusion (2 weeks after – 1st Visit) 35:49 6B: Taking Impression (2 weeks after 1st visit) 36:08 Appointment 7: Posterior Direct Adhesive Composite Rehab 38:45 7A: Lower Posterior Arch or Upper and Lower Right Side 7B: Upper Posterior Arch or Upper and Lower Left Side Appointment 8: Polishing 46:52 Appointment 9: Assessing for Occlusion 47:45 Appointment 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 temporaries in their mouth. And I’m very confident that already just part one and part two, you probably gained more value from some paid courses, again, something that me and Devang are very proud of. But in this part three, we really get into all the nitty gritty details, particularly sequencing. Now you have your patient temporaries they approved it, they want this treatment, you want to do this treatment and the patient suitable and everything’s ready to go. But how do you actually sequence it? Do you do the upper arch first? The lower arch first? When do you do the posteriors? How do you do the posteriors? So all those things will be covered in this episode. [Jaz]I truly believe that when a dentist moves away from single tooth dentistry at some point along that journey, sequencing is discussed and I think when a dentist starts to think about sequencing, that is a sign like It’s like in karate kid you know, wax on wax off like and suddenly Mr. Miyagi, thinks that Okay, now this kid has got it, right? I do believe in our journeys, when you start thinking about sequencing is kind of like that, you know, wax on wax off moment, okay, now you get it. You mean, okay, maybe you don’t get it. But you’re thinking in the right direction. So welcome to the world of sequencing, for those who haven’t considered sequencing before. This is a big step in your journey as a step that I’m learning more and more about. And it’s great to have guests on like Devang to sort of share his nuggets and his principles. And of course, different dentists around the world will do it differently in when it comes sequencing. And before that used to piss me off. But now I appreciate the beauty because you might find the patient that is more amenable to Devang’s way of doing it. And then you might find a patient who’s more amenable to another dentist way of thinking. And so if you learn all of these and appreciate the the pros and cons, then you can apply it to your patients. [Jaz]To celebrate the fact that Splint Course has relaunched. This is my flagship course, I’m so proud of it, have had over 400 delegates from 16 countries. And it’s not even, it’s almost a year old. So now it’s been tried and tested by hundreds dentists, and they love Splint Course. And I’m so proud of it. And so now we opened the doors again, to allow a new intake of delegates. This time, instead of opening the doors for two weeks, I’m just opening it for one week, I just want a select few bunch who are going to be committed for 12 months of support on Zoom online, and also on the group. And I want you to learn and start implementing how to diagnose and manage bruxism and the correct appliance for the correct patient when to refer and how to manage all the nuances of splint therapy. So if that’s something you’re interested in, head on over to splintcourse.com To enroll and join a community of dentists who want to do better for their patients who are in pain or just want to protect the patients from the harmful forces of bruxism, especially if you do full mouth dentistry so even Devang at the end of this episode, he discusses that, you know, as a part of the protocol of doing full mouth dentistry is that giving an appliance because the same things that the patient did to destroy their own natural God given evolution given dentition they will do to their brand new restorations, it just seems too risky to give these patients the restorations and rely on the idea of occlusion to protect that patient. It just doesn’t make sense. The forces of bruxism are severe. [Jaz]The pearl I’m sharing with you, you kind of need to access the Protrusive Dental Community to see this video basically. It’s a video pearl, and it was a live video of my nurses recording of me because I had this patient in who I’ve been seeing for almost two years now, one of the most severe bruxist ever, to the extent that he’s now awaiting to have a full implant reconstruction, upper arch and lower arch. So quite a big job by one of my colleagues. But he has destroyed everything. And he has been a tricky patient managed because he just comes in with these emergencies and to stabilize him we kind of need some go straight to those full arch implant so there’s no middle ground here. But for the first time he came in with a toothache, which wasn’t a toothache and eventually you’ll see the process of how we did it. It was kind of like a diagnosis of occlusion. You do your usual, you know, listen to history. Anything hot and cold. No hot and cold doesn’t give you any pain. You do radiograph, it looks fine. There’s no apical pathology, no teeth are tender to tapping, right? And then you figure out from the history that the pain doesn’t happen when the patient’s chewing. It happens just after the patient has finished a meal. And it intensifies. And when you get the patient to point to that source of pain with one finger, they don’t point to one tooth, they point all over. So he was pointing to his head down to his neck to his ear, right? And these are the clues that a diagnosis was not a simple toothache. It was non odontogenic. It was myofascial pain, with referral. And then the certain criteria we use, research diagnostic criteria and TMD. When we’re diagnosing myofascial pain referral, you have to sort of when you palpate the muscles and trigger points, it elicits a pain. And then you have to ask the patient, okay, is this pain, a familiar pain? And if they say, yes, they said, Okay, familiar to what, and then the main thing is that they say, Oh, it’s the pain for which I am seeking careful, it’s the pain for which I am seeking careful, that is the gold standard way to diagnose someone who’s having the pain from muscles referring to the head and neck structures. So there’s a video of me palpating the muscles coming up with a diagnosis, just giving you a little bit of like an insight into how we diagnose these things on the clinic. So if you want to check that out, go to Protrusive Dental Community. I’ll tag the video for the next couple of weeks as an announcement. So you can see that and I hope you find value from that. So you may be able to think the next time you have a toothache which doesn’t sound like a toothache. You can actually can take a step back and consider that could be myofascial pain. Right guys, no more rambling. Let’s join Devang Patel on part three of adhesive full mouth rehabs Main Interview: [Jaz]Dev, welcome back to part three of adhesive full mouth rehabs. It’s been a real journey in the previous two episodes. And this is really the nitty gritty, the sexy occlusion stuff coming up now. Now we’ve done the mock up and whatnot. We’ve done the mindset stuff. And now we’re going to talk about the how to get that wax up into the mouth, the different techniques, the how do we control the occlusion the left and the right and so we’re coming on to that and I’m gonna do a quick recap. Appointment 0 was a mindset for Full mouth Dentistry. Appointment 1 was the comprehensive evaluation was like a checkup and you sort of screen the patient who’s suitable. Then appointment 1A, you bring the patient back and do a full mouth assessment, some treatment planning, deciding are you going to conform or re-organize. In most cases, you’re reorganizing. Appointment 2 was record taking, we talked about Facebow, CR records, then we talked about your mock up technique and how you’ve guided the technician and you’re doing 4-4, you sent them home with the 4-4 mock up. And then when they’ve come back, you review the mock up, you’re checking how it looks, you’re checking the occlusion. So now we’re on to appointment five, which is you’re building up the upper and lower 3-3. That’s where at the moment so take it away. [Dev]Okay, so now I just want to divide two, next steps into two and we’re going to discuss about the adhesive composite build up but you need to understand the indirect steps or the indirect treatment as well. So the steps for the, if you’re doing a composite build up direct or indirect using some sort of, you know, stent or something will be you, for me, at least we’ll be building upper and lower 3-3 and stabilizing the posteriors and then building the posteriors, either one side at a time or one arch at a time will go into detail in a minute. So, it’s pretty simple, for occasion [Jaz]Are you going to explained by what you mean by stabilizing the posteriors? [Dev]Yes, I will Yes. So, it’s pretty simple or straightforward. But if you’re doing indirect, let’s say you’re doing all the crowns for upper and lower jaw, for complete indirect, full mouth reconstruction, traditional type, then it becomes much more complex. So by this time, if I’m doing in that indirect restorations, patient would have full mouth provisionals, okay? And we discussed about, you know, in when we were actually chatting, the provisional, the way I’d make provisional is I don’t ask a technician to do anything, I would have a wax-up of the area where I’m going to do the provisional. So let’s say I’m doing 4-4 provisionals, then I will prep the teeth, use the wax-up to make chairside provisional, but what I would have done is after prepping, I would have taken impressions just without retraction cord or anything, just impression nice impressions. So that technician can make me a Lab site temporaries as well. So on the day patient goes with my chairside temporaries, a couple of days or a week later the lab’s temporaries come back, and I’ll fit that in. Because I find having a shell temporaries, you know, shell means that it’s just too much faff. I will use them, and at least it doesn’t work in my hand that quickly so I would just I don’t bother with that. I will just make a provisional chairside fit them in. [Jaz]And then my experience of shells has also been quite traumatic. But yes, [Dev]Some people get it really right. Yeah, so I think that works really well, because patient, technician then has a real prepped teeth to work on. So you can give me a good marginal fit and everything. So I would do that. So patient will, by the time we think about finalizing everything, patient would have had a full mouth provisionals. And that could take number of appointments, I don’t do all provision in one appointment, usually, I would do four teeth at a time maybe. So it didn’t take me a lot time to do that. Once the provision is done, I would then do the anterior 3-3 final. Rest of the whole mouth will be provisional. And tier 3-3 in final crowns. Okay. [Jaz]Then again, once, I just want to clarify, we are talking here about the indirect? [Dev]This is indirect. [Jaz]So remember guys, we’re talking about the indirect protocol. [Dev]Yeah, this is indirect. So the direct protocol is very easy. We’re talking about indirect protocol, where everything’s temporary crowns indirect protocol, because you’re going to do crowns or onlays or some sort. So you’ve got temporaries everywhere, then you’re going to do lower anterior, 3-3, finalize them using porcelain, crowns or crowns, basically, or veneers. At this point, you still have full flexibility, because if you want to adjust anything, you can still have all the provisionals in the mouth, you can adjust, I’m not adjusting at this point, my finals. So let’s say on my final comes in, the bite is slide off, I can adjust the upper provisionals to get the occlusion right, okay? So you still have ability at this stage to increase the OVD if you want, okay? But hopefully you would have figured it out in a provisional stage. Once that’s done, my priority, my preference would be to then do the posteriors, lower posterior, so lower right and left both you can do together if you want, or you can do one side at a time doesn’t matter to get this occlusal plane flat, okay? So I will do lower posterior final, then I’ll move on to the upper posterior final and now you locked the occlusion, and then I’ll do the upper anterior, okay? So the, what [Jaz]So lower anterior, lower posterior, upper posterior [Dev]No, sorry, upper anterior and then upper posterior. So again, lower anterior, lower posterior, upper anterior, upper posterior. Having said that, if you want to swap, if you want to do lower anterior then upper posterior, upper anterior and lower posterior, you can still do that. But that’s it’s a completely different [Jaz]One cosmetic question I have for you straight away is when you fit your lower anterior crowns or veneers. And then you maybe have to do a bit of adjustment of your upper provisionals. Are you then taking an impression or a scan to send to the lab so that when they actually make the definitives of the upper, they’re going to now copy your slightly adjusted temporaries? [Dev]No, because to be honest, I’m going to I mean, you can do that for me, I’m going to take them out, mount them and redo them anyways, that the lab is only using the shape of the incisal edge, in length and the bulk of the buccal as a copy, which I’m not going to change most of the time. It’s just the palatal which is occlusion. So I don’t really bother taking another impression, because we’re going to remount the models anyway. So patients you know, I’ll get the occlusion right. So, no, I don’t but you can do [Jaz]At that point. Have you had to redo the face bow as well? [Dev]Every single step. Yeah. So every single time I’m doing indirect, I will do Facebow, new impressions and everything. So it becomes a lot of big stretcher. So that’s I’m saying indirect is completely different ballgame than doing a direct composite or doing any composite, right? Because you have a, you can adjust things a little bit in the mouth and polish really well. And it’s quite a bit more forgiving than doing the indirect restoration porcelain [Jaz]You’re spot on with composite, you really do get to use the patient’s mouth as the articulator as we discussed so much in episode one and two of the series, whereas with indirect, you’re relying, you don’t want to do as much adjustment of your ceramic, your glazed ceramic, so therefore, you don’t get the opportunity to use the mouth as articulate as much as you can do with composite. Which is why when you’re starting out with rehabs, just like the reason why we’re recording today, Dev is when you’re starting out the rehabs, adhesive is a great way to learn [Dev]100% And I would recommend starting with adhesive full mouth reconstruction because it will take away a little bit the fear of what if something goes wrong because you know, it is more forgiving. It’s not completely forgiving, which means you know, you can’t go back to zero, but it’s much more forgiving. So I would personally start with adhesive reconstruction. Having said that, you know, any full mouth reconstruction, you need to be really good at being single tooth dentistry, and that’s why when I actually started posting more and more on social media, and if you’re not following me then you know, please follow me and you’ll have some more information [Jaz]Please do some great content [Dev]And I started with posting single tooth dentistry, started posting single edge bonding. And people like, You do full mouth reconstructing, why are you posting? I said, Look, you know what I want people to understand that they need to be really good at doing single tooth dentistry in order to do the full mouth reconstruction. You can have rubbish because you will have, if you do rubbish one tooth you’re going to do rubbish 28 teeth, full mouth reconstruction. So you need to be comfortable doing single tooth dentistry. And again, you know, when I teach, I teach full single tooth dentistry as well as full mouth reconstruction. So when I do courses, or full mouth reconstruction, I would teach good single tooth dentistry because I know that that’s the foundation to do full mouth reconstruction. Okay, so once we’ve done all that, make sure that now we are at the stage where we are building upper and lower 3-3. Okay, so that’s composite build up. [Jaz]Now back to direct, we’re making a transition back to adhesive now. Dev, very kindly spoke about the indirect protocol to give you a bit more value from all these series. So look at that, you know, adhesive, but he’s also giving you some structure for indirect. But let’s go back now, put your frame in mind back to adhesive [Dev]Yeah, so now all the steps are adhesive, which is composite direct or indirect build up steps. Okay. So now we building front teeth, upper and lower with direct composite, right? So well composite, so when we building upper and lower 3-3, you have two options, well, three options, you can do direct build up using composite, you can do indirect build up, or you can do semi direct build up, okay? So if you’re doing direct build up, you can use freehand technique, which I wouldn’t recommend, you can use putty indices from your wax up and use that to create incisal edges of the lowers. So I always start with the lower first, even if it’s the same appointment, I’m doing both. I’ll start the lower incisors first. So I’ll use Putty indices for lower if I want to, you can use something called memosil, which is bluish material, which you can cure through. But I prefer exaclear, which is a GC product, which is amazing. And so once I started using that I don’t go back because you know, that’s the product I use for, for making my indices. So exaclear, I use for making the indices for the incisal buildups, or if I’m going to do palatal build up, then I can use and if it’s not too thick, then I can use a single sort of buildup. So put the composite etch bond prime, etch prime bond, the palatal aspect, and I use optic bond FL for all my bonding. Because I feel that that gives me the best result and composite on to the stent, I put some composite onto the tooth as well, because if I’m going to have an air gap on one that between the material rather than material and the tooth, so I would put composites on the tooth, and on the indices, and then squeeze the indices to get to stent. If it’s quite big buildup on the palatal shelves, and you can put little bit composite, cure it, put a little bit composite, put a stent on it, take it out, make sure it’s not really going anywhere else cure it. And then you build an increment using the stent by using like a stamp technique to just stamp it and make sure that [Jaz]but you’re doing a one tooth at a time here because I can see multiple [Dev]I’m doing multiple at a time. So I’m doing alternative teeth. Okay, so the way I would do that is I would putty, I will put PTFE tape on alternative teeth, and I would etch bond cure the alternative teeth, and then start building up alternative teeth. So three teeth at a time. Okay, lower teeth to start with, and then the upper teeth with regards to indirect again, we’re not talking about indirect today but you could use crown veneers, you know, all sorts of gold backing for the indirect or if it’s, if you’re not really comfortable building palatal because that’s where people are a bit more uncomfortable building the palatal sort of shells. Using direct technique, you can ask technician to build the composite indirect shells and you can just bond it like veneers, okay. With the composite heated composite, that’s what I use for if I’m bonding them, okay? The semi direct would be, approach would be composite on the palate and porcelain veneer on the buccal aspect. And if you listen to Francesco valetti who talks about that taking a sandwich technique which I think is a little bit confusing because we also in UK we talked about sandwich technique being posterior when you do just doing molar, you have GIC and then composite on top, we call it as sandwich technique. So is our call it direct indirect. So that’s how I would build the lower and upper three to three. Now there were two questions you were asking, one was, Can I do everything in one appointment you don’t need to. So if you’re doing lower build up, I mean to me, it will take, if it’s a good quantity of upper and lower like a lot of buildup, you’ll take me four and a half hours to do that I’m slow. So I’m doing all direct, I’m not using injection molding or smile fast technique, that’s another technique you could potentially use. To be honest, I don’t have much experience with them. And so I can’t really recommend long term results and people who have got long term data they don’t have 10 years data on them. So I’m not sure but you could use them if you want to [Jaz]I can just do input here and say that having used for some significant wear cases using a full mouth adhesive rehabilitation I’ve used both injection molding and smile fast and you know it’s just pick your poison, right? these are just techniques tools. It’s all about the planning that you do beforehand so I don’t get too hung up on which way I’m doing it but having done a few smile fast cases you know that four and a half hour because I’m like you I’m slow for me that four and a half hour appointment can become a three hour appointment so I do share save a little time but then you’re paying a little bit more lab fee as well. So it kind of works out you know, it doesn’t have to be a system specific you should experiment Yeah, [Dev]You can do incisal enamel, you can really use different shapes and everything as far as I believe. So you know if I’m not doing buccal veneer I would want upper incisor to to look a little bit better. So by doing a little bit different incisal coloring and stuff. Having said that I’ve restored lots of cases just one shade composite and they look quite good because the complex improved a massively nowadays so and I use G-aenial™ I mean I don’t get any kickbacks from, they support me for my courses, obviously, but they are really good material. G-aenial™ is amazing. So I really love it. And if you’re using single, [Jaz]I’m a huge G-aenial™ fan. I just remembered a quote from James Baker, Dev, I just want to share with you shell is Composite is a bit like being married to supermodel. Composite is a bit like being married to supermodel. Sometimes you forget how good looking they can be. [Dev]James, Composite is a really good looking guy you know that. He’s amazing guy. So with regards to build up, so these are the techniques you can use. And if I can’t do everything in one appointment of patients, like I can’t sit for that long. And if I’m not sure, then I would book patient next back to back. So if I’m seeing patient on Monday, I will book patient on Tuesday so that I can do the upper reconstruction. That means I don’t need to worry about too much provisionalizing stuff. So I would have pre plan Both appointments. But I want those three to three done pretty quickly. Rather within one or two appointments within two days, basically, [Jaz]Hi guys, this is Jaz interfering again with a really important message like have you ever done teeth whitening for someone, and the patient messages you or calls up or come to your clinic upset, because now they have these white patches on their teeth, at least two of you have shown me on Instagram, some messages from patients that really concern you as a dentist, because you weren’t expecting these white patches to appear on teeth. Now this is a, I wouldn’t say common phenomenon. But when this happens, when you start teeth whitening, it can be scary for the patient, and it can be worrying for the dentist. So I have my buddy Payman Langroudi to discuss all about this in this couple minute message, which I think is going to give you so much value if this has ever happened to you before. Or if it’s never happened to you, you probably haven’t done enough teeth whitening and it’s going to happen to you. So why don’t we learn about the techniques to make sure that you are well prepared to A) warn the right patient that this could happen and B) to reassure them because it’s something that’s not permanent. And we’ll go into that in a moment. I just want to take a moment say thank you to enlightened smiles for sponsoring this podcast. This episode, as we know enlighten is the premium brand of whitening and it’s so great to have their support and to be aligned with them. So let’s head on over to Payman Langroudi to talk about these white patches for a couple minutes. Before we rejoin the main podcast. [Payman]There are something like 28 causes of white and brown spots. And so you can’t tell by looking at it. Whether it’s mainly a hypo or a hyper calcification has caused that white spot and those two things are very different. So when the peroxide comes across hypo calcification, it does cause chalkiness when it comes up against hyper calcification, it doesn’t cause chalkiness, it’s harder to get through that area. So you can’t, the basic point is you can’t predict which white or brown spot will go chalky, but you need to predict and tell the patient, that there’s a possibility that any of them might. So that starts off with actually noticing that there are white spots, you know, paying attention to that, pointing to that for the patient. And then if the situation you brought up is actually very common in that, often if it’s a Hypo calcification very quickly, those areas go chalky. Often whitening is the first thing you do in a treatment plan. And so you’ve got a patient who’s not really being treated much by you already. And the first thing that happens is something like that. And the key to it is to inform them that that might happen. And that then when it happens, you look like an expert. And it’s often missed, people miss white spots, or maybe they see them, but they don’t tell the patient about them. So I think the key message is just inform your patient that any white or brown spot could go chalky. Now what happens next, the vast majority clear up by themselves in a definitely within the rehydration period, which is a two three week period. So, two, three weeks after the end of, even home whitening will give you dehydrate teeth a little bit, most of them will then clear up. If they don’t for me, I think microabrasion first, before resin infiltration, I’ve had much more success doing it that way around. For me, there are brown spots, that bleaching will turn into white spots, then microabrasion can reduce them, then I can then delete them. But the opposite way around doesn’t really work. If you go icon doesn’t reduce something that microabrasion might be nice. For me, the right order is bleaching first, consent the patient, if you can see white or brown spot, consent them for microabrasion resin infiltration or even composite restorations. And then if you need to so tell the patient look, if you’re after perfection, one or more of those may come into play. I can’t tell you which one or any of them until we’ve done the bleaching first. With bleaching will often delete things by itself. [Dev]So once I’ve done that, I will check the occlusion because it’s adhesive, polish everything, nicely make sure the occlusions there canine guidance and protrusive guidance using the the incisors, canine guidance using canine and make sure you have the space you wanted for posterior, right? Because sometime you start grinding the teeth down, that means you are reducing the OVD. So initially, you would have increase the OVD to have the nice posterior onlays done. And now you’re grinding the teeth to get the contacts better. And you decreasing the OVD so just be careful when you’re doing any adjustment that you’re not doing going over the board. I would rather add something to it. So then you’ve got a bit more OVD then reduce it, okay? So you can never have enough OVD. You know, you can never have enough space, especially for technicians if they’re making anything indirect. If you’re doing direct then yes, we’ve got a little bit levy for posterior. Okay, so that’s done, we’re happy with that, you know, polished everything, patients happy. Now we need to make sure that we stabilized the posterior teeth. Okay, you can’t because patients now got the occlusion on three to three. There’s nothing posteriors are in the air [Jaz]Patient now has a dahl composite in their mouth. [Dev]Yes, exactly. So if you’re going to do dahl, perfect, you leave them as it is, if you’re worried about them breaking things, then you can give a small Essex retainer for just the anterior teeth to wear at nighttime, I don’t tend to, you know, patient tolerated really well. If your occlusions really good, they don’t tend to break it. And obviously your bonding needs to be. So they don’t tend to break them because they are nice chunky composite that you know, good strengthen them. So I never, I don’t usually bother. Even if I’m doing dahl, I don’t bother giving them any sort of appliance, I just let them go. Like that. If I’m not doing dahl, then I would reach them many times I’m I don’t so that I would use two techniques for the posterior stabilization, right? So you want to keep that space, that’s the whole point and keep patient a little bit comfort because if there’s some teeth touching at the back, patient feels a little bit better than just the front teeth touching, okay? So the easiest way to do that is you use your GIC, glass Ionomer cement. Put it’s right in the center of the occlusal surfaces of the upper or lower, I select lower because it’s easier for me to use. Put Vaseline on the upper teeth, ask the patient to close okay, because your front teeth your anterior teeth are nicely done. They will act as a stop and the posterior teeth will close on your GIC. Hopefully it’s touching the GIC and that will then create your GIC would act as a stop for the posterior. Okay and nowadays GIC are really good. They last, you know, they will stay in there. So I would put GIC there and close it if you really want to be modern you can spot etch you can put a little bit bond, you can put some composite on there to get stops to get a bit more rigid stops but GIC works really well, especially if you’re going to remove them, you know as to whether GIC you know, it’s easy to distinguish rather than composite. [Jaz]Having previously used the composite for this I now regret not using GIC I think that’s a really great idea actually. So actually, I will now use GIC but any consideration to GIC or it’s a sexier superior cousin, RMGIC [Dev]No, I don’t use that RMGIC, I know people use it. The way I taught was that it’s the best of this, worst of both worlds basically, RMGIC so I tend to use normal Fuji 9 GC obviously. It’s really good product and works really well. I mean how I’ve treated patients, you know those patients who come to you with so many caries and you’re just not sure where to start, you put, remove all the caries put GICs in them. I mean I tend to, I mean I was quite sad so I used to call my GIC using a small fine bur and make sure nice and they stayed like that for like eight years because some patients just go right so they don’t have enough money or anything to then have the full mouth done and they come back and you know many of them are, most of them are intact. So GIC is good material. Although I still consider it’s a provisional temporary restoration, it’s a good material they come quite far. So put GIC at the back and.. [Jaz]And what else you can use GIC? What else can you use? [Dev]So this the second thing I use, so I only do two techniques GIC most of the time for adhesive composite ones, most of the time GIC. The second way you could do that is if you have had done full mouth wax up, you can take indices of the wax up of the posterior teeth, and put bis-acryl in there and put those posterior on there, so you need to do upper and lower obviously, and shrink fit like we did on a mock up stage. So you’re going to do mock up for the posterior teeth. For that you need to make sure that you have the full wax up model, okay? So if you have a full wax up model [Jaz]In this case, I think you’d be doing some little bit of etch in some areas? [Dev]Occlusal surfaces, I will spot etch, at the back, because those provisional will stay there for some time. Because I want to make sure that I’m assessing the occlusion. The problem with them in my experience is that patient doesn’t have freedom sometime to move their jaw and provisionals are not going to be, you know, because the shrink fitted and all that, it takes first of a lot of time to adjust the occlusion if they’re off the occlusion. And also you can cause some time because you haven’t seated the putty properly or whatever posteriorly some sort of a non working side contacts or some interferences so then they’re not completely relaxed, but it’s somehow giving them occlusion just anteriorly when they, when I see them for review in two weeks time they’re nicely relaxed because they’re just nicely gliding on their front teeth. GIC is literally just flat so, you know, there’s not doing anything any much. So again, if any of the tooth is poking into the GIC I would make sure that I would cut the GIC to the only tip of the tooth is touching. I don’t want posterior teeth to interlock into the GIC. I want them to be nice so that patient can glide on top of the GIC [Jaz]Occlusal stop [Dev]It’s like you and you know you’re doing Michigan splint you want just to point contacts, you don’t want like an intense into the splint exactly the same concept and that’s why I mean if someone wants to do full mouth reconstruction, learn to do the Michigan splint. If you’d learn to do Michigan splint, you will learn so many principles, you will be quite comfortable adjusting things because you know when you do restoration if you need to adjust you need comfortable adjusting things, if you want to, so when I start teaching full mouth reconstruction, I teach Michigan splint first and not because I’m, you know, that’s the best splint or anything but it just gives you occlusal concept, you know, dentist learned occlusal concept, which you then going to transfer into your full mouth reconstruction. So my first two days hands on is splint course, and they’re like Oh we’re here to learn full mouth reconstruction. So you know, by the time we finish, you will know why we started…it’d be not the last step. Last step is to give Michigan splint but we start the first because they need to know that. [Jaz]Fantastic. [Dev]Does that make sense? [Jaz]Brilliant. Absolutely. [Dev]Perfect. So we finished with the appointment number five. [Jaz]You’ve got the posterior stabilized now. So either on the GIC way or the Bis-acryl way. You’ve got the anterior is beautifully built up because they’re, Dev, upper and lower, you’ve got the posterior stabilized at that second visit. How long have you waiting for before you now convert the posteriors to your composites either direct or indirect? [Dev]Four weeks usually, because that takes the occlusion, patient to get used to with everything, making sure patients happy with it. TMJ is fine with it, you know, patients relax. So around four to six weeks, I have done within two weeks, you know, because patients are some, you know, something’s coming up, we need to build it quickly. But my preferred way to wait for four weeks because it’s important that we assess before we go to the posterior, okay? So four weeks is the time and then after [Jaz]So now we’re an appointment six, is that right? [Dev]The next buildup is before but I will see patient in two weeks time or a week time depending on how quickly I need to do the polishing if I haven’t finished everything. So I’ll see patient in two weeks time to review it to make sure occlusion’s fine. Patients not you know, the CS not change, patient’s bite not change since I’ve done the reconstruction, and then see them again in two weeks. And so I’ll see them two times in that four weeks, four reviews, okay? Within that two times, the second time, if everything’s fine, I would take impressions. And I would mount models, because now inevitably things change a little bit. Okay, so from your first wax up, then I would mount the model and I’ll ask technician, this time mounting model is easy because everything’s in ICP, kind of because everything’s touching you know, you don’t need to use a gigantic Facebow, upper lower impressions done. If you think the GIC is not holding very well then you can put small bite registration but usually you can locate model really well on hand articulator. So Facebow and do a upper lower impression, ask technician to mount the model. And then I would ask technician to do alternative teeth wax up, okay? So I’m building, if I’m, let’s say I’m building a 4, 5, 6, 7, I’ll ask technician to build four and six, duplicate the model and then build, on the same model built five and seven. So the second model will have all the teeth built up but the first model will have only two teeth build up alternatively. Does that make sense? Because this will help in the appointment number seven a lot, okay? So this is I mean, this will save you time I know and you can include the cost of second wax up again in patient mouth, if you doing digital it’s even easier to do that. You just need to click the buttons and print it, print the models. But yeah, so it’s, I’ll do second wax up, which is very important for me, it makes my appointment number seven much much quicker, okay? So now, technician got, we’ve got two sets of model, one model has got alternative teeth. The second model has got all the teeth waxed up. Okay, so you’ve two models. [Jaz]Are you doing just one quadrant now? Are you doing a full arch now? [Dev]So technician will wax up full arch, upper and lower everything because you can build them up one by one later on. But because your occlusion is locked, almost set now, technician can now go on and do alternative teeth for upper lower, right and left. And then all the teeth for upper lower, right and left posteriorly [Jaz]So you got four models in total? [Dev]Not still two models. So first model.. [Jaz]Two for the upper and two for the lower, right? Every other tooth model for the upper and a full mouth. [Dev]Yes, we have a total four models. Two for the lower, two for the upper. So four models. Now appointment number seven. In seven, again, there are different ways you can do the posterior teeth, you can do direct, you can do indirect. We’ll be looking at, we’re talking about the direct right now. So in the direct technique, my preferred method is using a stamp technique. So when I’m doing the GIC stops have intentionally not put GIC in between the teeth. So my GIC stops are going to be right in the middle of the occlusal surface. That means when technician has waxed up alternative teeth, my indices will sit really nicely using this in between space of GIC really well. So I’m going to make again exaclear index and one of the struggles I had with exaclear is very runny material. When you put a lot of execlear, it just runs through the model. So what I tend to do is I would put a little bit exaclear just to cover the occlusal surface. Wait for that to set. And then I’ll put more because when you put just to cover the occlusal surface, it will roll over, up to, it just drool a little bit. But if you don’t put too much, you’ve put a little bit, it’ll only drool for up to a couple of millimeter on either side. Once that’s done, I’ll put more, so I’d build in layers, okay? So but I need my exaclear really really thick, okay? I’ll indices needs to be thick. If you can bend them, then they’re no good. Because when you push them, they will just flex and the composite will go everywhere, you will get flat-ish crown, or your if one, flat is composite, and it won’t be as accurate as your mounting, okay? So then I would build again, etch prime bond, PTFE on the teeth which I’m not building. And I would, in this, in posteriot teeth, I will do one tooth at a time. So in the sense that although I’m doing alternate teeth, if I’m building four and six, I’ll build six first and then build four separately, I’ll do one tooth at a time. I don’t want to do two teeth on posterior. One tip when doing that.. [Jaz]When you’re doing this, are you using rubber dam isolation? Or does the fact because of the memosil, it makes it difficult to, how do you find it? [Dev]I have photos actually, I can show you at some point. And but I do use rubber dam. I know. Personally, I know that there is no evidence, at least even in my dentistry, where I’ve used rubber dam that I haven’t they both work superbly well. But it just reduces my stress. When I’m putting rubber dam on, I can go for a tea break, come back. And I know that everything’s [Jaz]They go to the toilet break. How many times a patient with a rubber dam on is going to toilet break and come back . Everything’s exactly the same [Dev]That’s the reason I prefer rubber dam. Not for scientific reason that it’s gonna, obviously it will hopefully help with bonding and everything. But there’s no kind of scientific evidence per se, to suggest that rubber dam helps with that. So I prefer rubber dam for sake of, and that’s why you can’t use a rubber dam if you’re doing smile fast, because you need, you know, or injection molding, you can’t use rubber dam and you know, if patients got a lot of saliva and everything is very difficult to do that [Jaz]The best you could do is split dam in those ways. But usually it just gets in the way. So usually, in anterior an optragate will be fine when you’re using those other techniques [Dev]Yeah, obviously just a cheek retractors. And so it just helps you move the cheeks away. So I’d do number four, number six, once I build them up, out, then number five and seven. So that’s whole arch system. Number five and seven, so you will have two indices per arch per side, you’re building, right? So the one indices for those alternative teeth using that model, and the other indices for or for again, the other teeth using the final model. The one tip, when you’re using the stamp technique is that you make sure that your indices are not extending too much beyond your wax up, bucally or lingually. That means that if the wax up stops, like 1/3 of the buccal, you just stop the millimeter after the wax up, beyond the wax up your indices. So that it’s easy to clean the excess of a an excess comes out easily, okay? So just make sure that it’s not going right to the gingival sulcus. But otherwise, you will have a nightmare.. [Jaz]And then also gives you space to put the rubber dam because if it goes all the way to the gingiva, your exaclear index, then if the rubber dam will push it up, you need to just go slightly beyond the wax up just as you said [Dev]Yes. And obviously check the indices fits after you put the rubber dam is one because otherwise, you load everything. And then this is not fitting. So you know making sure [Jaz]Here’s a really good idea I just want to share, you probably do this already. But one thing that Harmeet Grewal taught me is that when you’re making your exaclear on the model, or every other tooth or the full arch, you put the rubber dam clamp you think it will be using on the model. So now the rubber dam clamp is there as you’re doing the exaclear so that it’s less likely to interfere, right? Obviously, it’s not gonna be accurate, because the way that it will clamp in the mouth might be different because of soft tissues. But it just gives you another little trick. Tip to turban tip to Harmeet Grewal there. [Dev]It’s a good tip actually no thought of that. I just I would just cut it and then use it. But yes, a good tip. Thank you. I’ll try that next time. So yeah, so I’ll build them up. And then I would do, I personally prefer to do and one arch. So I would prefer as I said to the lower arch first if I can build up and then move on to the upper arch later on because then if I’m doing lower arch, then I’m getting occlusal plane correct. And making sure that everything’s fine because for me if the lower occlusal plane is right, then the upper will fall into place. And so I prefer to do lower arch first, but I’ve done one side at a time as well because it’s just easy as well for patient because they’ve got a one side bite. And then the other side is GICs. Does that make sense? So it doesn’t really matter too much, as far as you comfortable, touch your wax up have accurate and you’re going to replicate that in patient’s mouth. So I’ve done direct… [Jaz]I just want to the right side at one appointment and the left side another appointment? [Dev]Yes, but you can do lower arch in one appointment and upper arch another appointment. Does that make sense? But for patient, it’s easier if you do one side at a time because they got bite, nice bite on both side. [Jaz]I like the idea. [Dev]So I think that’s where we will be finish with the reconstruction, take everything off, make sure everything’s nice and tidy. Patients happy with it, obviously, you can do direct the build up directly, right. So you can do build up directly, if you really comfortable. And I’ve done that, lots of cases doing that. But it just stamp technique makes my life easy. And I just don’t like difficult life. So I like to make my life easier as much as I possibly can. Because someone was telling me about extractions, like I can extract a tooth using, you know, one force of one thing I said Why? Why make you know, if something makes my life easier, I’ll use that. I don’t want to show the skills, I want to be the dumbest dentist, even with the best tools and get the same result, you know, what’s the point? So do whatever was the end result is good, then that’s fine. So once you [Jaz]Now with over the few appointments, you’ve got your complete rehabilitation done now because over two appointments, you know, you’ve done maybe the left side, one appointment, the right side the other appointment, you’ve done your polishing, I find these interproximal sores really useful at these appointments to anywhere where the bond or the composite is joined together to clean away interproximal polishing I love using Eve twist a Polishers, personally my preferred one. What kind of polishes are using? [Dev]So I use, Yeah, I’ve used a twist, which they’re really good. So I’ve got different types of it, the car does nice polishing, polishing burs as well composite polishing both they were off quite quickly, but they give really good polishing results, but I tend to use extra brushes, you know, the astro, the golden ones, those polishing brush. [Jaz]Yeah, Astro brush, I think I know what you mean, yeah, the gold tinted them [Dev]Yes, those are the one then eliminate impregnated bristles, I think. They are good with the white stone and the red. So the gross sort of cleaning is done by using red stripe of bur, then the white stone, and then the polishing within using astro or some sort of a cup or something like that. So that’s all done and patients now you assessed the occlusion, make sure everything’s fine. Now, I review that a couple of appointments, because things can change all the time, really for a couple of appointments. And then maintenance. Maintenance phase would be to fit some sort of protective appliance, which is for me, it’s Michigan splint to start with. However, if I don’t see any, if it’s a patient with the erosive there, there is no need to give the Michigan splint I would give them a soft mouth guard [Jaz]Without parafunctional risk. [Dev]Yeah, exactly. I will still give them some sort of mark up to make me feel happy. But you know, they don’t have to add anything. And they’re, they’re still fine. So I mean, if you want to really assess the risks, which would be your first case, attririon case or erosion case, I would select erosive patient all night long, you can get really predictable results, very less complications than attrition patients, you know there are things you need to be bit more accurate. But again, technique wise adhesive versus indirect sort of composite versus indirect porcelain, start with composite, then go on porcelain and once you gain some experience and got some cases under your belt [Jaz]Amazing, then you have fully blown us away with all these appointments. So we’ll ask you a few more microsteps. Then I want to hear about how we can learn more about full mouth rehabs from you because I know you said he got some courses and we’re learning live stuff online stuff. Before we come on to that. Just want to just find out, how long you tell your patients that this adhesive rehabilitation will last and what is in the contract in terms of like, for example, when I do a bigger cases, I make it clear at the beginning that if you don’t attend for at least one annual checkups and some hygiene, then anything chips you’re paying for it. But in the first year, anything because you know I’m comfident in my sort of diagnosis stuff, any issues I will be there for you. But you also need to do your part. So what are you telling the patient obviously you told him beforehand, but it’s a good point now that you’ve described the process so beautifully. And you’re at the end now to describe the terms and conditions of this marriage [Dev]Again, Yeah, so basically, with regards to patient, I would have had this conversation obviously as you said, beforehand, before I’ve done all this, so I always tell patients that the composite, and again, I’m glad that you brought up this point, because when I was young, when I started my career, I did lots of composite veneers, right? So that’s how you start because they’re easy, cheaper, patients say yes to composite quicker, because they’re almost half the price than the porcelain veneers. You can less appointments, more control, because I can control the anatomy, I can control the shade. Whereas if you send it to lab, depending on how good the lab is, so I did lots of composite veneers. 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’re cheaper modality, I tell patients that look in a long run, they will cost you the same as porcelain, because they need maintenance, things will chip, you know they need polishing, depending on your diet, things will stain because I do everything same for all my patients. And sometimes some patient comes with staining every six months, I’ve got patient, and some patients come after four years and there is no staining everything’s fine. You know, it looks really amazing. And it’s not me, it’s patients so I’ve taken photos, and I would show them to my patients before I start the treatments saying, Look, this is one patient, this is another patient, I’m the one done the treatment for both of them within few months like that. So it’s not that my skills change. And they’re both showing different results. Because this depends on your diet, your hygiene, what you do. So I’m always going, I’m always telling them to take responsibility of what happens in their mouth, rather than blaming towards yourself, okay? So that’s very, very important to ask them to take responsibility, I would, I tell them, I’ve tested different guarantees. And in my experience, it has made no difference to my uptake, okay? So what I tell patients is that I would guarantee for a year, if any chips or breaks or anything, I’ll fix them. And then after that, you need to maintain it, if something happens, you need to pay for it. I don’t expect this to be filled with composites, they look the best on day one when you do it. And then it’s downhill. Now, depending on how good composite you’ve done, the color of that downhill come could be quite flattered. And then you know, gradually going down with a really bad job then after a month, it just started doing really deep downhill. So I would tell patient that five years is the time you need to expect from these things. And you may need some touch up, some refurbishment afterwards. Whereas veneers I would tell them around eight to 10 years. The difference is that again 10 years experience has shown me that, you know, if I have a space, and if I’m not damaging the tooth too much by doing veneers, porcelain veneer, I always prefer porcelain. Because it’s less maintenance, you know from patient and everything is just much easier. Much much much clean. So for me it’s not really cheap, how cheap it is the composite is how much damage I’m going to do to the tooth in order to, because if I’m adding a lot of wax up, then personally we all you need to do is just make a margin and you can stick a veneer in there. It’s not a big deal. So with regards to composite buildups for posteriors, for posterior onlays, I use something called valveless only, which is a very old technique, which is a second generation composite from Kerr and Pascal Magne used to use it before now he’s moved on to composite blocks, and which I’m also moving on to composite blocks, but most of my 10-year-old cases are using those onlays and they work perfectly fine. They’re really rare properties are so good, that they look really good. So for me, so that’s what I tell patients so they need to maintain hygiene. Six monthly hygienists Yes. Checkups, six monthly checkup. And I give them one year guarantee, does that help? [Jaz]Thanks so much for that and that helps a lot. And then just to say the problems I’ve seen from colleagues and for myself, when I’ve made a mistake is when in my planning of composite, I did not respect the material thickness that it needs. So I find when I’ve had posterior chipping, one of my colleagues about posterior chipping is because in that area over a cuspal tip, there was only 0.5 millimeters composite in that area. So I think th thicker the composite, the better it can handle stresses, we know that composite is very good and compressive and to minimize the tensile load by building in and dahling in your canine guidance and make sure it’s nice smooth, that will obviously improve the longevity. So respecting the material thickness, and also the ideal occlusal scheme is why you’re getting so much success as well Dev in that so it’s worth mentioning that. Please tell us, where can we learn more from you? [Dev]Oh, so I have, you can go to my website, which is drdevangpatel.com, I have various courses there, I have a full mouth reconstruction online course. So I have a pathway to full mouth reconstruction, okay? Because I want all general dental practitioners to be able to offer a full mouth reconstruction treatment to their patients, at least the adhesive full mouth reconstruction. For that, obviously, they need to make sure that their single tooth dentistry is good, which I am going to, I include that as well in my course. So the level that there is an online course, which describes everything that I’ve discussed today plus a lot more, it’s around 20 hours worth of online lecturing, and on practical demonstration of all the procedures, so it’s a practical demonstration of all the procedures. And it covers everything from start to finish, then if and my aim is to make sure that when someone does an online course, they start doing some sort of if a single arch and do something just by doing an online course. So that’s how I made my online course, however, we are hungry people. So you know, if someone wants to really get into the nitty-gritty and do a hands-on course, then level two is the hands-on course. That’s what I do as well. And once the hands-on course is done, you will have, you know, dentists will have a lot of confidence in doing the treatment. And if there are dentists who are like me who, you know, don’t have, they need someone next to sitting next to them for that very first case, then I’m doing one-to-one mentoring as well. So I will go to their practice. And make sure that when they’re doing their full mouth reconstruction anterior and posterior reconstruction, I’m there sitting, nursing for them, so that they get the confidence because once you do the first case, and everything else becomes easy because you’ve gone through that process and feel a bit more comfortable. So some people just need that, you know, just a little bit extra nudge. But the pathway is basically at the end of this pathway, either some people do an online course and they’ll be able to do full mouth reconstruction, some people might need hands-on, and some might need one-to-one. But at the end of the pathway, everyone should be able to do full mouth reconstruction adhesive using composites. So that’s the aim. And that’s the message I want to spread to all the GDPs because by doing that, we’re actually serving our community better. We’re making sure our patients are better treated, because I see a lot of colleagues missing because if you’re not doing the treatment, like you will see in practices where one dentist is doing Invisalign cases like 10, 20, the other they’re just not doing any Invisalign cases, and you’re thinking, the patients are the same. It’s the same practice. It’s because that person doing Invisalign is seeing more. So if you’re doing full mouth reconstruction, you’ll start seeing the patient because before that you probably didn’t look at it properly. It’s like buying a car right? So if you buy a car you start seeing the same car a lot on the road. The same thing. But yeah, so if you follow me on Instagram [Jaz]And I just want to say that is amazing. [Dev]Yeah, if you follow me on Instagram @dr_devangpatel or Facebook, Dr. Devang Patel, or go to my website, which is www.drdevangpatel.com. And, or reach out to me. And if you have any cases, I’m more than happy to help you guys. [Jaz]Dev, this one is really helpful, guys always got time for you. So thanks so much for being so giving to our community. I just wanted to say when I saw you in Edinburgh, the BACD, we were talking about this, and we were talking about how in the implant world, they have such good pathways and good protocols with ITI. And mentorship is such a huge part of learning implants, right? Whereas when we find that when it comes to this type of dentistry unless you do a talk postgraduate master’s degree, you don’t really get that opportunity of someone coming to your practice. And doing that, which is absurd. Because when we’re charging, the amount we’re charging for full mouth rehab compared to you know, one or two implants, they’re fairly comparable. So to have that ability for your level three, in your case for those who need it. I think that’s fantastic. And I think this is the future. I know the future is online as well. And I’m an alumni, a huge fan of online education. But I think it’s great to have that option of having over the shoulder learning, which I think to this day is the most powerful way to learn, my most powerful learning experiences have happened when I’m shadowing someone, or someone’s shadowing me, and I see how much they’re gaining. And I think that’s what you’re providing. So kudos to you, Dev, thank you so much for giving your time over the three episodes. Have been most enjoyable speaking to you. And I’ll put all the websites up and anything that you send me in terms of photos, PDFs, or whatever, I’m gonna stick it all on the blog post. And then hopefully people can log on to the website, see all the different stuff you have, and to follow you on social media so they can check out all these cases and all the tips that you share. I really appreciate you coming on, Dev. Thank you so much. [Dev]Thank you for having me, Jaz, thank you very much. Jaz’s Outro:And there we have it guys. Thank you for listening all the way to the end. Dev was spitting fire as they say right? It was absolute phenomenal. It’s kind of like one of those episodes where you could not do multitasking right? You could not do multitasking, if you’re chopping onions, probably chop your fingers, right? So it’s one of those episodes, hope you enjoyed it, hope you found value from it, you may have to listen to it again, and maybe a third time just to cement it. Cement the ideas, the bigger picture thinking into your head. So I hope you enjoyed that. Please do join Full mouth reconstruction for GDP. This is Devang’s little baby, little group on Facebook, which is just some loving seeing posts from other dentists and Dev sharing his workflows. Lots, lots of lots of great content on there. So do join Full mouth reconstruction for GDPs. I’ll put a link in the show notes. And of course, if you want to learn more from Devang Patel, there’s so many courses that he does got mini-courses. So if you liked his style of education, you should definitely check out his course, especially when it comes to full-mouth rehab stuff. He’s got courses on that and I’m going to put his website I’ll put it down below for those watching on YouTube. And I’ll readout for those who are driving and then sort of making a mental bookmark for later. Now of course I’ll put it in the show notes so you could click onto it easily, it’s drdevangpatel.com/courses-hub. So essentially if you go to his website, drdevangpatel.com You’ll find the Courses section and you can check out all of the amazing courses got on there. Dev, I know you’re listening to this one. Thank you so much my friend for making this three-part series. It’s been absolutely epic. I’m sure everyone’s gonna agree and what you’ve given to the Protruserati is amazing. So please guys show your support. Join this course, you will learn further. If you want to enhance your full-mouth thinking, check out Dev’s course. Thanks so much, Dev. And thank you for listening all the way to the end

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 6:30 Lack of Clinical Skills after Dental Schools 9:16 Advice for Fresh Dentists 12:17 Limited experience at Dental School 16:38 Advice for Dentists in terms of finding their niche 19:59 Best 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. I love that you’re out sharing knowledge. I mean, all of your listeners and listeners of podcasts everywhere I was listening to a podcast in the walk over should just be grateful that we have so much content to learn literally while we’re walking around, getting coffee, in our ear. So I really really admire what you do. [Jaz]I just pointed out for those of you who are listening right now not watching this also goes up on YouTube, as you guys know, but those listening right now, I’ve got Paul in front of me. He is doing a wonderful job professional mic. He’s got his Nacho Hoodie. I’ve got my Protrusive Hoodie, and he’s on the walking treadmill. And I’ve also got my walking treadmill but I’m not using it. But already that’s a huge similarity I found there. The other similarity I found it between us is you having this amazing community, the dental Nacho community, which I want everyone to check out and what a wonderful job you’re doing, your community is just so much energy, so much activity going on. So I can only aspire for my community to become like yours one day, so brilliant. And the other thing is that the kind of things that we’re talking about is A) trying to uplift our profession, trying to really get everyone thinking all the positive, but B) being down to earth and actually reflecting on dental school as an experience. So that’s very much the topic we’re covering today. Just tell us for those people, perhaps in the UK, in the world who haven’t heard of the nacho verse before dental nachos, how that came to be and what you stand for? [Paul]Well, like most good ideas, I have my wife to thank for the name. I have myself to thank for my obsession slash passion with Mexican food. So I was a restaurant server at 19, 24 years ago for a corporate Mexican place in New Jersey. I learned so much there about systems, working as a team how to treat customers so it was a wonderful experience. I always loved, I also was a little I was the kid, Jaz, that when you this how it works in the US. I don’t know in the UK I don’t know how simple when you sat down at a Mexican restaurant. When I was a kid they would immediately give you free chips and salsa. So I love that you could have food before you had the food right? There’s a South Park joke on that. So I thought to myself, I want to make a group I do a lot of different things. I’m a dentist down to practices. I’m a speaker, I’m a broker. I’ll have a like a lot of toppings. So let’s name it dental nachos. And then really the metaphor in the analogy you know if you if you do get a dental nachos swag, we’ll send it to you someone’s gonna say oh hey Jaz what’s dental nachos, right? They’ll say that the gym, they’ll stay at a coffee shop say it’s like a Mr. Rogers Neighborhood for dentist because dentist need help being nice to each other. They’re nice to patients. And I always say dentists are very good with patients, not as good with people because dental school makes us very, very weird. I really believe this Jaz. When my friends who I’m friends with today, we’re doing finance and business, and HR, we were in a basement burning ourselves with wax trying to make a tooth. And I think that we didn’t develop the skills, ages 22 to 26, 23 to 28, where social developments feels like my best friend works in finance in New York, when he was 25. Jaz, he was standing with a glass of wine at 11pm at some sort of networking event next to a guy who made $10 million. And his boss said, You got to talk to that guy. So they had to figure that out. So that’s where not just came about a place where we can learn, share, have fun, work on our business, have uncomfortable conversations with respect, buy things, you know, I have made it kind of like a 24/7 virtual exhibit, we have sponsors. So you don’t have to buy anything like a free part. But you can if you want. So that’s the nacho verse for you. [Jaz]Well, I’ll put the link for everyone to join. So if you haven’t checked out the dental nachos group and the community and the website, you must check it out. So you can obviously hear or watch Paul’s enthusiasm and his passion and the way he explains things is just brilliant. I’m a huge fan. And I read a lot of your stuff, and I watched all your stuff. And the common theme, which can be the theme of the podcast we’re covering today is how dental school let us down. Now, I hope that you agreement that this, we’re not making this to, I don’t know, hold up a grudge against dental schools or trying to point blame finger at them. There are certain circumstances that dental schools have to you know, be complicit with that leads to the kind of downfalls but really, I think the, I hope you agree, Paul, that the reason for doing this is to make essentially dentist realize that we have the shortcomings, but what we can do after dental school to make up for it. Would you agree with that? [Paul]I totally agree such a great point, I get known a little bit as being I say just be nice jbn, which is about being nice to your colleagues about if somebody decides to do a crown when you would have done a large filling, don’t call them the worst dentist in the world. Don’t make fun of them. But JBR is just be real. And being real is taking a look at what’s happening to in the dental school world. Taking a look at the lack of fundamental skills that dentists are getting in dental school for surviving and thriving. I’m a big I have to say I have the most amazing parents. They’re not alive right now. But they’re amazing parents, but they lied to me Jaz, you want to know why they lied to me? [Jaz]Yes, absolutely. [Paul]Because they, there was this theme. Instead of parenting. I have two awesome children. If you work hard enough, you can do anything you want, right? If you work hard enough, you can be anything you want to be. Well, I wanted to play professional basketball in the NBA. And that dream did not come true. So I joke with my parents, grew up without my parents. So what I share is if you played basketball, and you went to basketball school for four years, and they only taught you about dribbling, never taught you about passing and say when you’re going to learn about passing, you’re going to figure that out later. Well, when you get into the game in the real world, and you don’t have passing skills, or shooting skills or playmaking skills or defensive skills or what to do when the ball gets turned over. You become your morale goes down, your ability to to help patients go down. So I just really try to be a voice in a kindly, annoying way. One of my things is I kindly annoy people, my wife might say I regularly annoy people. But one of my best friends Dr. Todd Fleischman. He’s been our podcast. He’s a teacher, speaker for us. He’s done Kois, he’s done Spear. He’s amazing dentist, but even more amazing human being. Early on in dental nachos. I kindly annoyed him to become a speaker because I said you have to share this talent, Todd, and he goes, I don’t want to do it. And I say I don’t care. We’re gonna kindly annoy you to do it. So he’s always said, the more Paul Goodman kindly annoys you, the less annoyed you’ll be yourself. [Jaz]Excellent. I love that basketball analogy. And I think we there’s so many different ways that we can run with that analogy. And one way we’ve already touched upon is the communication aspect. Like, you know, being that little basement waxing up compared to our peers doing other subjects, we’re getting different kinds of real world experiences, more interactive with people who are not just in their own sort of, you know, economy, I guess, so it’s great to draw that comparison. But let’s draw in on another tangent here, which is the clinical skills itself. I mean, you you obviously in US, the tuition fees are astronomical compared to the UK. And one of the themes I get is that okay, I just paid all this money and so much debt, yet I only did X number of procedures. In the UK, I want to learn from you because we do have an episode about comparing UK and US but it’s one learn from you that in the UK nowadays, obviously because a pandemic has affected it as well. A dentist can graduate having done one molar root canals, or maybe two or three crowns. So how does that compare to, you know, you’re very much in tune [Paul]Exactly, it’s very much the same, even worse, some schools doing none so I will use another analogy I’ve learned a lot about analogies for teaching. So over this summer, we had a party for my seven year old at a place called primping play, it was where all these girls and guys can get, the young kids can get stuff done. So I’ll just use the example when I bought pizza for that party. And there was 12 Kids, if I only bought enough pizza for eight kids, I’m going to have four disappointed kids, right? So using this analogy with dental schools, if they accept more students than what they have clinical procedures for those students to learn, they are literally going to mess up their lives, they’re literally going to cause emotional problems. Because right now they are giving degrees to dental students. One of the things I thought during the pandemic, Jaz and I don’t know Scotland did this. But as soon as the pandemic happened, I said they should stop taking dental students for a year, skip a whole year of taking students. Now I do not know the economics of higher education. I do not understand if that makes places shut down. But what I saw was, the people graduating during the pandemic, through no fault of their own, got even less experience than what was already a problematic experience when I went. My dad was a dentist, who I work with for 11 years before he passed away. He said to me, Paul, private practice isn’t going anywhere, do a GPR, get as many skills as you can, you can never learn too much early. But What’s unfair Jaz is a GPR, AEGD, that’s extra training for the US. Dental students are paying for four years of school to get a degree in general dentistry, that if you want to use an analogy, like drinks at a bar, it’s watered down, it’s debilitated. It’s not what they paid for. And I believe that this is going to cause an enormous crisis in our industry, I believe it’s going to cause a mental health crisis. I believe it’s going to cause a practice transition crisis. I think if you are a dentist on Earth, who’s working, unless you’re retired, it’s gonna affect you. And even if you’re retired, you still need a good dentist, right? So I think these awesome young students to no fault of their own, and also what I think is cool about dentistry, as people start when they’re 35. So they’re not necessarily always young in age, right? They have been misled as to what the dental school experience is going to provide them to be able to use their career successfully. [Jaz]So how can we, what advice can we give to that young dentist who maybe has just come out of dental school, and they realize that they’re, you know, doing a cramp operation makes him nervous, doing extractions, scares them, because they did not get the backup of the procedures didn’t get the mentorship that they deserved? And they were all that while during dental school that you touched on this, they had mental health challenges, nervous breakdowns? Because they were trying to oh my god, am I gonna qualify? Am I gonna graduate? Because I only had X number of canals on the systems, they finally got through that. They’re on the other side, how can we give them some nacho, dental nacho.. [Paul]One are the signs in my office, one of quotes is “Everything that matters needs a system and everything matters. But always make the best decision in the moment.” So you may have a system that a patient has to pay ahead of time. That’s your system. But Millie comes in. And she’s a great patient, and she’s had a personal crisis. And for whatever reason she didn’t bring her credit card. Well, maybe in that moment, it’s best to let Millie go, right? I’m just using an example. So back to, your dental, graduating in Dental School. So now, this is one of these things. So I’ve been alive for 44 years, and I’ve been through a lot of different nutritional themes in the US, right? The processed foods used to be good for you now it’s not good. Maybe it was never good for you. But they made it seem like it was good. Eat whole foods. But have you heard that like, there’s such thing as good fats, right? But I’m in the 30s like good fats, avocado, right? So I’m like, I guess I could eat is you could eat good fats to be less fat, let’s say. So back to these dental students. That’s uncomfortable. For someone who’s grew up in the 80s. I still don’t feel totally comfortable when they say oh, you can eat these good fats. It feels weird to me, right? So when you have a lot of debt, I know it feels weird. You must invest more money in time into stuff that really matters. One of my friends, Lincoln Harris, who was on Ripe, you should interview him. He has an 80,000 member [Jaz]I already have Paul, and he’s the one who introduced me to you believe it. [Paul]He and I spent time in Philadelphia, we think a lot of like. Lincoln is a phenomenal dentist much, much, much, much higher clinical level dentistry. So for example, Lincoln put together this program where anyone from around the world can learn in their operatory. And maybe I don’t know what it cost. So maybe I’m saying too much or too little. But let’s just say that’s $10,000 for a year, but what I’m saying is okay, 20,000 a year you got to say hey, I just spent 500-, 600-, 700,000 on dental school 300, four years. I know I don’t feel like doing this, but these are the tips. These are the tools from Lincoln Harris that’s going to help me and I have to figure out a way to invest. Maybe I asked parents maybe I take out a loan because what happens is if you miss out on Fundamental dribbling, passing and shooting skills early, you may never learn that. So that’s one way. Then the other way. I’m a big fan of utilizing free resources I use them in through podcast is to really invest in how to learn to talk to people, how to learn to communicate. One of the, I do like three things well, Jaz, but one of them is being a public speaker, I’ve done training, I spoke at the DEO in front of 300 people when I got off stage, people go, you’re such a natural up there, which is ridiculous. No one’s a natural at getting up in front of 300 people. I put in so much training, and so much time, there’s a, on YouTube has been viewed millions of times how to speak by Patrick Winston, you can put in the show notes, how to speak by Patrick Winston, an MIT professor. I listened to it before every big speech I get. So it’s not about public speaking, it’s about getting your point across the people. So who do young dentists have to do that with jazz their patients in the operatory, their team, the dentist that owns the practice. So I was talking about your dental core, or your clinical hand skills, your mind skills, and your word skills. So if you’re a new dentist, use a Lincoln Harris type thing to work on those clinical skills, but combine it with both your business skills and your communication skills. [Jaz]That is fantastic. So we’ve covered two key key themes already, which is the lack of clinical skills, and how although the cost of dental school could be astronomical, especially in your side of the pond, is about investment so that you can come out on the other side and make up for the shortcomings. Let’s talk about the fact that the techniques that we were taught in dental school, they are very frustrating because they’re not cutting edge. And then when you come out of dental school, the first thing that my mentors taught me is Okay, forget everything that they taught you at dental school this is actually how you do it. So in this world what we navigate and like you touched on already, one dentist might say okay, do a crown other dentist might say oh, that dentist was the worst dentist in the world because he did a crown where something needed a restoration. We should be nicer. I really appreciate that sentiment. But how do you know, how, you know, who’s right, who’s wrong? How do you know which philosophy to align? Should you go Spear? Should go Pankey? Should go Kois? There’s so much noise. How does one navigate through this noise because when you come out you had limited experiences and what you were using wasn’t cutting edge. [Paul]So good. I want to point out, so John Kois is one of my favorite people in the world. When I was a resident, I sat the Hyndman in Atlanta, I heard him, I love how he teaches you know, patients don’t accept solutions to problems they do not have. What happens if you nothing. I had the honor of being on a stage with him. And just a funny story. So he was like my idol. I love him. He didn’t know anything about me. But I did with him the night before. And he’s such a classy individual that when he opened up this speech as the headliner first he goes, You know, I’m Dr. John Kois. I’m going to talk about occlusion. Dr. Jason Elixis. He’s going to talk about Aesthetic Dentistry. Jason litski is very good. Very good. In Florida, Gary tachiz is going to talk about practice management. And Paul Goodman is going to talk about nachos. And I just thought that was such a funny moment for me. I love that. But Kois said this so well, at that event. One dentist treatment plan of helping a patient is another dentist malpractice. And he says we have such bad standards. And it’s messing up everything. So what I would share is if you’re not learning, I always say dental school teaches MySpace of dentistry. And then you get out and no one has a MySpace account. And people go out. I don’t love this. This I think is just kooky talk Jaz when people go, you have to know how something was done. Even though we don’t do it anyway that way more. I think it’s the on the statement ever, right? The most dumb statement ever. You don’t know how, you do not need to know how MySpace works. You can know MySpace was an original social media thing. And it morphed into Facebook and I went oh, this is so like, you don’t need to know how to invest and cast a gold crown. It’s pointless. It’s a waste of time. It’s a waste of time. If you want to know gold was done. And maybe sometimes people use it occasionally. But you’re not going to have, I always ever showed why in dental school, would they take people who didn’t know anything. I let them play with this thing that spun around and like shot out fire. Right? I don’t know if you did that in your dental school. But we didn’t have any luck. So what dental students and new dentists need to do is just to embrace whatever they are learning in the real world and strive to discard stuff that doesn’t make sense. Keep things that do make sense. There’s dental students right now learning how to prepare a crown in a really great way at dental school, right? So keep that. There’s also dental students doing the fourth reset of a denture or an alter cast RPD which is likely going to be discarded and I just have to share it’s a very, very difficult thing. But strive to hang out with dentists who are doing the up to date things in the real world and embrace that technology. [Jaz]I would say, to add onto that, get exposure, get out there, shadow other dentist because you will get your eyes open to what is out there and then you’ll be able to figure out okay, what is it that really is your calling within dentistry? I mean, one of the many episodes and themes that we covered is finding your niche and I just know you’re going to have a good analogy or an answer for this. If you were to give a dentist, any dentist I don’t care how experienced they are, some advice about find out what is going to be their happy place in dentistry. Any ideas in terms of how that dentist can figure out what it is that they can really make their thing? [Paul]Get right. Yep, sure. I have a good one. It’s the Goldilocks thing, right? So Goldilocks said, This is too hot. This is too cold. This is just right, right? The only way for you to do this, like Gary Vee said is to taste test a lot of things. In dentistry, what I would encourage someone to do right now wherever they are in their career, but especially a dental students associate is to walk into dental offices and go up to the front desk and say Hi, my name is Dr. Paul Goodman. I’m a dentist in this area. I would love to learn more about what dentistry is like in this area. Could I take the practice owner out for lunch? Could I take the practice out for lunch? If you do bring cookies for the front desk or fruit if you do this magic will happen because I already tested this. A dental student did this and one time was offered a job on the spot by doing that. [Jaz]Wow. I totally get it. [Paul]We’re such a cave mentality. But it’s not about jobs. It’s about seeing how other people operate. So maybe someone takes every insurance and that’s for you. Maybe someone takes no insurances. I’m friends with Jason Smithson, amazing dentist, one of the best on earth just like on Lincoln. I don’t know exactly how dentists in the UK works. But seems like either people can pay out of pocket or kind of be in this government funded, you know, plan. He’s not in that. Maybe there’s merit to doing that. So go and see how other dentists practice in a kind, humble and genuine way. Because I want to share this with you. If anybody lets you into their dental office, to watch them, they’re doing you the favor. They are going out of their way. When someone comes to watch me. It’s more stressful, I have to work slower. I have a stranger in the office. But I’m doing it because I want to showcase what dentistry can be like. So if you go and ask, you’re going to get people say we’re not interested, you’re going to get people hanging up on you. But if you go into dental offices, and just say that, “My name is Dr. Paul Goodman, I’m a dentist in this area. I’m a dental student. I would love to know what dentistry is like, Could I take the practice owner out to lunch?” Just say those things and magical happen. [Jaz]Well said and I totally agree. And I think the opportunities are out there. And sometimes centers were shy to ask or what if I get rejected? It’s like, you know, when you’d be giving treatment plans Or what if I get rejected so I’m not going to be comprehensive? If you don’t ask, you don’t get and I think the, you have way more to lose by not messaging your peers that you respect, they can learn so much from than getting rejection, it doesn’t matter. I think I totally agree with you. What a great way to do it the way you suggested. [Paul]And well, you just made a point, I’ll just add just one minute of value. So Lincoln Harris is amazing at talking to patients and then amazing at doing dental care. I learned a lot about implant through my career, but I do not do the clinical things that he does. But both of us talk a lot about how to communicate with patients. And my secret to getting high case acceptance is one sentence. My secret to getting high case acceptance is one sentence. I do not care what the patient chooses in any way. I care about delivering the menu. I care about saying salsa gwoc nachos, which one sounds best to you. I say even if you decide to do nothing, we can still be friends Jaz people laugh, right? And it comes off of my body. It comes off of my energy that I do not care in the kindest way what they choose. But I care a lot about presenting all the options to them in a genuine and patient friendly way. [Jaz]Phenomenal value there. And I love the whole get menu, you almost, you might have missed it in, the ways that menu and the way you back it up with the food two choices. That is amazing way to relate it. And I love that. Paul, the mic is over to my friend. Do you think there’s any other major point that we haven’t covered yet that we should do to finish on in terms of how Dental School let us down but how we can overcome that? And what’s the best way to overcome that [Paul]Yeah, so one of my, one of the best things people have a phone and they have notes in their phone. And if you look at mine, I’m sure I’ll show you mine in a sec. You’ll see like 83 notes started because whenever I have an idea or something I want to remember I use my notes. So what I would encourage people to do in dental school is to and this is one of my consultants to make a ‘keep doing’, a ‘start doing’, and a ‘stop doing’ list. And whenever you find something like maybe you listen this podcast and I don’t tell people Jaz that their teeth fail, I say their time for their teeth to retire. So maybe you have this thing and say Paul Goodman says Don’t say fail say retired. Okay, don’t say that. You put that in the ‘start doing’. ‘Stop doing’ might be I saw my dental school instructor. Share with me that if I don’t do this this way, I’m not going to be successful and it’s some sort of thing technique from the 1950s say, I’m not going to do it that way, you could still be nice to the dental school instructor, you can still be kind, and then start doing right I’m going to find out about Lincoln’s courses, I am going to find out about how to buy practice. One thing that dental students do is they wait until it’s too late to take action. So prepare and aware yourself early. This is your career. This is what you’re going to be doing for 30 years. One of my good friends, Laura Brenner. She runs dentistry side gigs. She retired from dentistry after 10 years. And she said, I feel like dentistry is a career you marry. And buying a practice is like having a baby with a career you marry. And I’ve said that numerous times, the practice purchase is a three year old child that never grows up. I have a three year old in my house. It’s part awesome. All the time, insane. So my message to you is there’s four decisions in your life, finding a job, career, finding a job, buying a practice, hiring an associate, selling your practice, figure out how to be successful in each one of those worlds. That’s kind of my parting thoughts. [Jaz]I love that. And I think I’ve enjoyed the high energy, high impact value of this chat with you. Please tell us for those listening right now who haven’t come across nachos, What’s the best way to connect into the nacho verse? [Paul]So I’m a huge sports fan for anything. So I created an ESPN style website for dental nachos.com. So, you know, I do, I’m really, really proud and I’m really thrilled to be on this. When I do this online C course I call it Nacho-C on TV, I get dentists from India, and England, which is great, right? So I have a text code for anyone who wants to get a free C-course it’s text nachos to 2155436454, but sometimes Jaz, it doesn’t work with their cell phone. They’re so they can just email Nacho gift to salsa@dentalnachos.com So if anyone emails, Nacho gift to salsa@dentalnachos.com, we’ll send them back a free resource, they can go to dentalnachos.com I love meeting new dentists from all over Earth. And so grateful that you had me on your podcast. [Jaz]Amazing. Well, I’ll make sure I get that link on there. So people have a direct link to get to that email. And that phone number is definitely worth it guys, and also join the Facebook community. So much positivity, you know, there’s so much negative stuff, especially in the UK, Paul, and you’re on the dental groups. It’s a lot of negativity. But when I anytime I see something from nachos, it’s always positivity galore. So do join that guys, and check out Paul’s amazing content. And it’s great to connect with you, Paul. I’ve been following your stuff. So it’s nice to have you on the show. And our mutual friend Lincoln. His ears must be burning. Have a lovely day, my friend. And thank you so much once again for coming on the show. [Paul]Thanks, Jaz Jaz’s Outro:Hope you enjoy that little interference cast with Paul. Listen, if you want to catch any of the links that he said, any of the resources, just read the show notes and you’re like, Well, how do I read the show notes? Well, if you’re unfamiliar, it’s going to be in the YouTube description. Or if you’re listening on Spotify or Apple podcasts, you should be able to click and expand. It’s not so easy on Spotify. It’s much easier on Apple podcasts or Google podcasts. I’m not the biggest fan of Google podcast by the way. They kind of had hidden a lot of my episodes basically. So the best way to consume it is protrusive.co.uk, the app which should be out by now at the time of recording this so the app will have all the links easy for you to click onto. And of course the protrusive website. Anyway really appreciate you watching, listening all the way to the end and I’ll catch you in the next one

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 14:55 T-scan in terms of occlusal adjustment 19:34 T-scan in terms of differences in adaptive capacity 24:53 Importance of patient’s feedback 28:58 Treating patients with TMD through occlusal equilibration 35:45 Dentists’ concern about the thickness of the T-scan 41:20 Level of precision in diagnosing patients 46:50 Why 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. And eventually what could happen is that you end up just adjusting away all the blue dots until you don’t have any contact anymore. [Jaz]So this is why I think there’s a huge benefit of something called a Tek-scan, or a T scan. And I was, well I had huge reservations about this. And when I met Dr. Robert Kerstein, who’s the guest on today. He’s from the USA. He’s done so much research. He is the go-to guy when it comes to anything to do with the Tek-scan. We shared a very intimate study club together. It was three delegates and Dr. Rob Kerstein. For a whole day, we were talking in geeking out about occlusion so you can tell I was emceeing my elements. And you know what I was heckling, Dr. Rob Kerstein a lot. We’ll talk about that a bit. I was disagreeing with him. I was arguing with him. In good nature, we were debating, okay? And I think it’s important to debate, you know, you shouldn’t take everything that you hear at face value, you should argue and debate. And so we did that, and I had a great time. And I went away thinking that okay, to be able to measure the force and time has some value in many situations. When it comes to bigger cases, it is for me now that I have a T scan. And the reason why this episode is coming out so late since I recorded it is because I was waiting for my T scan to be delivered. And now I’ve used it on some patients, and I am really loving it. So talk all about that journey. In fact, I’m going to do a whole occlusal adjustment episode just to elaborate on my experiences as a beginner using the T scan, and what cool and fascinating anatomical things I found by using it. But I don’t want to distract from the meat of the episode today, which is Rob Kerstein, all about how articulating paper marks aligned to us, and the role of being able to measure the force and time and the benefit that gives to us and our patients. Before I met Dr. Rob Kerstein in Brighton, I had heard of a Tek-scan, but I’ve never actually seen it in the flesh. And I got to see it. And if you haven’t seen it before, it’s like articulating paper, it’s like a horseshoe shape. But it’s completely digital, it looks like a little paper version of a circuit board. And what the basic benefit of it is that when you put in the patient’s mouth, and get the bite together, it transmits all this data to the computer. And you can see which tooth hits first, what is the sequence of the tooth contacts and which teeth are hitting early and which the teeth are hitting late, how much force is being distributed across the arch. Now, think of it already like with implants, right? For example, when we’re working with traditional articulating paper, we’re trying to make sure that we can get some degree of clearance on single implants, right? We don’t want our implants to hold shimstock foil. We want a little bit of clearance now ask different dentists they’ll tell you different microns of amount. But now you can actually quantify that and verify that digitally using something like a T-scan so many numerous benefits and we’ll talk all about them but the thing that took me by surprise is that there’s actually so much evidence when it comes to CT scan. Like we know that in the field of occlusion General, the long term studies, follow-ups, conclusions are poor quality overall. But then Dr. Rob Kerstein opened my eyes to all this evidence basis. To share this Google Drive folder with me with so many PDFs looking at the different trials and studies have happened with the different evolutions of T-scan. And some of it was just really eye opening. So if you want to geek out with that, he’s given permission for me to share these PDFs with you all. All you have to do is go to protrusive.co.uk/evidence. That’s protrusive.co.uk/evidence, and I’ll give you access to every one of these PDFs. So if you want to just geek out or learn further, or critique the evidence, we should always critique the evidence when it’s available. Check that out. [Jaz]My experiences so far, T-scan has kind of been pretty cool. I can’t wait to share that with you in the extra episode, like I said, but I take great comfort in knowing that great dentists like Dr. Bobby Supple from the US and Dr. Riaz Yar, UK, his very own doctor, Professor, Riaz Yar is also using it. In fact, he’s sharing on his Instagram story pretty much every day, different T scan cases, just great to know that I’m in good company when it comes to that. Actually acquiring a T scan was a tough thing to do as an associate, right? I’m not the owner of the clinic, I’m just an associate. Therefore, it was something that I had to have a real in depth conversation, my principals because ultimately I was going to be the only one there’s gonna be using it. So I felt bad that my principals were gonna have to pull out their credit card and buy something that’s just for me. So I sort of struck a deal with my principals, as an associate up I’ll pay for it. But let’s work out a little business deals. So if you don’t hear about my business deal, I’ll talk about that in the outro. I don’t want distract from the main episode any further. So if you listen to the outro, I’ll tell you about the conversations I have with my principlas, and how the T scan has some degree of an ROI, has a return on investment. Now in episode four, all the way back when in episode four, I did discuss with Dr. Neel Jaiswal about microscopes and how microscopes something that you buy, because you want to improve your dentistry, it doesn’t really have an ROI that you can’t charge X amount for your root canal treatment. And then you can’t charge an extra subsidy for the microscope, it just doesn’t work. But with a T scan, I’m able to actually do that. And patients do realize a wow factor when it comes to this. So I’ll talk about how the business arrangement works. If you listen in the outro. [Jaz]The Protrusive Dental Pearl I have is about articulating paper. Now you’re thinking Jaz, you’re talking about the T scan, which is supposed to replace your articulating paper because it’s like the new age thing. And now you’re going to give us a tip about articularly paper? How does that work? Well, actually, when you use a T scan, you interpret the data, but you still need the ink from the articulating paper because that’s all the articulating paper does, it transfers ink from the contacts, it doesn’t tell you the true contacts always, and doesn’t tell you about force and time so but you want to know about the ink points. So when you’re interpreting that T scan data, you’re marrying it up with the articulating paper mark so they’re still important and they’re still role of the article in paper ink. Now sometimes you might realize that no matter how much you get the patient to occlude together the ink is not rubbing off on the teeth and quite classically glaze ceramic will be difficult to actually have the articulating paper mark show up. So the little hack for you is to get a tiny smear of Vaseline please please please put a sparing amount of Vaseline, like a microbrush for example. And then you paint that Micro Brush on the articulating paper. Now, obviously articulate papers are different this works on Accufilm which is the one I use, and then you paint both sides of it, and you get the patient to bite together. And there we are, before you could not see the ink mark and now you will be able to because the Vaseline has an effect on the articulating paper which allows it to stain or ink the teeth more effectively. So that if this really works and helps you know scenarios, we just want to see where exactly the contact is on your ceramic restoration. So hope you enjoy this main podcast, you know, open your mind guys open your mind. I know we’ve been taught a specific way and like I said I was the biggest heckler Rob Kerstein ever had. But I think there’s a beauty and listening to different people’s opinions. And let’s give our, you know, warm Protrusive Welcome to Dr. Rob Kerstein and listen to what he has to say. Because I definitely have found so much value from it and I hope you will too. I’ll see you in the outro where I talk about my business deal with my principlas. Main Interview: [Jaz]Robert Kerstein, Welcome to the Protrusive Dental Podcast. How are you sir? [Rob]I’m good. Thank you for asking. How are you doing? [Jaz]Yeah, great obviously was great to see you at the Tubules Congress. I was one of the guys that your lectures and I when I email you say I said hey, I was the annoying guy who kept asking silly questions and stuff and we were having you know, it was good fun. It wasn’t many of us but that made for a very intimate discussion. And I got to have a lot of one to one with you. And we exchanged philosophies and debate and I felt as though with occlusion it was really good and important that we kept it was still with mutual respect because we see all the time, different occlusal camps, right? They’re at each other’s throats. But my mindset is very much like okay, I want to hear your perspective. Now, I might not agree with everything you had say Rob and definitely you wouldn’t agree with some things that I believe but I think what this podcast is about, what protrusive is about, is bringing these different occlusal philosophies together and just sharing with one another. So that’s why I’m so grateful for you to join me today. You obviously had your UK tour. Now for those of you who don’t know you are, Rob, please tell us a little bit about yourself, where you practice, obviously you’re a prosthodontist, how you got involved with the objective measurement of occlusion and how that’s evolved over time? [Rob]Well, first, thank you for having me on the Protrusive podcast, and I’m honored to be here. I’m a prosthodontist, as you said, and I began my training at Tufts in 1984. When I graduated dental school, I was a dental student and went on to prosthodontics. And in my program was built the first T scan, T scan one, we’re now on T scan 10. And I began using it without really any knowledge other than you know, it was something that you can measure time and force and although it had a manual, it wasn’t really understood how you would use its data. And what Heitler for example, how would you make a better denture with it? How would you deliver a crown and bridge case with it? You know, how could you diagnose someone’s occlusion with it, but it had some very interesting features, mostly the timing aspect, you could measure timing, and you could measure force levels. And when you use that information to make intelligent choices about what to adjust or to treat, patients responded much faster than when it wasn’t used. And as a personal resident, I was delivering different size temporaries, I was delivering different crown and bridge cases we were at the beginning of implants. So that wasn’t really part of my program other than the introduction to implant dentistry. 1983 was when Brandon Mark wrote his important paper about how to do osseointegration. So I was 1984. And the T scan was built then and it was transferred to 16 Dental institutions in the United States, all prominent prosthodontic programs. And I was the only person who really took to it in a sort of studying it scientific way. And I saw things weather that you couldn’t see without it. And certainly you couldn’t see with traditional occlusal indicators, like carbon paper, for example or silicone imprints or mounted models, because it was dynamic, you have this time element. So I began studying it with my professor who built it. My Professor Bill Manus, William Manus, he built the program, T-scan 1 with five engineers from Massachusetts Institute of Technology. And I was the first real researcher with it. Which was led to me becoming more and more involved with it over time, and I’ve been part of every iteration in some way from T-scan one, all the way up to today’s version of T-scan 10. And I should say in full disclosure, I am a consultant for the Tekscan Corporation. But I do not receive compensation for sales of any Tekscan product. I’m strictly education, research and training. And I’ve been an advocate, of course, because I’ve seen how powerful it is compared to what traditional occlusion offers and the T-scan has found solutions for many problems that dentists face routinely that traditional occlusion has not found answers for. So that’s really how I got into it. Now 38 years later, I’ve published hundreds of articles about it, most of it research and hard science, some commentary, but most of it is hard science and research on timing, and excursive function and how that influences the neurophysiology of the human somatic ethics system. I’ve been fortunate enough to collaborate with many experts around the world to publish five volumes on digital measured occlusion. That really is an incredible compilation of all that we’ve discovered with using digital occlusion compared to using traditional occlusion and it’s a major advance for the patient to have digital occlusion be performed on them. So you know, I my whole role, my whole life has really been tied up in the T scan. Although I didn’t start out that way I started out, I was going to be a prosthodontist who crowns lots of teeth and made beautiful smiles and I did that, but I use the T scan to help me do that. And that was a huge advantage through my years of clinical practice. And now I don’t practice anymore other than to do live demonstrations and to treat patients in seminars. But I collaborate with many researchers throughout the world and continue to publish lecture and trained dentist and how to properly use the technology. [Jaz]Well, I think the best place to start would be some people who are listening who may have heard about the Tekscan or the T-scan and maybe even just roll it back a little bit. You know, what is the alternative that we’ve been trained to use it in dental school and we use all the time and I think you made a great point of the fallacies or the fall backs or the problems when using articulating foil or articulating paper. So if you just explain to dentist, what is the traditional way. And what are the disadvantages of relying on articulating paper marks in terms of the “the way to measure the occlusion?” And what does the teeth can offer, above and beyond these paper marks? [Rob]Well, it’s a very good question. First, the traditional method is very important because it marks the teeth if you’re going to specifically talk about articulating paper. But that’s its true use, it’s not really designed to measure the occlusion and although Dentistry has given it those attributes, by sort of describing size as a way to choose force, or color depth, or distribution, lots of marks that look like they’re everywhere means you have a balanced by and actually, research shows, none of that is actually true. For example, large paper marks are only forceful 14 to 21% of the time. So if someone always picks the largest mark as the highest force, they’re going to be incorrect 86% of the time, and studies actually bear that information out. So the research on both articulating paper as a medium to detect force actually is very, very strong in that it can’t be done at all, right? And if you asked an engineer, it’s very simple. Actually, if you asked an engineer, can you measure by force with carbon paper, any marks and they would say, No, it doesn’t measure anything, it’s just ink, because of a lack of measurement tools prior to the computer era used these analog materials like wax and silicone imprints, and articulating paper markings to try to determine what was going on with the occlusion. But all the mediums really do is detect size of contact, not the type of contact quality, not the timing of it, not the force. And research again, bears this all out this, there was recently a published systematic review, I looked at all the literature on valid studies that show whether articulating paper for example, can measure force. And there are only 20 papers in the entire continuum of dental literature on articulating papers capabilities, and none of them show it can measure anything at all occlusal. So, as I said, Dentistry has given it this credibility that it should be used to detect force and it can’t do it at all. Alternatively, the T scan does measure force, time and pressure by capturing the electronic displacement of applied pressure to the teeth as it spreads out over the teeth. You know, when you bang your teeth, hands together, it’s like banging teeth together, the force spreads out, you know, across your hand, depending on how you impact and what angle of attack you have. That’s what the T scan measures. So as the teeth approximate each other, grind over each other clench together, gnash together, the T scan can capture those interactions of the result in force across a time continuum. And that allows one to make very intelligent decisions about what aspects of the occlusion there’s too much force in, there’s too little force in which side hits too early, which side it’s too late. You may remember in our seminar, our patient demonstration, the dentist that we measured his right side always hit the floor and.. [Jaz]Shout out to Ian, top guy, funny guy. So yeah, we did with the Congress is we used Ian as an example, we use the T scan on him. And yeah, you’re right. It was always the right side in terms of timing that was shooting up to his maximum pressure. Now, just to continue this theme, the reason why I am on board and reason I purchase and the reason why I brought you on stage, because, you know, I think there’s a huge role in terms of spreading the knowledge about the benefits of measuring occlusion, which this podcast will evolve. But a lot of people listening right now or watching will be thinking, Well, I’ve been using articulating paper all these years. And I also I’m using sound some just like (blop sound) that you know, which is fine. Okay, you’re getting some of that using your fingers to check for PDL movement. But what did it for me, what the benefit I find is that it’s a tool that’s going to make me at other things more efficient, more accurate, and especially in the era of implants, and we’re trying to be careful to move forces away from implants, I see as a huge tool that will ultimately save me time in terms of justments Like, just today I was, I did some resin build ups, upper 3-3, lower 3-3, and I was relying on carbon paper markings. And if I just had the Tekscan I’m all avoided. I’m waiting for it now. It’ll just give me a quick reference to adjust it. However, some dentists are concerned about the Tekscan that Hey, why are we even adjusting these occlusions in the first place? Like why? Why are these timing issues even a problem? Because what most Dentist will argue is that the literature supports that occlusal adjustment doesn’t help TMD now the real issue is poor. And I think you’ll agree with that Robert, the literature that’s done that cuckoos occlusal equilibration and stuff and we’ll come to that isn’t great literature in the first place. But a lot of dentists have this concern that T scan is this tool doesn’t encourage Dentist to start grinding away contacts, or has actually had they continued their life without that occlusal adjustment. They may have been just fine. So how can we speak to that cohort of dentists? [Rob]Well, those dentists that don’t measure the occlusion, use a lot of subjectivity to make occlusal assessments, like you mentioned, sound and feel, none of that quantifies the actual occlusion in any, you know, measurable way that allows you to make again, intelligent decisions about what to treat. And this is not necessarily related to solely making occlusal adjustments on natural teeth, it’s you just said you did six composite build up, so three and three against each other, delivering that it can become a real problem for an office if they choose the wrong contacts, because they chose the paper marks that they thought were the ones they should treat. But actually, they left a lot of bad contacts in place, or they removed good ones, thinking they’re removing bad ones. And so the value of measuring for any clinician is their choice to use the T scan to treat occlusally, but certainly in the restorative realm, in the implant realm, in the prosthodontic realm, not guessing at paper marks, we still measure forces a huge advantage for any treating practitioner and just what you mentioned that it would speed up your end result, yes, it would actually guide your end result, it would allow you to make again, intelligent choices as to what to remove after you did your buildups. And that principle applies to whether you’re delivering a denture, whether you’re delivering a fancy implant prosthesis, whether you’re adjusting in natural dentition, because the patient has TMD symptoms, whether you have you know, occlusal issues that keep showing up after you’ve done a quadrant of fillings, and the patient keeps coming back saying it doesn’t feel right. These are all things that plague a dental practice. You know, I’ve given seminars, courses and live demonstrations all over the world. And I always 100% of the time receive patients in these demonstrations that have had dentistry done, that they aren’t comfortable with. And they’re not able to get comfortable with sometimes months or years of follow up of traditional occlusion attempts to manage their case. And what’s fascinating is, the patients are amazed that I can actually measure their bite and fix what’s wrong in front of a group of people, not ever knowing them, I didn’t have any pre-determination of what their situation was. In other words, I didn’t choose them, they were chosen for me. And I was able to many times in just that short appointment that was in a live demonstration, resolve their problem for them because I was able to measure. So that translates into if you have a T scan at delivery, you measure the outcome, you improve the outcome with intelligence and knowledge as to what contacts to treat as opposed to subjectively trying to decide which ones to treat. And the patient saying I think it’s high over here, I think it’s high over there. All of that is eliminated by having the T scan to give you the incorrect forces where they’re located on the teeth to show you where there’s too much pressure and your new restoration. And then you adjust accordingly. And that speeds up the treatment for both you and the patient. And, you know, just to follow on that thought not to overplay this, but the idea of having complications after dentistry, that’s something that came to see me in my office to my 37, 36 years of practice, all more than any other thing that sought me out were patients who were uncomfortable with the dentistry they received, patients came from all over the world to have a T scan evaluation. And again, many of them left in one or two visits with a markedly improved situation that really the only difference between me and the treating practitioner was I had the information about force time and pressure, that the dentist who made the teeth, the fillings, the crowns, whatever it was it had set this patient off and it wasn’t full mouth rehabilitation. It was quadrants of fillings, a few crowns together, orthodontic end result, a tooth was extracted in there by change. These things were all manageable at the moment they occurred if you have knowledge of force, time and pressure so the dentists who who say, you know, well the T scan is encouraging us to adjust this. There’s so much adjusting going on in dentistry, every dentist adjust things every day. And imagine if you could control you know, so many more of your outcomes that you know, you didn’t have the guesswork of subjectivity that traditional occlusion brings to your day to day practice. It would save you so much time. [Jaz]But moreover, these patients that were finding their way to you on these courses, which were you didn’t pick them they just came in they had a problem and you were solving it. Do you think there could be an element of the fact that the same dentist who treated that patient initially who now had a bite that wasn’t happy for whatever reason, that same dentist who’s also treating many other patients, those other patients maybe had a wider scope of adaptation or a adaptive capacity. And then there are certain group of patients, everyone’s adaptive capacity might be different. And some people’s bites just may be more sensitive than others. And because that difference, this cohort of patients treated by that same dentist didn’t feel the comfort that the other patients usually do it. Do you think there’s any merit in that? Is there any research behind that? [Rob]Well, I can’t speak to if there’s research behind that, but what you’re talking about is called, you know, is really the central nervous systems ability to modulate the occlusal neurologic output that comes from the teeth. And the challenge for any dentist is, we don’t know the adaptive capacity of each person, even though they might sound nice in the chair before we started working with them. 10 visits later, after they’re still complaining about their bite, we didn’t know that that person was, let’s say, more sensitive than someone else. So the reality of using the T scan, it allows you to get high precision outcomes with every patient, and therefore you aren’t, you know, you’re really in a way controlling, I shouldn’t say controlling, but you’re optimizing their adaptive response to the installed occlusion and to the other patients that you’re discussing, the ones that may not have felt their bite was off, or their bite was problematic, their ability to describe what’s going on occlusally, although accepting, it doesn’t mean that the case is good. You know, I, here’s an example of that I recently trained a dentist in a state near mine, you know, two hours away. And he had a patient come in who had a fancy, upper implant case done, like a fixed hybrid against natural teeth on the bottom. And he said, Yeah, it feels really great. And you know, I’m having no trouble with it, we put them on the T scan, he was 70% right 30% left with all the force concentrated on two or three implants. So he wasn’t able to describe the real problem. And so even though his adaptive capacity might have been high, his ability to discern quality occlusal district force distribution was very poor. And then the interesting thing is when we rearranged it to be much more balanced and much less concentrated in one corner of the prosthesis, which if you put that out now, five years, seven years, with that corners receiving 70% of the bite, it’s going to break things, it’s going to loosen implants, it’s going to cause screws to come undone. You know, it’s hard to say what would happen, but there’s no question with that overload that it was going to have some sequelae. So after we finished rearranging, he goes, you know, that really is a lot better. I didn’t realize how much pressure I was putting in the front corner of my mouth until after I had this pressure relieved, right? So the response of the patient is obviously, a critical factor in, let’s say, how fast they adapt to what we do. But it doesn’t mean that the person who doesn’t feel their bite or is aware of their bite isn’t suffering occlusal overload in certain parts of their mouth, or isn’t having gum recession on a few teeth, or isn’t having wear on a few teeth, because they’ve still tolerated their bite, it doesn’t mean that they’re not having occlusal problem. [Jaz]I just want to add to that Rob and I agree that just because a patient says it feels fine, doesn’t mean it’s fine. Because so many times my career, I’ve just done my restoration, I’ve taken rubberdam off, I get an underbite together and say, I just stupidly asked prematurely, how’s that appeal, and they say it feels great. But when you had a look, here’s a huge discrepancy, you know, which I would never accept, you know, and I would never want to leave that patient without huge. I’m talking like, you know, a whole millimeter on the other side. And then only after I adjusted, oh, yeah, it still feels great. But now at least I’ve got everything in contact and conformed to the previous. So patients subjectivity is something that we shouldn’t rely wholly on, which I agree with. Now, an interesting thing that you mentioned, this is deviating a little bit, but I thought it would make for an interesting discussion point. Just to learn a little bit about this from you, cuz this was really fascinating. You mentioned about if by equilibrating someone’s MIP, so that the you got a better balance. And I may be using the wrong terms here, Rob, so please correct me, you improve the patient’s a gait and I think you may use that word or another word, but just to tell you I actually had, I was posting about the Tekscan on Instagram. And someone reached out to me on Instagram, who was a patient who actually received a T scan treatment, and this is what he had to say, This is from Peters Health Journal. And he said, I had my bite adjusted through T scan. The effects were stunning after alterations not visible to the eye, such weird sensations went through my body from head to toe, and it says occlusion, this guy he’s not a dentist said occlusion has a big influence on the whole body. And this was after you’d mentioned about some similar things that you’re on the Congress now, Dentist naturally We as a collective group dentist, we think that this is a lot of hocus pocus. But what patients tell us what is important, what they tell us the feedback they give us is important. How could you, How many times have your patients described such an effect to you? And what do you think is behind that? [Rob]Well, the first part, many patients have described, peripheral improvements that they did not expect to receive from having their bite refined with the T scan in specific ways. And it isn’t only balancing the bite, it’s treating the excursions and treating the excursive function that’s actually one of the most critical components to obtaining high-quality outcomes. But the response that you’re talking about the peripheral postural response like this person had is due to the fact that the posterior pulpal fibers and the posterior PDO, periodontal ligament mechanical receptors, they input noxious stimuli into the brain directly because fibers from them go directly into the center of the brain into the reticular formation, which is a huge brain center. So Morpheus, middle of your cerebellum that controls breathing, respiration, digestion, posture, and balance and sexual function. And the teeth are hooked up to digestion through the swallowing mechanism and chewing and masticating. So the center of the brain receives this output from the teeth every time teeth are rubbed together, compressed, flexed, chewed upon, ground over cleansed against every time, it’s not something that human can control. And the person who’s susceptible to it has poor modulation of it in the central nervous system, which may be termed as per our last discussion as adaptation. But the nature of it is it’s an ongoing, electrical, toxic influx that teeth put out that unless the human has a resistance to it, it takes its toll in many different ways. And again, this is because of the neurology, which is not well taught and not well understood by dentistry. Occlusion is taught biomechanically, you know, it’s not taught neurologically. And yet, it’s an extremely, the occlusion is an amazing neurologic trigger, it’s the biggest trigger point in the head and neck, that’s not ever been considered a trigger point. And, but it constantly is throwing out electrical stimuli in order to modulate swallowing, and digestion and chewing at the brain level. And so why someone would have, let’s say, improve posture from having their bite adjusted with the T scan, which is actually a very nice study that just came out on 90 patients who have dramatically improved posture, after having their bite adjusted with the T scan is because of this pathway into the center of the brain that the posterior pulps and PDL fibres make, and it’s not a synaptic entrance, it’s a direct, no switch right into the center of the brain. And so then the electrical stimulus that comes from the teeth, if it’s a lot, which is, again, what is the individual humans modulation of it, if it’s a lot of electrical activity, which we can measure some of that with the EMG in service muscles, but the same negative energy goes out to the center of the brain, it will influence other structures. And so people have told me that they had brain fog go away, after they had their bite adjusted, they always felt like weird and unclear and they couldn’t find anything wrong with them. And they had to, you know, MRIs of their brain and scans done to their head and when their bite was adjusted, they their brain fog lifted, right? Well, that’s a similar component as to someone saying that my shoulders aligned after I had my bite adjusted or I stopped having throat tension, like, very interesting thing that happens to singers is singers can sing better after they have their bite adjusted. I’ve treated opera singers, who would say I can’t get the range I used to get in, and my muscles tighten up. And you know, and it just feels like I can’t be free with my singing. And then we free them of their noxious stimulus that comes from their pulse, and they PDLs with the posterior teeth, and they can sing better, longer, wider, taller, deeper, higher, with less muscle strain that’s very noticeable. And it’s in a short period of time, it doesn’t take months to kick in, it happens within a few short weeks of improving this noxious output that the teeth make [Jaz]My Britt and I shared this with you when we met my British dental brain is very much like what is this Hocus Pocus, like and that might be a response that you may get. So but I know that you said you’ve got you know, this T scan data that shows this but when you look at the mainstream evidence on the works of Manfredini et al, who really is a whole opposite camp, whereas you know, there’s a camp where says you know, there’s so high importance in terms of the correct bite, whereas there’s other camps that that suggest that for example, TMD hasn’t nothing to do with occlusion. These are bold things, even the systematic reviews which again, the studies aren’t that great are against it. So, therefore, as a defensive dentist practicing in the UK, I would find it a very bold claim to make to a patient that we can improve X, Y, and Z by adjusting your bite by know that you have got lots of patients that you told me that you’ve been able to for example, treat that TMD through occlusal adjustment which as a profession as a whole in the UK, especially then was talking to us but UK that is frowned upon treatment as especially first-line Okay, so first line will be various other things physiotherapy explains whatever. And then potentially there could be some occlusal adjustment that is, but a dentist in the UK would have to think twice before doing that. So tell us about your experiences in treating patients with TMD through occlusal equilibration, which has been guided by the T scan. And why do you think occlusal camps, different occlusal camps, different dental schools on taking this technology and using it in the way that you’ve seen benefit many patients? [Rob]Well, it’s a two-part question. So the first part with respect to treating TMD, equilibration is not actually what we do. That’s the first thing and most, but it’s important because most of the studies that looked at TMD response to occlusal adjustment actually had a form of occlusal equilibration done. And that’s actually not what the T-scan-guided treatment is all about. So equilibration is making CR and CO equal. And if you do that, you will lessen the CR, CO discrepancy. But you won’t treat any symptoms with any predictability, because positional improvements aren’t a solution to TMD. They’re there. That’s why the schools have a hard time not the dental schools, but the schools of philosophical fog, they believe that they find this ideal position, the symptoms will go away. And that’s true with the appliance between the teeth. But once the teeth come back together again, no matter what position you’re in, the neurologist goes back to work and often people that are re occluded, let’s say after a month in splints, their symptoms come right back when their ortho puts their teeth together or their prosthodontics puts the teeth together in this new so-called position. So it’s actually the teeth themselves that create the symptoms through neurologic output into the brain, as I described before. And this is a component of occlusal adjustment that hasn’t been addressed by the outdated studies that used occlusal equilibration. And they also know studies and this is important to also those studies, only treated CR CO discrepancy and balancing inclines but not treat working. So group function contacts in those studies that people like. Let’s say the biopsychosocial camp would say that there’s no relationship between occlusion and TMD. They asked in treatment, they actually didn’t treat the most important component. We’ve discovered through many papers now, research papers that we using EMG that working so good function contacts cause most of the problems that dentists face when it comes to symptoms. And so those studies that a lot of people use as evidence that bite adjustment or the bite has nothing to do with TMD actually didn’t treat the correct thing. And so of course, they got no resolution. Now we’ve been treating working side group function in a procedure called disclusion time reduction, which is an exclusively based occlusal adjustment that’s done in MIP, maximum intercuspation, and it’s not done in CR there’s no position in the patient in CR and there’s no appliance phase needed before you do it in correct patients, which are patients that have high muscle firing reasonably good occlusal relationships both skeletally and dentally and have no significant joint breakdown, they can call pop and click and they can have mild displacements, but they can’t have a bone to bone contact and they can’t be have condylar damage and they can’t have fully displays discs. And so that actually makes up a wide range of TMJ patients who have mostly muscular problems that’s actually 80% of the TMJ fee population. So, you know, we’ve proved over and over and over again in studies not again my word in research environments, treating many different groups of patients at different places in the world, with different practitioners using the T scan in these specific ways to treat the dissolution time. And the results are comparable study to study that the occlusion is the number one cause of TMD, especially muscular TMD. Well, it’s because of this neurology. So the last thing I want to say is you quoted some, you didn’t quote them, but you pointed to some systematic reviews. All the systematic reviews about [Jaz]Luther 2010 is a classic one the orthodontic community [Rob]You won’t find any t scan studies in any of the systematic reviews. They’ve been purposely left out and I’ve been dealing with that since 1984. There have been Many years that important T scan studies were done about the disclusion time reduction about treating TMD symptoms, controlled occlusal adjustment studies, treating timing force and pressure. And the none of them have made it into the systematic reviews until recently, until recently, there’s a 2021 systematic review that looked at all the different occlusal indicators and how useful they are for measuring occlusion and for treating patients. And, of course, that one actually included about 90 T scan papers. And that’s that’s the first systematic, [Jaz]I will check that one out. And I’ll share that with the community you know, because one of the things about this podcast is just to share as much knowledge as we can in there, especially in the realm of occlusion. So it’s great to share these concepts. Now. One objection people might have is what the sensor is 100 microns thick. Now what Rayne told me when she came up to practice those 100 meters, but when a patient bites together, it becomes 60 microns. Some dentists might suggest that okay, because there’s 60 microns between the teeth. How is it really recording what you think we’re recording? Is one objection that dentist might have been in equally in the carbon paper world, we know that we get false marks all the time, we get false-positive marks all the time. So that’s one thing for that. But what do you have to say to a dentist who may be concerned about trying the Tekscan on their patients because they are worried about the thickness of the actual T scan itself? [Rob]Well, the thickness has been an issue for a long time with the naysayers of the T scan, because instead of recognizing that the sensor is a sophisticated printed electronic circuit that measures incredibly detailed occlusal dynamics that can’t be measured in any other way. The fact that it’s 100 microns thick, and gets reduced to 67 microns is actually inconsequential because of what it does, right? It measures things you can’t see in any other way for spread over teeth. Like I said, if I go like this, the force spreads out of my hand, I can’t measure it by looking, right? But if I put a T scan sensor in there, I would be able to see the full spread where it went, which parts of my hand, which parts got overloaded, which parts didn’t get any force, right? So the sophisticated printed electronic circuit is an incredible device. It’s actually used all over the world, in many applications that people don’t question its thickness, because it works in such unique ways and give such unique information. And it’s used in hundreds of industries, it’s just that Dentistry has thought that it should be thinner. But unfortunately, the gold standard of measuring time and force is the T scan sensor, right? Marking teeth might be carbon paper at 30 microns or 20 microns. But marking paper doesn’t give force time and pressure information. And it doesn’t allow the dentist to know any of the information that the T scan sensor knows. So the sensor itself has to work well under compressive, load repetitive pressure loads and clenching and grinding actions and not get destroyed. And actually one study that was done on all the different occlusal indicators showed that the T scan was the only occlusal indicator that could reproduce the test environment 18 out of 19 times, all other occlusal indicators, carbon paper wax, silk ribbon silicone, they all got destroyed after they got through 4, 5, 6, 7 uses. And of course, that’s not the case with the T scan sensor. So the thickness is a positive attribute to being able to gather this very unique and highly precise information that can’t be gathered in any other way. And I think that’s really just sort of like an argument that’s gone by the wayside. You know, if you want the information that the T scan gives you, the sensor thickness is not really a concern, right? And having said that, it’s well within the range of many occlusal indicators that dentists use routinely. For example, this carbon paper that’s 200 microns thick that no one complains about using, right? No one ever says it’s too thick to use. Well, it’s the same. [Jaz]None of my listeners use that one. None of my listeners use that one. But yeah, please don’t use 200 microns [Rob]The point being that wafers are much thicker than these guys, right? And certain common papers are thinner. But the thinness doesn’t mean that the information that the T scan offers a clinician is negated because of the sensor has a certain thickness to work well under many compressive load situations and report highly sophisticated data, right? It’s like you need that thickness so it doesn’t get destroyed while it’s being chewed on, right? And so it works extremely well. One of the most interesting things about that argument is there are no papers written about the T scan, where the sense of perforation is a problem, right? In other words, people Don’t write things that say, yeah, the sense of breaks, you know, you can only use it three times, you know breaks very often. And when you, when that happened, you get corrupted data, you don’t get a hole in, that doesn’t mark ink, you get a corrupted electronic entity. So the thickness is really an important attribute to be able to withstand the stresses of occlusion. And as I said, it’s well within the range of many occlusal indicators that people don’t question its thickness. [Jaz]I mean, yeah, for me, it’s the whole additional information that that thickness gives us in terms of timing and pressure, which was for me, the lightbulb moment and why I’m excited to use this technology to help my patients. Like we debated about this already Rob and you know, I’m not convinced yet, I’m not convinced yet. And I’m still young dentist, I’ve so much to learn. The thing with me is I’m open to the fact that in five years’ time, I might change my mind. And as long as that’s led by some degree of evidence or good clinical sound experiences, so if for example, if my patients after my T scanner adjustments in the future, do come back and they start bruxing, which is what something that we spoke about, you said that okay, there is a belief that once we get the everything adjusted 50-50 or near abouts and we get a reduced the excursion disclusion time that patients may start bruxing, I’d like to find that out for myself through sophisticated methods and whatnot. And I was speaking to Ian, we want to hit up East Grinstead hostel, want to do some sleep studies, it’s what we do with EMG. That’s the pinnacle, so to prove some of that, but you know, I’m open to it. And I want to work with the technology to grow dentistry in the glow, the measuring of occlusion. So I think that’s important. And I just think it’s a fantastic tool the way you describe it. So there’s definitely a place in it. Why only and I have to ask this because I know my listeners know, my thoughts on this is that we have these people who are 20-minute chewers a day like people who just don’t spend much time in MIP. So I know you wanted this very well when we left the Congress, but I think everyone else is here as well, is that if we have people who are just chewing their teeth 20 minutes a day, and they’re not that parafunctional, for example, this group of patients, then do we really need the to go to that level of precision, especially in an asymptomatic patient who may have an anterior open bite, and they’ve had it for many years and have no issues and stuff. And they’re only 20-minute chewers and not having any signs of occlusal disease. Is it overkill to have this level of precision? Is it really necessary? [Rob]Well, it’s a very good question. It’s certainly not overkilled to be able to adequately diagnose anyone’s occlusion to a high level of precision, it’s more beneficial to both the patient and to the clinician. But what you’re asking about is, why is it that you know, if the teeth are only used for 20 minutes, is this occlusion such an important issue, and it’s because people swallow 1000 times a day, and in order to swallow, you have to put your teeth together and swallowing is what actually creates the hyperfunction of the musculature, because it has to go on, it’s a central nervous system-mediated response that we have no control over it, to lubricate your throat, to protect your airway from swallowing food, to ensure that you’re able to eat and chew and digest and fuel your body. So swallowing makes up a huge amount of time that people put their teeth together unknowingly. And just to point out above the 20 Minute study, most people don’t know about that study, that study was done with a three-unit bridge, which is only three teeth in the mouth, right? That’s not all 32 teeth being used, right. So that’s a.. [Jaz]I thought it was done by complete dentures. Graf 1969, I think but I may, yeah, it’s a difficult study to get hold on. I’ll tell you that. [Rob]Right. And that’s and again, doing it with complete dentures if it’s a different study than the 3 unit Bridge study, which was an 18-minute study, meaning that that bridge has functioned for 18 minutes, you’re not able to do with a denture even in any way replicate the human function, so it’s not going to comparable. It’s not going to comparable environment to be able to test how many times a day someone put their teeth together. But the overriding element to answer the question as I did in the seminar that you were at with me, is that the swallowing mechanism puts teeth together 1000s of times a day and that those compressions inflections of the pulp stimulate muscle activity that tire out the patient. And that’s what TMJ comes from. It’s when the swallow mechanism is actually backfiring. And then the person can’t chew well because their muscles have been contracted too many times to swallow for years. And now their jaw doesn’t chew well or they get headaches because they’ve been contracted. The temples have been contracting to swallow 1000s of times a day and they build up lactic acid and that’s been person goes and uses their teeth and then they get a migraine, right? It’s all tied into the central nervous system and the Swallow mechanism of the person can’t control so these timing of teeth studies are just, they’re not comparable to what really goes on in the human condition. And as a result, it’s not an environment that can really test out how someone might respond to their occlusion. So the second part of the question is, you know, do we need this kind of precision, the challenge for any dentist is that you don’t know, we don’t know how well the patient will adapt to what we give them. And so there’s that element. And then there’s the breakage fracture and dislodgement element, we make them something nice. And then six months later, there’s a chunk of it missing, that shouldn’t be missing, because it’s brand new, but it’s missing because the occlusal forces were managed. So everyone needs this kind of precision for their patients to get predictable outcomes, measuring the bite with the T scan and optimizing it with the T scan data, enclosure and excursions. And that’s important that people understand that it’s not balancing the bite. Balancing the bite, people can live with a five to 10% imbalance in their bite much more comfortably than they can with poor excursive function. Because balancing the bite is really not a generator of high muscle firing. It’s chewing, eating and moving around that causes high muscle firing. And so excursive control, excursive treatment with the T scan is very, very important more so than balancing the bite in the natural tooth patient. But in the prosthetic patient balancing the bite is very important to preserve the dental materials and to make sure that that one side isn’t taking 70% Like that patient I described, right? so that the implant doesn’t get overloaded. So the answer to your question is Who needs the precision, every dentist needs the precision, they’re fighting against the occlusal forces in their practice every day, whether they believe they are or not, the occlusal forces are at work every day in your practice, you may not be treating them but they’re they’re breaking teeth on the patient. They’re causing gum recession, they’re causing headaches and jaw pain. They’re breaking you new ceramic inlay that was just put in or they’re not allowing the person to adapt to the new ceramic inlay that was put in. So the nature of measuring only improves the outcomes for the dentist and the patient. And so there is no you know, answer that. Yeah, it’s okay for some you don’t really need it for everyone. You only need it for the top 10% who can’t get used to what we make them. No, that’s not true at all. Every dentist needs control over the occlusion. It’ll save so much time if they measure that, you know, the problems dentists face tied to occlusion more than any other aspect of their practice. There’s no question about that. [Jaz]Hi guys, it’s Jaz again just interfering with this helpful nugget, which for some of you will save you a lot of money. If you are in the market for a T scan, then either twisted the arm of Clark Dental to give you a discount. So if you use the protrusive, that famous protrusive code, you will get 200 pounds off a T scan unit use it contact clock Dental, this is an exclusive offer for the Protruserati only because you guys are ones that are geeky and love occlusion. That’s why you listen to podcasts. So if you head to clarkdentalsales.co.uk. That’s Clark without an E, that’s clarkdentalsales. I’ll put it in the description on the show notes. So you can check it out. And you can get a 200-pound discount by using the code ‘protrusive’. So hope that helps. [Jaz]It brings true whenever I’ve got a patient in temporaries, right? And I’ve inserted some temporaries. And I just liked the idea of being guided by technology that measures the time, the pressure to be able to adjust that and to guide that adjustment. So that I’m being led by technology so at the end of that procedure. I can I have proof from that video that CCMP does that. Okay, things are balanced. And I feel better about that when someone’s in temporaries and moving that on to definitives. I’d love to maybe see you again five years, maybe over a beer, and say, You know what, I’ve been using it and this is some other findings that I found. So I’m excited to try this technology. But you know, I think there’s no doubt about it. Precision, which one of our patients doesn’t deserve our precision. I think they all do and deserve our best hands. And nowadays, with everything going digital, there’s obviously been around for 37 years takes care. It’s not like it’s new technology. But I think there’s a huge is a time now definitely more than ever, where we to use all the tools we can to level up our game. And I think that’s what T scan offers in terms of the occlusion realms. So my last question is, why are some of these? I mean, I’ve been you were there when I told you I’ve been on so many occlusion causes, like so many like I’m a massive junkie. Why didn’t anyone else rave on about the importance of getting it right and being you’ll just be or just being able to measure with using a Tekscan? It was seldom mentioned [Rob]Well, that’s a good question, and I’m not sure I have the correct answer for or a single answer. But I think that the answer that I tend to believe is at the core of it is that fortunately, or unfortunately depending on your perspective, the T scan has disproved all the Principles of the different philosophies over and over and over again in science validated science. And so their lack of adoption by some of the dentist throughout the world has been that it’s challenged what they’ve been learning and teaching for some time now an example would be, you know that you need to be in the right position to control the patient symptoms. And of course, we treat people in MIP, we don’t have to move them, we don’t need appliance therapy for many of them, we can treat them right in their MIP. That’s disproving a positional belief system, right? And then there are many of those, there are at least three major positional belief systems. And, you know, for many people, the positions don’t solve their solution, don’t solve their problem, just fixing their MIP solves the problem. And again, this is something that’s been studied. Another example of what the T scan is this proved many, many times over is the common paper marks, they don’t measure anything and the choosing them. Another thing that the T scan is disproved, is that dentists can’t choose the right marks with any accuracy, three separate studies on 600 to 700 dentists so that dentists will choose the wrong paper marks 85 to 95% of the time. And so there’s a lot of things that T scan has challenged and disruptive technologies are often, you know, held back from adoption, because they make people uncomfortable to face the realities of what they’ve learned may not actually be correct. And again, we have research, many, many, many studies to back up these philosophical, let’s say challenges that the T scan offers dentistry, and all of it is betterment for the patient. Right? It’s not that, you know, if you can treat someone’s, let’s say, taking positions as an entity, that, you know, is typically how TMJ is treated in some new position with some appliance-based location. Well, for the patient, imagine if you can not make an appliance. And you don’t need to change their position. And you treat their occlusion in precise specific ways that you have to learn how to do to be a T scan user, which I think I’ll talk about in a second before we sign off, and the symptoms go away. Most of them go away in 7 to 90 days, which matches up to 30 or 40 studies which show that same thing over and over and over again in different populations and different classes of individuals and different practitioners doing the same kind of treatment sort of replicating each other’s findings. And you’re a patient who can get rid of most of their symptoms in two to three months, versus wearing an appliance for 18 months to two years, then maybe getting rid of their symptoms, maybe not getting rid of their symptoms, and then having to go through orthodontics to put their teeth together in the new position. And they’re all prosthodontics to put their teeth together in the new position, which is very costly and time-consuming. When the T scan could treat that same patient, possibly or a dentist using the T scan in specific ways could possibly treat that patient in their MIP in 30 to 90 days, right, the value to the public is huge. And the value to the dentist is predictable outcomes that have been validated in many research studies. So the last thing I wanted to say was, you know, you said What if I’m five years, we’re having a beer, and we are telling me you know, you have had great experiences and you find some new things? Well, I would certainly encourage that. Because, for example, you mentioned doing sleep studies, I’ve hoped to do a sleep study, because we have many studies which show that people stop grinding their teeth. So it’s sleep study would be a perfect, you know, the extension of that. But the secret to being able to be effective with the T scan is not only one, it’s being trained to use it well. And so one of the challenges of T scan has people, you know, take it out of the box and they try to use it and even though they might get some introductory training, there are actually many skills one has to develop to be an effective T scan user. And they all start out with recording in specific ways and setting up recording parameters to capture useful data. And that then translates into data analysis that allows one to intelligently assess the occlusion and the excursive function and the balance and the timing and the things that matter to the patient’s neurophysiology. And the third level of training is to actually take that information to the patient’s mouth and make intelligent adjustments that control many of these problems that traditional occlusion has no answers for. So without the training, just only one won’t do it. So if you can train intensely meaning you or a dentist who chooses to become involved with the T scan, they have to train intensely to get good at it. It doesn’t work by itself, the user makes it work well, and that skill development that we teach you that you have to then practice and evolve. And once you do that, and it becomes second nature, your patients will greatly Thank you. Because you’ll speed up many procedures, you’ll control end results, you’ll have longer-lasting dental restorations, you’ll be able to, predictably treat patient after patient. And it isn’t to say that just because you have a T scan, there aren’t people that come back and need touch-up bite adjustment visits. But the fascinating thing about that is as a prosthodontist, I’ve delivered many, many, many cases, all different types of things, from implant cases to crown and bridge cases, to denture cases, combinations of all of them partial denture cases, the numbers of people that came back for problematic occlusal adjustments in my practice, from work that I did with the T scan was so little compared to those that sought me out from all over the world who had routine dentistry done that they couldn’t live with sometimes for years, I got an email from one woman just to show you how impactful this problem is. A woman said I had my bio adjusted, you know, after some fillings, and I got TMJ, this is to paraphrase. And I was 25 at the time. Since that time, many procedures have been done trying to help me and I’m not sure if the T scan can help me but I’m reaching out to you to find out. I’m now 67 years old, the woman went back 40 years with a post-operative dental scenario, that was a routine procedure that translated into over 40 years of jaw problems, right? So any dentist can have a problem like that arise. And so the nature of the T scan, it allows you to once you learn how to use it well to predictably obtained outcomes case after case. And that, of course, is a benefit to your patients. And it’s certainly a benefit to them in practice. [Jaz]Well, Rob, I appreciate you giving your time to share about all your experience that you’ve had and the good work you’re doing in the teaching side of it. And I’m excited to use it technology to benefit my patients. Ultimately, everything I do is about my patients. And also you know, because I’m a big geek and I like my toys. So having an occlusion toy was like, really important to me. So I’m really excited to use it. If you don’t mind, of course, I’ll email you to get your advice. And I’d love to share some cases with you so I can get some mentorship and grow. Because I appreciate the fact that you know, I’ve got Riaz in the UK, who’s obviously learning as well and using it, I’ve got other great clinicians, but you know, it’s to be able to stand on the shoulders of giants to be able to accelerate how fast I can learn will be so important, rather than just guessing. So I appreciate you so much for sharing what you have with the listeners today. And let’s see where this journey takes me. And I think it’s been it’s very, I’m sure it’s been very fascinating to a lot of people to hear about some of the benefits they talked about. A lot of people will be like, well, this is all Hocus Pocus, whatever. And it’s you know, we there are some dentists who will think that but my philosophy is, you know, listen to everyone, give your ears to everyone, all those camps, and then be a student forever, and be willing to appreciate others perspective. So thanks for sharing your perspective today and giving up your time. [Rob]Well, thank you very much for having me. And I just want to state that the opinions that I expressed mine and not those of Tekscan the corporation. And you’re going to have great health in the UK from people like Riaz and Clark Cental and Ash Palmer, they’re, you know, really taken to the T scan. But I think the fact that you mentioned that you’re open to many camps, you open to many you want to blend it all together. Just for everyone who’s listening to understand the T scan crosses all camps, you can use the T scan no matter what your philosophy is if you want to do neuromuscular dentistry in and open the mandible and advance the mandible and crown all the teeth and you know, put it all together, you can use a T scan on the orthotic phase, you can use the T scan on the crown or bridge phase, you can use the T scan on the temporary phase, the T scan is universal in that way. It’s not filosofi. [Jaz]And also you can use the T scan on the splints and as well I’ll be, well next year I’ll be getting the EMG data for my splints as well to use it alongside the T scan. So I’m quite excited to do that as well. So yeah, it can be used as a tool for those phases as well. [Rob]Yes, well, a splint is a really good example of something that you know, you can make a splint where the balance on the splint on the occlusal contact pattern is again 70% Right 30% Left, that 70% side is not going to be tolerated well by the TM joint of that side. And so the effectiveness of the splint is then compromised. But with the articulating paper marks or the silicone imprints or whatever people are using to assess the splint quality, occlusal quality, there’s no assessing. It’s just Ink Spots. It’s just holes in wax. It’s not quantifiable information. So the T scan will help you in anything that you make it If you learn how to use it well, and that’s really the important thing, your training will make all the difference to Jaz. And so I look forward to helping you. And I’m certainly a resource for any T scan user, you can email me, you can send me cases. And I often, [Jaz]Please do share your website, so I can put it on the show notes. So for those who want to learn more, especially if you know, how do you have a lot of listeners in the US as well, who may be just want, you know, for you to come back to the office, as you suggested that at the Congress or in around the world who wants your help and guidance, as someone who’s extremely experienced that, you know, the, you know, like, I wouldn’t say founding member, but you know, I mean, you were there with the chap who made it, and you’ve been using it along, it’s more than anyone I guess. So to have your expertise, I’d love to share your website and email. So people can grow and learn from [Rob]you. Well, I can certainly give you that information. And, you know, if you want any research papers that we’ve done, I can certainly provide those to you as well. So, and we share with the podcast if you have requests for certain, [Jaz]Oh, we love papers, or I say, my group listens we all we do is before we sleep, we read papers. If you can send anything over, I think it’d be a great help to a lot of, I mean, it’s good to be a skeptic is good to reason is good to go by evidence. So as you know, as soon as someone mentioned new technology, there are people who, willy nilly will go for it. So but it’s always good. Like I questioned you a lot, obviously, it’s good to question things, but it’s also good to do your due diligence and read the papers and read the studies and not turn a blind eye to what’s out there. So yeah, good send, I’ll be able to share with everyone and again, thank you so much for sharing your knowledge with us. [Rob]Thank you for having me. I hope you enjoyed interviewing me. [Jaz]I certainly did. Thanks so much. Jaz’s Outro: Oh, there we have it, guys, thank you for listening all the way to the end, if you want to check out the evidence base. Once again, it’s protrusive.co.uk/evidence to download all the papers that Rob Kerstein kindly shared with us all. So you can get an idea of the evidence base, I’m really enjoying my experience with T scan so far, I think for multiple units, and I’ve got patient in temporaries, it gives you the confidence that things are balanced, I can even check something called the disclusion time. So when the patient is an MIP, and the excursing left and right, yes, we can talk about canine guidance and group function, etc. But one really important thing is that it should, they should not be in that excursive motion for too long of a duration, you want it to be quick and smooth. And using the objective data of the T Scan allows me to do that. [Jaz]Now I promised you in the intro that I’ll talk to you in this outro about how I struck a business deal with my principals. So I think it was fair of me to say to our principals that okay, I appreciate that. I don’t want you to get it to me, because it’s a big investment if you get it, and then if I’m the only one using it, is that really going to help you guys? So I said, Okay, let me buy but then let me also get a bigger slice of the pie when I use it. So the way it works is that I knew that some dentists like Ash Palmer, I heard would charge a subsidy. So here’s your plan is x 1000s of pounds dollars, and you’re gonna do veneers and crowns or whatever. So I’m using it more and more to my bigger cases. And also for evaluation. So I have two set fee prices. If I know that for a case, I want to do a T scan bite analysis, I will charge X amount, okay? So 150 pounds, okay, so I’ll charge X amount for a bite analysis, if I was going to use the sensor, and I’m going to use it in a patient and I’m going to get some data gathering, then patients are happy, you know, as part of the, you know, when they pay for wax-up or when they pay for planning stages. patients understand, Okay, before we proceed any further at with these tests, and once they see the technology, they’re like, Wow, okay, that’s pretty cool. It’s a great visual thing to show patients and patients actually, you know, really understand that the bite should be balanced, you know, patients often get that in a bite, there should be some degree of balance. Now, obviously, the background that I come from is occlusion versus occluding, very much inspired by Barry Glassman, and we can definitely talk about that in the occlusal adjustment that I’ll be doing following this. But essentially, I have a price for bite analysis. But then the bite, the price I have for a bite, a T scan lead bite adjustment. So basically, if I’m doing a bigger case, let’s say I’m doing like recently, I had four crowns, anteriorly and a chrome denture. And therefore at the end of that plan, I’m going to put in a T scan sort of bite adjustment, and I will charge 2x or 300 pounds as an extra, but that anything I charged based on a T scan, it would come to me as the Associate 100%, basically. So I still respect the time, the surgery time, and I still Bill according to the surgery time. But as an addition, I will charge this sort of a subsidy for the T scan. And that comes to me. And therefore it’s like a return on investment for this investment of T scan. And it also doesn’t take anything away from the clinic. If anything, it adds like a USP, add something unique to the clinic. And I do see myself getting more referrals in the future for this kind of stuff. So that’s how I do it. That’s how I agree. So kudos to my principals for agreeing to that. Thanks so much, John and Chris. I appreciate that. And I think it’s a win-win for us both. I get to get a return on investment for the investment that I made is 100%. But we also get more patients hopefully, and I get to do the kind of dentistry that I love. Okay, I think all principals want a happy associate and I’m very happy with my T scan mounted on the wall. So I think this is a win-win. hope you gained value from that and I’ll catch you in the occlusal adjustment, and so many awesome episodes yet to come with great guests. So I look forward to sharing that with you all. I’ll catch you in the next episode, same time, same place

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 7:53 The best type of Fixed Retainer 10:29 How to avoid warpage on Braided Type of Fixed Retainer 12:21 Step-by-Step on how to place a Fixed Retainer 15:14 Chance of relapse on Fixed Retainer vs Removable Retainer 20:01 Cephtactics 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? We’ll you need to check out my email newsletter. So what are you gonna do is you’re going to head to protrusive.co.uk/emails, that’s protrusive.co.uk/emails because on there, you get a sample of some of the emails I’ve sent out and the goodies are in those emails. But you’re also then got the opportunity to sign up to my email list. Why is that important? Because the app is coming soon, like we are so ready that has taken us months of hard work to put together the protrusive app, and I hope they’re just as much value as the episodes give you, the app will make you go so much further like has this section called centric relationships. We will have different offers and courses that you can enroll on with a discount code. They will also be sections where you can actually get certificates for all the videos that you watch. So you can now learn but also get the certificate that showed that okay, this is account towards a credit as for your CPD to sign up to all that. Go toprotrusive.co.uk/emails and I look forward to have you on my email list and I will probably email you at about every two to four weeks. Let’s join the main podcast and the end of this video will be the fixed retainer video step by step, the one that I’m hyping up so much, it truly is fantastic. I’m also going to upload it on YouTube as a standalone, I want to make sure that it’s really 100% confident with them. But after watching this video, and after this podcast episode where we discuss the rationale behind the exact wire that has been used to make this video and how to get the little bends perfectly placed using the Tucker that’s all sort of described in the conversation with Raj Jabbal. Let’s kick that off right now. Main Interview: [Jaz] Raj Jabbal, specialist orthodontist, welcome to the Protrusive Dental Podcast. How are you? [Raj]Thanks for having me. Very well. Thanks [Jaz]You and Rohit. Rohit have an episode. I’ve been so excited to get both of you on at some stage. You’ve taught me so much already. It’s been great to be part of the cephtactics team teaching. So the bit I do guys is I teach about how patients can stop from chewing up and breaking their retainers and screening for TMD. And when to treat and when not to treat, or looking at joint issues. So thank you for having me on the team to do that. Raj, just for those who may have never heard of you or seen you before. Give us a little bit a brief background of what your interests are, where you work and how cephtactics came to be? [Raj]Yeah, I mean, I’m a specialist orthodontist, and I’ve been working in private care mainly for the last round about 10 years old. And specifically, my interests have always been around growth and development, maybe genetics, stability, relapse almost came into that, and fit really well into that specific idea. And the enigma of all of this is that we don’t really understand it very well. And that’s what really made me more excited about it. Because in orthodontics, you can make things very mathematical and succinct, an A plus B equals C. And then suddenly growth comes around, and it’s like the demon in the back. And you only start to understand more about growth, the more and more you see cases of yours going, let’s say topsy turvy, you know, and that’s when you start to question it more and more, especially when it starts to look at things like genetic factors as well. And you ask around to the parents and How tall are you? And How tall is your your dad? And where are you from originally? And all these little aspects which come and knit together in orthodontics, I think this is a really big, really interesting thing, which I would love to walk around more. [Jaz]Raj talks a lot about genetics, and the bigger picture kind of stuff, phenotypes and whatnot. He’s the only guy who I’ve sat through a lecture and he starts talking about how Columbian teeth are different from Japanese teeth, are different from Estonian teeth, etc, etc. It’s quite special medicine. So his knowledge is limitless, obviously, the amount of stuff and metaphysics that you know about genetics is crazy. So at the moment, you’re teaching dentists how to implement orthodontic practice safely. And you do a whole like 10-Day prototype class programs on [Raj]A 10-day program with lots of assistance on the side, we do some zoom sessions as well and all these other bits of this but the 10 day meet in the bone. That’s what we want. We want the guys to come in and you know, whenever we look at a lecture, we want to have enough meat on the bone that you actually go back famished, okay for more [Jaz]Amazing. I love that philosophy. Now, today, this episode is very much about fixed retention. It’s a big bugbear. Maybe in this, I know in this fascist community because I’m part of your Facebook groups, loads of specialist orthodontists on it. And it’s a it’s a real annoying thing that orthodontist find and also GDPs. I find it super super fiddly. And in preparation for this episode, Raj, you saw the Facebook post I made to the Protrusive Dental Community I said, Look, we find fixed retainers really annoying, really fiddly. How can we make it easier for GDPs? And just yesterday, I placed them lower fixed retainer went fine. And I had a challenge on the upper one. And I want to pick your brain about that. But before you get to that, I’m going to go to structured order. And you’re about to be doing a lecture now just on fixed retention and hands on models. You get your delegates to place fixed retainers, which I think is amazing to be able to do that on the models. So if anything that I’m going to asked you is covered in that lecture, then don’t answer it now because I rather just extracted from there to be understand. So firstly, I’m going to ask you, do you routinely use fixed retention IE, as part of your specialist plans that you do that may be more elaborate, more pushing the boundaries compared to GDP perhaps? Do all your patients get a fixed retainer and a removable? Or is it customized for each individually? [Raj]Yeah, I mean, before what I used to do is it was a blanket statement. And I used to have fixed retention in the top and bottom arches and removable retainers for everyone. And and now slowly but surely it’s becoming more and more of a situation where your, the fixed retainer in the lower arch is by far more important than the one in the top. And, you know, lots of patients will report, they wanted they say no. The idea is that a lot of these situations are customized. And I work with a clinician in Escrow back. And she is a specialist orthodontist, trained in New York. And she has right now she’s on the face program n Spain and Italy. And you know, the most important aspect of their treatment has always been, did you get the occlusion right? Did you get the bite right. And that’s more important than both the retainers put together. And that’s [Jaz]Because stability, right? [Raj]Yeah Stability. [Jaz]It contributes stability. [Raj]So I mean, I still probably most of my patients will get though the kitchen sink sent to them. But you know, when I’m [Jaz]Suppose we’ll get fixed and removable as a blanket. Top and bottom? or? [Raj]Top and Bottom. But the upper arch, I don’t usually extend it to the canines as much unless I brought a canine down from the heavens or something as such, you know, that sort of thing. You know, but most of the time, I think most of the time you’re looking at that, but I’m dipping my toes into being a little bit more brave. And I think I would be okay, because I had a patient yesterday on and he said, Raj, I want this fixed retainer off and I said, Look, I love your teeth. They look fantastic. I don’t want to take it off. He said No, Raj, you know that they’re not going to move and I’m like, okay, Christmas present this year, I’m going to take off your fixed retainers and Lea, my receptionist said, Are you serious? I said, Yes. He’s our experiment. To make sure that the bite is right [Jaz]Okay. Yeah. So what the angle you were coming from is that there is a belief that If you get the bite right, and you get the correct incisors in the right angulation with each other, you know, incisal edge to the cingulum. And you have your setup correct that maybe that is a huge player in stability in orthodontics. Obviously, we have soft tissue factors as well to consider, we can get into the time and whatnot. But the answer I guess the main answer is yes, you are on the hole. Most patients will get fixed and removal. Yeah. So what is the best type of fixed retainer? Is there a best type? So the ones I used in the past, the GDPs out there listening dentists, chain. So this is the one that was taught my diploma but I know Raj feels very strongly negatively towards retainer and I’m sure he will add that. And actually Mandeep Gosal on the Facebook group, he actually mentioned that he only use it for the lower because he’s concerned about relapse on the upper in his experience. So I’ve used the chain, I find it really easy, so easy to place a chain. Almost too easy. Okay. Yeah. And then that’s when it was also taught to me my diploma, I started doing it. The other ones is the braided. And then there’s the flat. So it’s like a rectangular, you know, not rectangular, but like 2D rectangular [Raj]Like a ribbon type [Jaz]Like a ribbon. Are there any others I’ve missed out? I’m sure there are ways and one of the most wanted for GDPs [Raj]Those are the main ones. I mean, of course, you get the cast ones that have been used all throughout the older days, you know, I mean, the first fixed retainers are actually matrix band, you know, with lots of holes in them, you know, remember the tofflemire and all that. So people are not using them. And they used to just shape to make lots the holes, but when you look at them, like the coaxial types, you got the twist flex, you got like the ribbon version, which is multi stranded as well, but flattened in a way. The thing is, I’m always very careful with the round, twist flex, yeah, because these are really, really important wires to know the metals behind it, because they can actually unravel and if they unravel, you start getting this warpage and you convert your retainer into an orthodontic appliance. [Jaz]Just disheartening. Yeah, I’ve seen it post on community I’ve seen in my own patients that I review, not the patients I placed on because I don’t actually tend to use that retainer but I’ve seen the consequence of it. And I’m sure you guys have as well. And one of the questions you’re asked about, okay, how do we prevent that? For is it for that reason that you’ll avoid braided?bhv [Raj]I generally try to avoid them. Yeah, I generally try and avoid them. But you can anneal the wire, that means we can put it under some heat, and then put it on [Jaz]But let’s make it really tangible because people actually want to know that right? So the way the way I’ve done in the past when I had to use it before is I will get lighter. And once I’ve got my right length, and it’s ready to place. I will just burn it until it just goes I think it glows. It glows. And then I wash it. It turns a horrible black color. But now it’s no longer going to be able to impart force. [Raj]Yes, and you’re not, what you’re basically doing is you’re converting a specific phase of the metal. So you’re moving from martensitic phase to austenitic when you put that heat. The only issue I have with it is that has that word has is it enough. Now on every year I’ll see about four or five patients in the situation where you start seeing weird torquing movements, etc. I haven’t seen it in any of my patients. Touchwood. Yeah, because I did use it quite a bit when I was just out of university and stuff like this. But the other issue I have with this is that retainer doesn’t sit really nicely onto the onto the tooth surface. So you gather almost a bulky appearance of the composite. And so.. [Jaz]When placing directly [Raj]When you place directly. When you place it indirectly, you tend to get a thinner version, you know, and you might get it a little bit better. But the best benefit I’m getting, I mean the best retainer I will say is going to be the flat ribbon type of multi stranded retailer. And look, I don’t know if we should be promoting one or the other and all that sort of thing but be very careful with anything too flimsy as well. Because if it’s really flimsy [Jaz]Like a chain [Raj]Like the chain because the reasons why the cast retainers will the best retainer ever was because they attached to one canine and the other canine and kept the IC width, the intercanine width, which is the first thing which collapses into relapse. It’s the first thing that starts to go down. Because what happened with the Bishara studies was that they said it’s remained stable. But the beauty of the Bishara studies, they made lots and lots of models of people over long periods of time. And you could start to see that the intercanine width starts to reduce. And if you look at any of your Invisalign cases, you know, when they send you the clincheck, if you ask for no IPR in the lower labial segment, you will see they’ll start to operate intercanine width. And that’s exactly what you want. And as you operate the intercanine width and if you keep it that way, the upper doesn’t collapse. And so that’s why the perfect retainer would be trying to keep the retains, the two teeth apart, the two canines in the lower arch apart. Okay? [Jaz]So what we’re going for here is that the one that you are using and one that you will teach your delegates [Raj]We were going to be looking at the flat twisted [Jaz] And I’ll show you the video of that probably something on your screen now as we’re talking. So as we’ll put that in. So fine. So we know about we wanted, you all answer your question as well, how to prevent that from happening, avoid twiflex is the most logical way to do that? And we’re going to show you step by step on how to place a fixed retainer. So Raj are going to go through that. How do you bend it neatly, so it adapts to the embrasure spaces. So usually, when I’m, I’m still wanting to prove like whether this is your first retainer in place, or 100 like me, I’m still not perfecting it. And sometimes I’m biased towards an indirect laminate one, because they look so much better than my own. I want to be able to level where I can make beautifully well adapted. Are you going to show that? [Raj]I’ll show you how that is. But there’s another aspect of this, which I think is really important, we must understand the more bends we put in the retainer, the more points of failure there will be. So I love retainers which going on the margins, and etc, etc, all that sort of thing, you want to keep it in the contact point. If you keep it in the contact point, there should be the least number of bends possible. Now, when we use the twist flex, I mean, the one that I’m going to be showing you [Jaz]Not the twistflex, the ribbon [Raj]The ribbon type of retainer, you’re going to see that it actually is extremely easy to bend. And now there’s a really important aspect of this as well. Because I use the least number of flosses involved. You can use eight flosses if you wish I don’t mind looking and all those sort of things. But if you use the least number of flosses, what you can do is test whether the wire is passive or not, you can release it and see where it’s going. And you can bend it into positions a little by little as it goes around the edge. If needed. [Jaz]If it’s not passive and you release that floss. If you’re thinking Wait, where’s floss coming in this time, don’t worry I’m going to show you the technique and how we use floss to stabilize it. But if you pull the floss and then let go and it moves, if you were to pull again and just bonded to that position, that is creating a force. [Raj]That’s exactly what’s happening. And that’s why whenever you use this, I use the back end of Tucker, and you’re going to be, it’s literally just polishing the retainer onto it. And you can release the floss and see how well that it actually does adapt because it’s the material is amazing because it’s it’s really, really bendable. So the austenitic phase is really high in this material. And the beauty of this is solid, it doesn’t cause any of this sort of movements, which is the most dangerous ones, okay? It doesn’t have that twist ability. [Jaz]I mean, so we’re gonna see how to adapt it. So we’ll add that in. I had an issue yesterday, I was using that exact wire on the upper, and I had the correct length all laid out. I was going to go from canine to canine, because I did some movements of the canine. And when it was on the middle of, let’s say the right canine, by the time I brought across the bridge, there was enough vertical discrepancy. It was either gonna go gingival or beyond the canine tip. Yeah. So is the answer for that is that in those cases, you have to go indirect? I can’t bend it. [Raj]So the thing is this, the idea would be you start bonding from Centrals, and you work your way upwards. So the stress distribution goes that way. There’s another way that you can do it from one side, but there’s a chance that you start canting the retainer. So the idea is to start in the Central, and then move to the next Central and just release the floss and see, you will see that things are actually okay. [Jaz]It’s heading towards the gingiva you can’t get in that type of ribbon. Why you can’t bend or can you? Bend that level and describe it? [Raj]Because as it comes closer and closer to the canine, sometimes what people do is they do this yeah, they merge it around. So if you start doing this, you stop putting strain on this point here. You might fracture some of the strings, okay, on the wire, but the main thing is this, it’ll allow a little bit of a drift, but if you drink too much, then maybe okay, but now if you want to do anything lab, I would say you want something which is cast and maybe machined. Okay, so like I think if I’m not mistaken, there’s some labs, which are actually machine cutting retainers into position. These are cast sounding very expensive as well. Those, especially anatomy, like we were talking about the different types of anatomy. South American, spine of South America specifically, you will see this almost peg spade shaped arrangements of the incisors. That’s when you’re like you’re not going to win, you got into this lab, and that’s a you know, it’s a one off, but the thing is, yeah, that’s where prices start to become a little bit more. [Jaz]Yeah, that that helps me enough, right. I know that I probably wouldn’t have had been able to do it direct that one. So we’re gonna see it step by step. We’ve talked about why is becoming active and unraveling. So Raj, last question before we actually get to more hands on clinical stuff, which I’ll be, we will be filming for you guys to get advantage of, is those clinicians who are part of the Protrusive Dental Community, so shout out to Richard and Zach, two good friends of mine. They found that over time, they’re all of their fixed retainer problems went away when they stopped using them. And now they give Viveras or equivalent three sets of really high quality, clear pressure formed retainers, and the old is now on the Patient. As far as the evidence goes, I believe that fixed versus removable. If someone, if a patient is really religious with their removable, as long as the retainer that the rural retainer doesn’t get damaged or warped or put in the hot water, as long as the patient wearing it, there’s no chance of relapse? Is that a fair statement? [Raj]I don’t think we can go down that path that simply because the fact is the fixed retainer and the removable retainer are two completely different jobs. Now the removable, like if you talk to Romania, and he talks a lot about orthodontics being a crucial rehabilitation. And if you’re doing any sort of denture or anything like this, what are we doing? We’re impinging on this space, which is near the sulcus and you got to cheeks in all these different areas, you know, where we modulus, we know all about the modulus activity in orthodontics ever. And the more and more we looked down this path, and we realize that the arch form itself is critical, right? And now I have, I have all been praised for the Viveras except one thing, the one thing I have an issue with is them giving three. Now there’s a reason for this, what I’ve realized is that rather when you start looking at growth and development, it is wrong to sit in perpetuity, and think that there’s going to be some sort of static nature in your whole career, in life and that’s it. You need to be perfect until you’re in the box, and you got to say, see, it’s a Peter and say hello, and you’d like well done, ain’t never going to happen, okay, it’s always going to be some sort of flux and change, which happens. Now there’s some change, which is acceptable. And there’s some which isn’t. Now wear of course, dental wear happens throughout life. And we always have that, that’s not taken into account at all, whenever we use retainers and people tend to use retainers less and less and less and less and less, until then they end they’re gone. And that sort of thing. And then it’s so important to, rather in orthodontics, to say that you’re thinking in the finite game theory, which is that’s it I want and that’s my teeth, and that’s what they going to be for the rest of my life. It’s a dance, it’s always gonna be here and there and here and there, you will lose sometimes, you’re going to gain sometimes, patients gonna worry [Jaz]There will be Periodontal changes. [Raj]Yes, exactly. And that’s why I say I need both, fixed and removable have a place to play. Now, if I’ve got a patient who’s so good, and he’s wearing Viveras by the way, he’s wearing Viveras. And he says, Listen, I’m wearing Viveras every night and I’ll be like, the chance of his teeth moving are extremely low, extremely low. [Jaz]And even if they did a little bit will say, Well, you know, right, it will not be, it will be the case will still be a success. [Raj]Exactly if he wears it once or twice a week at night on like Vivera? Yep. A normal Essix? No, no, no, no. Now we started to go into a dodgy zone. The beauty of Viveras, of course, accuracy, robustness, you know, and all that. So if the patient is wearing them, I’m happy. My biggest failures with fixed retainers are not bond issues. Their wire breakages. Now why a breakage is happened when there’s a force on the wire all the time. [Jaz]The  tongue [Raj]The tongue is the book you know, why don’t they just, do we really need it? But you listen, the tongue is the biggest issue it keeps hurting the area and if you keep pressing on it and not only chewing chewing chewing that’s why those the cost retainers are only attached to two units usually go through less stress than the ones which are attached to mulitple points of failure can occur. And that’s the problem. So if someone says no to the fixed, I’m like, okay, Viveras? And you better behave, you know, and I’m like, I’m actually okay. But till unlike you know, just don’t give them three, change is every three years or something you know, change it again, get a new one, it’s the accuracy is the key. Not when it has undergone plastic deformation. You know, the most plastic deformation the second one will not fit as well. So they’ll always be a little bit of something there. And so that’s why even when my patients come and ask me, I’ve had my mold, can you make the new retainer to this? I’m like [Jaz]To exist, my old model from three years ago [Raj]From 3 years ago or some even some like four or five years ago and I’m like, No, it’s not going to fit as well because it’s always changed. [Jaz]Hi, guys, it’s Jaz Gulati here and I’ll be just coming in various moments really important moments in this epic video, just to give you a few hints. Now when it comes to air particle abrasion. I’m not aware of any evidence that when it comes to fixed retainers, what’s better? 27 microns or 50 microns? Traditionally, for intraoral bonding, we use a 27 microns but you can use 50 microns. Now you have to think, What are you trying to achieve by using air particle abrasion. For me the main benefits for when it comes to placing a fixed retainer is twofold. Number one is you’re removing the biofilm, okay? So so important to remove the biofilm before you do any bonding and number two is that you help to remove the aprismatic layer of enamel, which may also cause an inferior bonding basically, so you get higher bond strengths to enamel that’s just below the aprismatic layer. Whoa, whoa, now you’re thinking Ah, but Jaz, I don’t have an air abrasion unit. What do I do? Well, let’s think how can we remove the aprismatic layer and how can we remove the biofilm. Now for the biofilm, I would use a bristle brush and some pumice slurry and that will really help to remove the biofilm. And to remove the aprismatic layer of enamel, I would actually use like a fine rugby ball Diamond Bur and I will just lightly scratch the enamel. You only tried to move like 30 to 50 microns of enamel here so not very much. And for those of you getting very nervous about removing enamel, you’ve probably just done a whole lot of IPR so calm down yeah. [Jaz]So when we see this image here, in that still, the amount of etch that’s applied? It’s not enough for me, I want a little bit more surface area of etch you should always be etching a little bit more than where you think your composite will be placed. [Jaz]So when the floss was introduced here, and it was being placed, you probably closed watching really closely. Okay, what’s going on here, I don’t understand. But now that is in this position, ie, you’ve literally just gone between the canine and lateral incisor on each side. And that’s it. That’s all that’s happened so far. This is really easy. This is the beauty of this technique. Because what I’m used to doing is I’m putting these little loops in multiple different areas, multiple different contacts between the teeth. And just overcomplicating it, I love this technique of just putting it putting one piece of floss, not even two pieces of floss, one long piece of floss, okay, carrying it over making two loops, which you’re about to see. And this is just genius, rather than faffing around with multiple different flosses. [Jaz]Remember that placing a fixed retainer is a four-handed job, okay? While you’re feeding the fixed retainer through, it should be your nurse who should be helping you by pulling this floss. And you should obviously have this conversation with the nurse before you do it for the first time. So show them this video, okay? Let’s train your nurse together before you actually do the procedure. So your nurse not looking funny like what do I do I pull? How hard do I pull? When do I pull? Okay, all those things should be known to a nurse before you do this. [Jaz]Guys, this is the most beautiful part in the sense that you’re using the Tucker and you’re pressing into the embrasure areas, in the interproximal areas where the contact is to create that little bend. Now you don’t want too many bends and you don’t want too extreme of bend. And so how can you ensure that the amount of a bend that you have is not excessive? Well, if you make sure that your fixed retainer is along the contact points so it’s not too apical or too incisal to the contact area, you want to keep it at the contact area, therefore it doesn’t have to bend into the tooth very much, okay? And the other thing you could do is just lightly pre-bend your wire to the rough shape that’s going to help you and then you’re using that Tucker and you’re putting that a fair bit of force here to just press it against a tooth and kind of bend it in each contact area at the contact point. And that’s what’s gonna give you that lovely shape that we all desire. [Jaz]Now, before you actually placed the composite flowable here, here’s what you got to do, okay? You just get the nurse or yourself or whoever’s holding the floss to just let go a little bit and observe. When the floss is let go on one side, does the fixed retainer does it sort of bend away from the tooth? If it does, then that is not passive. Okay? You need to do a bit more bending there to make sure it’s passive so an ideal retainer here is that when you let go of the floss it holds its shape and it’s not moving away too much just like we discussed in the main podcast Episode. [Jaz]Well there we have it guys hope you gained a lot of value from that. Now, this episode happened because you guys voted for it. So sometimes I give you an option okay, like do you want this episode or that episode? So it was a toss-up between fixed retainers and force and timing data when it comes to occlusion and why articulating paper marks are lying to you. And that’s exactly what the next episode is about. It’s about the T scan and how that gives us so much more data that we can’t get from traditional articulating paper. So do join that episode and one after that just to really whet your appetite will be the one with Devang Patel part three of three of full mouth rehabilitation. So listen if you gain value from these episodes, if you’re enjoying them, please do consider leaving a rating on Spotify, Apple, or wherever you listen to it, and I look forward to join you in the next one.

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 00:50 IPR Strips 12:52 IPR Burs 20:17 IPR Perforated Discs 24:25 Intensiv Swingle Review 28:12 IPR 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. Would it be great if these courses had a hands on IPR component? I think that’d be really cool. Because it’s not as a simple thing. And it’s important to do right. And it’s important to do safely, I think. So I’m hoping that by the end of this podcast, or the video, which I’ll tell you about in a moment, that you’ll feel much more confident in IPR. 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.  Now back to my old boss Hap Gill, who taught me so much about orthodontics, Invisalign, and how to do IPR. He is a huge fan of using burs. And so he taught me how to use burs. And I kid you not like my palms were so sweaty, the first day I had to use a bur for IPR. And it was the only time that someone actually taught me how to do it. So I felt more competent than just winging it. But I still felt uneasy about putting a bur between his teeth, you know, coming from a minimally invasive background and enamel is king and now having to remove this enamel with a bur. It seems scary for me. And I know I’m not the only one I know you guys can also feel as though that is a scary thing to do. So lots of colleagues are stuck on strips, because they’re afraid to use burs. And the interesting thing about using burs for IPR is that some people and some orthodontists are really pro-burs like it doesn’t, there’s only one way to do it, you’ve got to be burs, it’s gonna be quick, it’s gonna be good, and it’ll be fine. Whereas other orthodontist I know if like, for example, Gos, who was a previous guest of the show, I know that he is quite anti-burs when used anteriorly. In fact, he said that in the Facebook group recently, and I know other dentists who say never use it posteriorly so here we are, some people are saying burs are great. Some people are saying don’t use burs anteriorly, other saying don’t use burs, posteriorly. So where do we go with that? So don’t worry, I’ve got you covered. I’ve got you covered with burs both in this audio episode and in the video, which I’ll tell you all about.  Now this episode that you’re listening to right now, it came to fruition, because you might have seen on my Instagram story, I had found my old disc, so I bought some IPR discs in Singapore. And I completely forgot about them. And in my sort of associate box, I just found them at the bottom of it. And I was like, Yes, I found my discs. Let me use them today. And I used them with great efficiency. And I thought wow, this allow me to have a 10 minute break on my appointment today. And I got to have a coffee and I thought wow, this is such a great way to do IPR. It was much more efficient. So when I went to the next Cephtactics course, which I teach on, I teach about TMD screening before doing orthodontics, TMD diagnosis and how to stop your patients chewing up your retainers. So that was my lecture talk. And while I was there, I met Saj from TOC dental and I asked her Hey, Saj, Do you sell these discs? I’m looking to buy some more discs because I rediscovered, I remember I had these discs and I forgot how awesome they were. And Saj said yes, we sell these disc but Jaz, if you’re interested in doing efficient IPR that’s high quality, then I’ve got something better for you. So that really piqued my interest. And he was telling me about an oscillating handpiece called the Intensive Swingle. So it’s called the Swingle. So he really wanted to show me this. So I said, You know what, in two weeks time, my brother-in-law is coming in, he’s having some Invisalign. I had to do quite a fair bit of IPR in him. Why don’t you bring just everything over? Because you’re gonna bring the Swingle anyway, why don’t you bring the Swingle, some burs that you guys sell, some strips, add some discs, and let’s do a little educational experiment, okay? Let’s keep the same practitioner ie me and the same patient. And let me just choose different contacts and make some educational content from this, but also test out this Swingle that you’re raving on about. And this happened.  So on 31st January, my brother in law came in, and Debbie and Saj from TOC dental was such great sports, they bought everything in that I need to use. And Saj was carrying around the camera as I was doing the IPR. And we made some great footage, how to footage for, how to use a bur, how to properly use strips, how I use a discs, how to be clever, and measure the teeth before you do the IPR, and measure them afterwards in certain scenarios. And this is all now on a separate YouTube video. So the main message I send you is that this audio episode is unique. And I will go through my experiences of using various IPR forms. And my aim is that by the end of this episode, you will feel more confident about what’s out there for IPR, and also to improve your IPR come Monday morning. But if you really want to gain from all the filming that I’ve done, then you should check out the YouTube video. So usually, my podcast episodes are our copies. So IE the audio version is pretty much the same as the video version. This episode is unique. The audio is completely unique. I’m recording audio only just for you guys. And the video is completely different. I share some similar themes, but in the video I focus more on the how, how to do the IPR, which contacts, why I’m doing what I’m doing. And also showing you how I found the experience of using the Swingle, how I found the burs, how I found the disc and and how to use those things appropriately. Whereas this audio episode is more about the why and how to be a bit more clever when it comes to IPR. So, you know, check out both, but I really think you’ll get the full immersion, the full experience, especially if you’re nervous about how to do the IPR that will come from the video. So do check out the YouTube video. The channel is Protrusive Dental Podcast, and it will be easy to search and find the IPR videos, I’m pretty sure something called ‘Which is the best IPR system’ So check it out. Let me know what you think. Or you can visit protrusive.co.uk/iprvideo. That’s /iprvideo and it’ll take you exactly to that video, but let’s continue with this discussion on IPR.  Now before you listen any further you need to understand that I am no ortho specialist. I’m just a GDP, who’s palms used to get very sweaty when I had to do IPR. I’m just sharing my experiences like if a specialist tells you something opposite of what I’m telling you, then listen to a specialist, okay? Because they are probably correct. But if you’re happy to listen to someone who’s got his hands dirty, who’s experimented, who’s experienced, who’s failed, who struggled and has got a postgraduate diploma in orthodontics thrown in, then I do hope that this IPR resource will be very useful to you. My aim with this episode, and that the video is to make something that I wish I had access to when I was starting out in orthodontics, and I was struggling through IPR and I still struggled through IPR hencewhy this episode was made because I was looking for more efficient solutions. And finally, I think I found it. So listen to the end of this episode to figure out how I think I’ve nailed that scenario. Now, in the remainder of this episode, I’m gonna be talking about the different forms of IPR. And I’m going to be rating them like giving them like an out of five stars, which is best for safety, efficiency, and quality, which I think are three really important parameters when it comes to IPR.  Now the Protrusive Dental Pearl I have for you is very much linked to the quality of IPR. The Pearl is that no matter how much IPR you think you’re doing, do some more, because you’re probably under doing the IPR. I know there’s the case because I came across a study from 2021. So just last year, Tony Weir based in Australia published this piece of evidence in the Australasian orthodontic journal, and it is just so eye opening. So what they did is they looked at 10 orthodontic practice, not general practices, specifically, orthodontists and orthodontic practices, and they looked at 10,000 cases in the Australian aligner research database within Invisalign, and using this data they calculated, how much IPR these orthodontists were supposed to do, versus how much IPR was actually carried out which is very clever. And the results were absolutely shocking. To give you the TLDR of this, if the plan the average IPR was 0.29 millimeters IE for all the IPR that they had to do where they had to do an IPR, the average they needed to do was 0.29 millimeters across these 10,000 patients. However, they only achieved 0.13. Let me say, again, they only achieved 0.13 millimeters for every 0.29 they were supposed to do. So really, they only achieved 44% of the IPR. So that is crazy. That’s a shortfall of 0.16 millimeters of IPR per contact, which was supposed to be 0.29. That’s really, really crazy. Think about it, because these are A) orthodontic practices and B) less than half of the planned IPR was actually carried out by the time they finished the aligners that’s really saying something. Now this study will be available on the Protrusive app coming soon, will also be on the Protrusive Dental community. And I’ll put it on the blog of the website as well. So you can check it out this really fascinating study. And I don’t think it’s new information. I think we’ve always known this, that dentists were a little bit shy to do IPR. And we don’t do enough, but I hope you can appreciate to do the correct amount of IPR will be important for efficiency and predictability of movements, you know, you need to create the space to get the movements. So this is a really important study to consider. And if you think that okay, you know, I think I have 0.2 millimeters here, then you probably don’t, and obviously, that’s where the use of the IPR gauge or thickness gauge comes in, which I also demonstrate in the video.  The other interesting thing about the study was that all practices were effective. So every 1 of the 10 practices was underperforming the IPR, but it vary greatly from practice to practice. In the study orthodontist I, so they labeled this orthodontist, orthodontists I, and he was the best orthodontist in terms of IPR. He only managed still 75% of the IPR. So he missed out 25% of the IPR. But the the real shocking thing is that the you know, “the worst” orthodontist here, obviously, you know, what I mean here is that the person who underperformed the IPR, the most only manage 9.9% of the IPR. Like, let’s say you needed, you know, two millimeters of IPR across the arch, they would have only done 0.2 millimeters that is absolutely crazy. As I was reading this study, I was trying to figure out okay, is it because maybe they were using strips, is it because they use a certain type of IPR that these orthodontists were not achieving the targets or the required amount of IPR. And then I came across another study by Johner et al on references, reference number 25, within this study, and this study found that actually, the stripping technique was not a significant predictor of the actual amount of enamel reduction in vitro. So we don’t know yet whether those orthodontist who use strips only are more efficient than those orthodontist that use burs, we don’t know if that’s the case or not.  But let’s talk about strips as the first main tool, because this is something that I think we all start off using when we enter the world of orthodontics. And it is something that’s been around since about 1944. And you get different thicknesses and different coarses. Now, I personally have a bias towards single sided and perforated diamond ones. Okay, so single sided, I like single sided, because when you’re getting the slightly crowded areas, it’s just makes sense to use a single sided because what you don’t want to do is as you’re preferentially removing tooth structure perpendicularly to the proximal surface, then you’re also scraping the tooth next door, and then you’re catching that sort of the labial part of a different tooth, at the same time as catching the palatal part of another tooth, and that just makes for Ugly IPR. So I prefer single sided. Because if I have two perfectly aligned contacts that need, let’s say, some IPR, at that point, double sided makes sense, because then you’re happy to remove from both of those teeth. So my bias is towards a single sided. The typical way I’ve been using strips for the past few years is sequential IPR IE, if someone needs 0.3 millimeters, let’s say across the lower incisors, then I will do 0.1 or 0.12 millimeters, okay. And then maybe six weeks later, I might do another 0.1. And then another six weeks later, I’ll just slightly going with strips again until I feel as though okay, I’ve done 0.3. So maybe that is one reason why we are under doing the IPR is because we’re not being so accurate. And maybe because we’re doing it a little bit by little bit, we don’t actually get a gauge of exactly how much we’ve done.  I find this useful because the main reason I do orthodontics for patients is because of crowding. And with crowding, when you’re planning on the ClinCheck Invisalign, we try and avoid doing round tripping. So round tripping is, for example, we’ve got some lower crowded incisors. And if you align these incisors and you let them unravel and just proclaim and expand outwards, without doing any IPR then and then once they’re aligned, to then reduce the overjet again, you then start stripping and doing the IPR, and then you bring the teeth back in, that’s round tripping, because you’re tipping the teeth out, then you bring the teeth back in. So to avoid round tripping, so you say, Okay, why do you want to avoid round tripping? Cool, I was taught that you should avoid Round Tripping because you risk disturbing the gingiva IE, you might get recession, you know, by proclining and tipping the teeth forward, you might get some recession, and then that’s not good. So you want to then ideally minimize how far forward the teeth are coming. So we want to avoid round tripping. So the way to avoid Round Tripping would be to do the IPR, while the teeth are in a kind of crowded state. And this is where it becomes tricky. This is where I think you can only really use strips, and discs. And maybe if you know the Swingle system I’ll tell you about at the end. If you’re clever about it, you could do it. But really, this is where strips are champion, because you can wrap the strip around and really make sure that the part of the tooth that you’re actually stripping away is the correct part of the tooth, is the proximal, the mesial or the distal of the tooth. Too many people will do random stripping, and as long as they have that space between the teeth, they think they’re done but no. IPR is always planned from where the future contact will be. So that’s from the proximal, this you know, the mesial and distal, not the facial-mesial, not the lingual-mesial, the actual, you know, mid-mesial area and the mid-distal area. So it’s really important to wrap around the strip perpendicularly to the tooth that you’re removing. The other thing you could also use in those scenarios is discs. I’ll talk about that very shortly when I talk about discs.  Now the problem with IPR I mean that they’re versatile, because you can get different coarses and get different thicknesses. Two problems for IPR one a common one, which I used to believe as well, is that okay, I know that the red perforated diamond IPR strip is 0.1 millimeters in thickness, ie, if I get this in between the teeth, I know this strip is occupying the width of 0.1 millimeter. So I used to think that, okay, if I can get this in, if I can just do a bit of stripping, it’s very easy to get 0.1. And then I thought, okay, if I now double this strip up, so you fold a red strip in half, and then technically you have 0.2 millimeters of metal there. So then when you put that in a contact and you start stripping, it’s kind of logical to think that okay, now you have 0.2 millimeters of space. It’s very far from the truth, actually, when you actually go ahead and measure with the IPR gauge, you’ll notice that okay, you probably don’t have 0.2, you probably have like, you know, 0.15 or something. So just because you can get that thickness of IPR strip in, it doesn’t mean you have that amount of space, because you have to account for the PDL movement. You know, when you’re putting something between the teeth, there’s PDL, so they move out of the way, and that makes you think that you have more space than you actually do. And of course, the other downside of strips is the time it takes like, fine. If you want to do 0.1, even maybe 0.2, you know, going through a sequence and polishing, it’s okay. But anything more than 0.2. And stripping will give you RSI, will give some serious, repetitive strain injury, your patients will not be thanking you. It’s not that comfortable. It’s horrible noise. And it’s just too much time especially we’re doing multiple contacts Stripping appointments in the past, when I’ve done stripping only and I’ve gotten multiple contacts, and I’ve done attachments at that appointment. You know, that could be a 90 minute appointment, right? That’s far too long. I think now I reflect back and I think wow, I was spending too much time doing attachments IPR, it is just not efficient enough. And I’m hoping to cover some other ways of doing it, which can make our IPR more efficient. Now, so if I was to give you a sort of score, I would say for safety, IPR strips are a five out of five, okay? you know, no matter how crowded you are, if you use a nice a thin strip and you go very delicately, and you’ve got full control with two hands, and you’ve got the patient’s got the opera gate on which to move their lips out the way, I think to do iatrogenic damage is very difficult to do ie so low risk for damage. It’s, you know, yes, you can make the gums bleed and stuff, but that’s okay. I had a mentor who taught me that blood is lubricant. Okay, so when you do IPR, I use blood as my lubricant so I wouldn’t worry about gingival bleeding. Patients don’t really complain that much, that is painful. It’s just annoying. But overall, I think it’s safe because you can’t ledge. So safety five out of five. Efficiency is where the downfall is off strip. So efficiency is I’d give it like two out of five, okay? The real reason I’m giving it to a not a one is because you can get some quite meaty, thick IPR strips double sided. So if you haven’t got that well aligned contact then you can get some really, you know, fats strips and that can help you in getting some degree of efficiency. But again, you have to work your way up to that. And finally, the quality I would say is four out of five. To actually achieve the nice quality. You have to have the whole sequence of strips and then go back can polish and stuff to get really good quality of IPR. It just takes too much time. But I think every person doing orthodontics should have some strips in their possession, it’s probably gonna be used for every time you’re doing an IPR. So if I only had one thing in my stock, it will be strips.  Thankfully, you know, just like we don’t have one bur for every prep, we don’t have one bur for every scenario, we have different types of bur. I think with IPR, we should be having different equipment, especially for doing a fair bit of orthodontics to make IPR more efficient. Okay, so, next thing I’m gonna discuss is burs. Okay, so remember, we talked about burs, people say don’t ever use it posteriorly. Don’t ever use it anteriorly. Well, when we’re going to supposed to use it? Okay, I’ve broken both those rules before. And I use a high magnification, I use 7.5 magnification with lighting. And yes, I have caused a ledge before, thankfully, a minor one, okay? Thank goodness. But you have to be super careful. The bur,the mosquito bur is just so rigid, right? So you have to be really careful, and how to be along the so correct long axis and have a patient who’s perfectly still, and maybe don’t have too much coffee that day. Like my principal was a huge, is a huge fan. You know, Hap is a huge fan of using burs. I am okay with it. I was very nervous about the beginning. But now that I’ve done it for some years, I’m happy. But I do worry about you know, the tiny little veering off left or right, and it can go horribly wrong. And I’ve seen some, you know, we’ve all seen those radiographs of ledges, right? How scary are those images of ledges, right? So we have to be really careful.  And in the video, I show you how I use the bur, especially if I was to describe it in this podcast, you kind of do a brushing stroke labially, you do a brushing stroke palatally, keeping the long axis of the contact, okay, and then that leaves a very thin amount of enamel in the middle of the contact, which is really easy to strip away. So you can literally get the green coarse strip at that point and just strip it away. And it all just flies off. And so it is extremely efficient. So let’s talk about this, okay? Efficiency wise, it’s a five, okay? There’s no doubt about it. If you know what you’re doing, and you’re happy to use burs, and you’ve got a well aligned contact, then it’s a five out of five. But that’s the thing, you kind of need a well aligned contact, like you can’t have one tooth that’s a little bit buccal and one tooth that’s a little bit lingual, and you can’t really do IPR. And well, you can, you can’t really use a bur really well there, the way you’d have to do it is you’d have to measure the tooth beforehand, then use the bur to remove some enamel and then measure the tooth again, but it just disorients you, so it’s much better to use a bur, if you’ve got a well aligned contact already. And then you can race through it and try and remove even amounts of tooth structure, if that’s your aim amongst the two teeth in the contact.  So burs five out of five efficiency, safety, I’m going to give it a two and a half. Because you can ledge, you can veer off to one side. And you will notice in the video actually when I show this that the problem is that because the bur is a wider in one portion and thinner at the tip, you do get like the correct amount IPR more coronally, and maybe you’re a little bit deficient, gingivally. And then I had to go back and use the strips to get a nice sort of consistent, equal amounts of IPR all the way through the contact. So I would say safety is 2.5. Because aside from the risk of ledgering, there’s also the risk of trauma to the tongue, the cheek, the lip, whatever can come in the way and obviously the gingiva as well. So that’s why it gets 2.5 for safety. And for quality, I’m going to give it three because although you can get quite a lot of space really quickly so that’s a good thing for quality, we want the correct amount of space. The bad point is that it’s very difficult to use burs to finish and polish. So then what are you gonna do you’re gonna go back and use your strips anyway. So you’re relying on strips for the actual polishing and contouring and finishing so it’s not great, the quality of the IPR can suffer a bit, it can make teeth look like tombstones, right? Because it really flat, so you had a lot of work afterwards with discs and maybe sof-lex discs and strips to get a nice curved polish tooth surface as it should be. So quality will be around about a three out of five and and as I mentioned before, sometimes you get more IPR higher up the tooth and less IPR gingivally. So that is an issue as well.  The next one to discuss is discs. Now, I rediscovered disc recently and I was like yes, I’m so happy and I find that once I’ve done the initial space opening with a strip because obviously you have to create the space to allow your disk to fit in. So imagine you got a well aligned contact between the lower Centrals for example. I will create a little bit of space like you know 0.1 millimeters with the strips and then I’ll put a wooden wedge gingivally to help get a bit more separation. And then I’ll use my IPR disc which is like a perforated diamond disc and I’ll do like a brushing stroke upwards, up and down, trying to keep the long axis of the tooth, but also to de-triangulize the tooth. Imagine you got lower incisors that are fan shaped, I want those fan shapes incisors to be a bit more parallel shaped incisors, because I want less black triangles. So that’s usually part of the strategy of IPR, you’re trying to change the shape, not only create the space, but also change the shape of the teeth, so the disc can be good. And where I found discs really useful is that scenario I mentioned earlier, where you got a bit of crowding. So one tooth is very labial and one tooth is very lingual, so you can’t really access the contact isn’t? There’s no contact to stick your strip in. But what you can do is you’ve got beautiful access to the mesial, or distal surface of a tooth or both teeth. And so what I would do is I would measure using like a measuring gauge, a digital caliper, let’s say the tooth is 6.5 millimeters in width. And then I will use the disc to remove some tooth structure mesially, let’s say, and then I will re-measure the tooth, and maybe now is going to be 6.3. So I know I’ve done 0.2 millimeters of IPR there without getting even involved in the contact because I know that’s where my future contact will be. Does that make sense? You’re not just randomly creating space, you’re creating the space from where the future contact will be. You have to be really careful with disc because you can go off on a slant and that makes a really ugly IPR. The lower incisor will look as though is deficient and you have to maybe you know, put some composite there or something to make it look like the correct shape. So be careful. And the other danger is making the teeth again like a bur, looking like a tombstone, right? Because these discs are very rigid. You can’t really use them with great ease for polishing and finishing. You’re still relying on your strips to get that polishing, although you can get finer discs, just because the rigidity of it doesn’t lend itself well to polishing and finishing. And of course, the elephant in the room here is safety concerns. Like if you go into a room of orthodontists and you talk about discs, you get some real horror stories that you talk about people’s their lips being lacerated, tongues destroyed. Like this usually gives orthodontists a lot of palpitations, and there are some systems out there, like we just got a disc and a guard attached to it for protection, which makes sense, but I don’t know how much that limits your visibility. And I had an opportunity to try this. But the guard wasn’t the right shape as the disc, so we couldn’t actually use it on the day. But overall, the main thing to remember is there are huge, huge safety concerns. Mostly because this thing is spinning really fast, it’s really sharp, and it can do some real damage real quick. So be very careful if you use going to use disc. In fact, it’s probably a reason not to use discs, because of the danger aspect and the whole slanting issue and doing ugly IPR and the fact that you need something else to polish anyway.  So discs, I would give a safety rating of two out of five, I would give it two out of five, be very careful. Efficiency, I’d give four out of five, you can be very quick. And quality again, three out of five just like the burs because you get this tombstone type appearance, which is very straight. So you need to go back and do lots of finishing and contouring.  And finally, we’re now going to talk about the oscillating handpiece. Okay, so this handpiece that they showed me is called the Swingle. And I was able to demonstrate it and you have to watch a video. It’s really clever, because the file that you put in, it’s got a metal base, which can bend, you can bend this metal. And I absolutely fell in love with this feature. Because now around canines for example, you can actually bend the IPR file. And it was just genius way to create space. And that’s why I think these single sided files in an oscillating handpiece are really, really fantastic. So what is an oscillating handpiece, so it basically is a handpiece that oscillates, it creates these vibrations, so you put a file inside you put in the contact, and you don’t have to move your hand. The handpiece does all the work. Now, how much work does it do? Well, interesting stat, five seconds of this file in this oscillating handpiece called the Swingle. So five seconds of the Swingle between the tooth, the file has traveled three meters in five seconds. So in a minute, it’s traveled 36 meters. So in a minute of IPR, that file has actually moved 36 millimeters. So that’s good because when even when using strips, or even when you’re brushing your teeth is the changes of direction that give you the result ie when you’re brushing, you’re changing directions constantly. And that produces plaque removal. And when it comes to IPR  strips, if you was going very slowly back and forth, then that’s not going to be as efficient as when you’re going really quickly back and forth, back and forth because there’s a change in direction that does the damage if you like so that’s what we want to do. We and the good thing about the handpiece of Swingle is it does all that for you. So it’s an oscillating function that creates the efficiency. Now after using the Swingle I have to say I am converted. I found it really quick. So in the demo video, which you’ll see I compared burs versus discs versus strips and the Swingle. And The Swingle as an example of an oscillating handpiece was hands down the best way of doing IPR. Because it was efficient, it was really quick, but it was really safe. And what’s safe, because I had full control. And it’s safe because I was able to bend the metal part to actually get the right contour. And then bend it back the other way. That was genius for me. That one of my buddies, though, the host of Ortho in Summary podcast for Faruk Ahmed, who is like one of my ortho mentors, he is a huge fan as well, and he loves the space opener. So remember to, just like a disc, right? If you want to get a disc between the teeth each create the space for the disc. So the way you create the space for a file is that you put a space open a file inside the Swingle. And that’s got like a serrated saw. And then (buzz sound) was that through and it creates a space to now allow you to put the next file in, and the next file go (buzz sound) and go all the way down. And the next file (buzz sound) all the way down really quickly. And now suddenly, you’ve got like, you know, 0.2 0.3 millimeter of IPR in quick time.  But then the real clever thing about this system is the finishing and polishing files. They really, this company intensive, they’re basically, they may not be the market leader in diamonds and IPR and whatnot, but they focus on quality diamonds, so all the burs everything they make, it’s all about quality. And they’ve taken that to the Swingle because it allows you to really work through the finishing and polishing. So they’re very passionate about creating well polished, but efficient IPR. So they’ve got these finishing and polishing files, which you take away all the hard work, so you don’t have to be there with strips for too long. You know, now that you have this handpiece, you’ve got the Swingle, you stick in the finishing and polishing file, you bend the file, and you put it in and a few swipes, and it does all the work because remember, it’s moving three meters in five seconds, it’s doing all that movement for you. And that’s what makes it really efficient. So, for me, the experience of using an offsetting handpiece, like the Swingle was brilliant. So I’m going to get one, the practice agreed to get one, and I’m going to give it a four out of five for safety. The only reason I didn’t give it five out of five for safety was because at one point I had to really get it under the gingiva just to counter it. And you know, my brother-in-law was, yeah, that was a little bit uncomfortable. You can hear his thoughts and stuff. But that’s what he said. But that was only because I was going subgingival. But I feel as though with the serrated saw, the space opener, if you are not careful, if you as the operator is not careful, because it’s a bit of a learning curve, then then you can potentially ledged the tooth. So you have to be a little bit careful here.  And just like all the other forms of IPR, other than strips, you have to have fairly well-aligned contacts to do the IPR. So I’m going to talk about that in just a moment. But safety four out of five. Efficiency four out of five. The reason I didn’t give it five out of five was because you still have to use a few different files, right? So you go for the space opener, then you go for like the 40 microns, then you go for the 80 microns. And actually, when Debbie from TOC was showing me these files, I was thinking 80 microns, like is that, how thick is that? I don’t understand. So obviously I was being stupid because 80 microns tells you about the coarseness of the file, the thickness of the file varies. So for example, that the 60-micron file from the Swingle, double-sided is 0.28 millimeters. So it’s 60 microns, which is the sort of coarseness of it, but the thickness of it is 0.28. So this is great for if you’re doing let’s say, you know 0.3, 0.4, or even 0.5 millimeters of IPR, you can put this disc in or even the 80-micron disc in which 0.31 millimeters, okay, so 0.31 millimeters. And if you want to do really efficient IPR of 0.4, 0.5 millimeters, their sort of tagline, their sort of marketing is that you do half an hour’s worth of IPR in one minute, half an hour’s worth of IPR in one minute. And I think I definitely experienced that.  Now, I know the finishing and polishing takes a few extra steps because you have to add in the, you know, the finishing file and the polishing file, but it’s so worth it. Because the quality of the IPR was absolutely brilliant. I had a look at the end. And I thought, wow, this is the right amount of space was really important. But it’s anatomically correct as well, because of the way that you can bend the file. So for the quality of IPR, it gets five out of five. So safety, efficiency, four out of five. Quality five out of five. If I was to recommend one thing, and obviously you need to have strips, I think, because when you got crowded situations, there’s nothing to do other than using strips. Maybe if you want to use the disc in the way that I described earlier, that’s fine, but just be very careful using discs. But essentially, the things you need to have is strips. And then if I had to have one more method of IPR in the practice, especially if you’re doing a lot of it, but you want to save time so that 90-minute appointment would become hopefully a 45 minute appointment. And you would get, you know, if feasible, you could do all the IPR in one go if feasible. Now we’ll talk about that a little bit as well. So I would say the Swingle would be the best bet. So strips and the swingle, for me is going to be the recipe of success with IPR going forward. And I know loads of other dentists who have already been enlightened about this, they’ve already railing on about how good the Swingle is. So I’m a little bit late to the party. But I’m excited to keep the party going now and using the Swingle because I just think it’s gonna really save me a lot of time to my IPR appointments.  So I hope you enjoy that overview of the different things that are used for that video. And I urge you to, you know, watch that video, but just a little bit on IPR planning, because we need to be a little bit clever in the way that we plan that IPR and also just a footnote here, really important. One of the most common questions I get from dentists who are starting orthodontics is they’ll send me a ClinCheck plan. And they say Jaz, how do I do 0.5 millimeters of IPR in this one area, like lower left bicuspid and canine or something? And they’re like, how do I do it? I’m like, Well, you do know you don’t need to do all the IPR in one go? They like, Oh, really? So when on the ClinCheck in appointment three, it flashes 0.5, Oh I need to do the IPR, it doesn’t mean I need to do the entire 0.5 at that visit, what it means that you should create some space because if you don’t create some space there, there’ll be a collision, the teeth will collide, they will get in the way of each other, and then your movements will come less predictable. So it’s totally cool to do 0.2 millimeters of IPR. And then some weeks later, do another 0.1 or 0.2, and do it sequentially. But if you’ve got the contact well aligned, then it just makes sense to do some strips, or use the space open of the Swingle and then go up to 40 microns, 80 microns, and polish and you’re done, okay? So it’s very appealing to me as a busy dentist who wants to reduce the time of IPR, but not sacrifice the quality to use an oscillating handpiece like that, and I would be inclined to do all the IPR when I can.  Now you can be clever when you’re planning your IPR, with your aligner company of choice or Invisalign, whoever you can tell the technician on the other side, say that I only want to do IPR when the contacts are aligned, right? So you have to accept some degree of Round Tripping here. But if you can get away with the biotype of a patient with a little bit round tripping, then you can make your sort of workflow and sequencing much easier and just do all the IPR once all the contacts are well aligned, which will be really efficient. The other thing to consider is if you’ve got lots of areas of you know, 0.2 0.2-0.2-0.2 everywhere, consider converting those, you know, four 0.2 IPRs into two 0.3 and 0.2, if feasible, okay, obviously got a look at the shapes of the teeth, because that’s one contact now you don’t have to do any IPR on. So if you look at upper arch, lower arch, can you buddy up the IPR if the tooth anatomy allows it, so you don’t have to, so you have to do less contacts, because every time you do a new contact, you have to go through a sequence. So that’s how another way we can make our IPR more efficient when it comes to planning.  So hope you found that a little overview that discussion about IPR, for some of you that that will be teaching you to suck eggs because you’re already quite proficient at doing IPR. And maybe you’re doing orthodontics for years. But I think the person who may have really benefited from this is the young dentist who’s new to the world of orthodontics, and it starts to get sweaty palms just like I did when it comes to IPR which case you should definitely check out the video because got the full sequence for how to use each piece of equipment and the Swingle in action. So just want to thank TOC Dental for coming down bringing their burs, strips, the Swingle, the discs, and allowing me to film that and to support the podcast in the way that they have done through allowing me to make this episode for you guys. So I’ll be putting a link to TOC Dental, please show them your warmth and support for this episode if you’ve gained from it. And again, thanks so much for listening all the way to the end was quite intense that one. My head’s hurting a little bit and hope to catch you in the next one guys. Thank you so much.

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) 11:35 Patients’ Vibe as part of Assessment before planning treatment 18:29 Load Testing as part of Assessment 24:22 Type of toothwear to consider the type of arch reconstruction 31:48 Curve of Spee as part of Assessment 36:25 Guidelines regarding Re-RCT before restoring 40:40 Comprehensive Evaluation among Patients 45:32 Appointment 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 Course, he had my stabilization Splint module and his feedback, five out of five stars, by the way, and then he gave me some feedback. And he said, Yeah, I need, in capital letters. I need to start charging more for my splints. And like yeah, hell yeah. So I discussed this with my Splint Course group like yeah, we started charging off splints, but then I took a step back, and I thought, You know what, we need to start valuing our Dentistry more, we start charging more for dentistry. So there’s four main reasons why you might not charge enough your dentistry. And I suggest four different fixes. Now, if you’re not on my email list already, and you want to be anyone check out that email that I sent, then go to protrusive.co.uk/emails, that’s protrusive.co.uk/emails, and on that page, you will access some of the more popular newsletters I’ve sent that I made public for you. So if you don’t love me enough to see me in your email inbox a couple of times a month but you love me enough to actually check out this email, then go on that website. [Jaz] I also want to share some an announcement with you about the course that I’m doing. So I’m doing an occlusion one day course, hands on and theory for the Kana Dental Academy. It’s on Friday, the sixth of May. And the Kana Dental Academy is one of these diploma programs over 12 days. And the cool thing about it is that you can pick out like 15 or 16 different options and make, you can custom make your own postgraduate diploma. The full name of the diploma is a PG diploma program in Aesthetic and Restorative Dentistry. And I think it’s a cool concept one that’s quite popular nowadays to actually design your own diploma because you might have already seen one speaker, or you’re pretty confident with one aspect of what’s offered in the diploma so you can actually customize it to your own learning needs. So this is like a diploma cohort that you do for several days and you sign up for 12 days, you can do a standalone course as well. But I think there’s a lot of value in doing the entire 12 days. If you’re looking for an all encompassing course that has a bit of perio, bit of communication, bit of aligners, bit of occlusion, bit of treatment planning, a bit of everything to set you up ceramics composites, I mean some of the speakers are brilliant and I when I was reading through the list of the speakers for this diploma, it made me smile about how many alumni of the Protrusive Dental Podcast ie previous guests that we’ve had on this diploma like we’ve got Shaz Memon teaming up with the singing dentist and they’re talking about communication. Shaz came on episode 37 about personal branding. Koray Feran, I mean I’ve got so much time and love for Koray. He did a equilibration with us on episode 94. If you haven’t checked that one out and he’s doing treatment planning and consent, a whole day on that which is a huge, you know, contemporary treatment planning on the diploma program. We’ve got Shiraz Khan and Harmeet Grewal, who did the rubber dam Episode, episode 26. We’ve got Nick Sethi that episode 59 on ceramic onlays, which you guys love so much. You know, so many of you listened to that again and again, and you send me photos of the notes that you make, so that’s epic. Chris Waith on sectioning and elevating teeth. We had him on episode 85. And so you know, we can call this a Protrusive diploma if you want to. But you know there are some other amazing speakers. I’m just gonna just show the image on screen or post on the blog of this website, protrusive.co.uk about who all the speakers are, so you can see some great names on there. So do check that out and if you want to check out the website is kanadentalacademy.com based in Milton Keynes, that’s Kana, K-A-N-A, kanadentalacademy.com. So you can check out all the dates and all the speakers and see if this is gonna tickle your fancy. [Jaz] The course I’ll be presenting for the Kana Academy is no nonsense occlusion, pragmatic principles and a risk based approach. It’s gonna do exactly what it says on the tin. Dentists were able to carry out occlusal examinations on each other, as well as muscle and joint evaluations and be able to take that through onto the examinations on Monday morning. It’s about identifying the high risk patients, the ones for which the occlusion is a super sensitive issue and how to tread carefully with those patients. As well as the daily skills that you can use to improve the longevity of your restorations. It’s occlusion made pragmatic because the best articulator is the TMJ. [Jaz] And finally, the Protrusive Dental Pearl that you’ve been waiting for before we joined the main meat and potatoes of this episode. So the Protrusive Dental Pearl, following on from what I covered last time about how I communicate an oro-antral communication, I’m going to share with you a few pointers, I’ve picked up myself about how to communicate an RCT risk. And what I mean by that is, I actually dread and obviously, I’m learning to manage it more now. I’m gonna share that with you how I manage it now in terms of communication, but I used to really hate treating deep caries lesions like, I kind of want them to be not very deep, so I can restore them and tell the patient you’ll be fine, don’t worry, or I want them so deep that I know the answer is a root canal. But most of the caries that we treat nowadays is like, oh, there’s a higher risk of root canal. It’s quite close to the nerve. It’s not in Interpulp, but it’s, it’s quite close. And therefore you to have that whole conversation with the patient that, okay, we’re gonna do this restoration or this temporary crown wherever. But there’s a chance that you might need a root canal, do you know what a root canal is and explain what it is. And it’s messy. It’s annoying, it’s stressful, and no one likes it when you do a large restoration. And then six months later, a patient comes back in pain, because if you haven’t communicated it to the best of your ability, or some patients, they just don’t get it, okay? Oh, my tooth wasn’t hurting before you started drilling into it. And you did this big filling. And oh, you know, you hear this all the time. Oh, my dentist, I think my dentist drill too much. And now I need a root canal. But we hear this all the time for our patients, so they don’t get it. So how can you make sure our patients get it. So some patients will be just fine with look, there’s a risk that you might need a root canal treatment explain because that YOUR decay, Remember I always say YOUR tooth decay (in YOUR tooth), YOUR filling was very deep. And that’s all they need to know. But if I ever get like a bad vibe, or if I just feel that this is a troublemaker patient, or they are just not getting it now to really make this consent process crystal clear to them. I will say the following, Okay, remember, we treat all our patients differently, okay, because everyone is different, they have different personality. So certain groups of patients, I will say this too, I will do the whole thing, you know, YOUR filling, YOUR tooth decay, etc. But then I will say that, if we do nothing, then your tooth will eventually be in a worse situation. And you may lose your tooth. And 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, drilling away the old filling that’s leaking. And drilling is not a nice thing. Your tooth was never designed by God revolution really believed in. Your tooth was never designed to be drilled. So even the drill is damaging to the tooth. So by drilling, I’m damaging the tooth. Okay, so there we are, I’m being very real to the patient. Okay, so an endodontist called Steven Godfrey taught me this, and I always stuck with me. So by drilling, I am damaging your tooth. But if you don’t treat this, you’re gonna lose a tooth anyway. So I’m going to try and help you. But your tooth is in a very bad condition. And I’m drilling it and I’m hoping that your nerve will make it and survive this drilling procedure. If your nerve doesn’t make it, you might need something called a root canal. Explain that. So the reason I like that for certain patients is that you know, I just put my cards on table and say, okay, yeah, what I am doing is destructive. And I don’t want to be doing this, but it’s your, you got yourself in this position, your tooth is messed up. So yes, you might need a root canal, okay? Do you want the risk or not? What do you want to do? So again, it’s makes it very clear that it’s a very real eventuality, and they might need root canal. And if and when they’re the patient that, you know, a few months later, a few years later, they end up having an abscess, or they end up needing a root canal treatment, you know, they’re gonna be one step closer to remembering that, Oh, you know what Jaz did tell me that, you know, the drill is damaging. So I know this is not everyone’s cup of tea, but for that certain type of patient it really drilling into them, excuse the pun, so that it sticks and it’s memorable. And like I said in the previous episode, the whole point of consent is that if they decide that they don’t want this treatment anymore, then that’s good. Okay. Then that’s the whole point of consent. You know, you don’t say, Oh, if I warn them too much. Then there’ll be scared and they won’t have the restoration, well, that’s the point of consent. If there is a real risk here, communicate it. So that’s one way to do it. So let me know what you think, email me, message on Facebook Protrusive Dental community tell us other ways that you communicate it there, which are innovative, or useful or memorable for the patient. And remember, this is what I was sharing with you is not the best way to do it. It’s just sharing a way that for certain patients I like and that was taught to me by an endodontist. And I think it really sends a message clearly to the patient. Anyway, let’s join the main episode with Dr. Devang Patel. And I’ll catch you in the outro Main Interview: [Jaz] Dev. Welcome back to part two, we had a really jam packed full of information, part one. And it’s good to talk about the next step because everyone’s now eager to know, what do I do next? What do I do next? So Dev, just recap for us what we spoke about last time, and where we’re going to pick up from today. [Dev] Well, I’m glad to be back. Jaz, thank you again for inviting me. So we discussed about the mindset, which is really, really important. Mindset of full mouth reconstructive dentist, very important investment, investing in yourself. We talked about appointment one, the mindset was appointment zero, if you remember. Appointment one is really when you’re doing examination, you gathering all the data, you’re really discussing with patients what are you planning to do? You’re doing full mouth assessment examination, you’re kind of discussed about conformity versus reorganized approach, how we can do and how, what are we going to do? Appointment two now is really records. So you need to take good set of impressions, you need to take some sort of a Facebow record so you can mount your model. And you would have decided by now that whether you want to restore the case in MIP, or CR or CO for that matter. So most of the time, you I do not mount models in MIP, I would mount model in CR. And even if I’m restoring in CO or mount model in CR and if my mounting is correct, if I drop the pin, it will.. [Jaz] I’m very anal about CO, you’re using CO as a definition as an MIP. Yeah? [Dev] No, CO is..Correct definition of CO. [Jaz] Yes. The Centric Relation Contact Point. Okay, fine. I just want to clarify that because people listening maybe they haven’t listened to some of the early episodes and like, Yeah, fine. First Point of contact. Perfect. [Dev] Just to recap, because as you quite right to be honest, if you pick up Glossary of prosthodontic terms of 1999 CO is equal to MIP. If you pick up you know there’s different time, different definitions, but my understanding is CR is your relationship, [overlaping conversation] hinge axis, and teeth apart relationship. So it’s quite reproducible. CO is when you are, when your conduct is nicely seated, and you’re now closing your jaw and first point of contact is centric occlusion. And then MIP is when you have the slide or shift or if you don’t have a slide if you don’t have the case, then you.. [Jaz] We have the same language, Dev. This is the first time in occlusion. Two people are speaking the same language [Dev] Very good. Yes, because to be honest, you made a great point. Because when I do the course I first start with terminologies because there are so many different terminologies to different I mean, in UK, we use RCP, ICP. But however I stopped, I use CRCO and because that’s more generally use terms. But if you’re in UK, if you’re reading some UK journal articles, then RAP is equal to CR. RCP is equal to CO and ICP is MIP, which we know anyway. So what I was saying that I would mount model in CR almost all the time, because I’m not going to restore, if I’m doing one arch or full mouth reconstruction, then I’m not going to restore patient in MIP, for me, it’s just not ideal. So I have.. [Jaz] Often increasing the OVD henceforth, the traditional way of working in a reorganized centric relation, sort of position or centric relation contact point or beyond the centric relation contact point like we talked about last episode about sometimes when you can open up just exactly what how much you need. It gives you a playing field where you can get complete control and I liked that when we discussed that. Remember that everyone and also just want to just check out just for those dentists listening they think okay, articulator, what type of articulator just briefly, what? [Dev] Articulators, I mean, I do quite complicated full mouth reconstruction, I don’t use fully adjustable articulator, I mean I use a semi adjustable articulator how many times I’m changing condyle inclination, I don’t know I mean if I do 500 cases, maybe two times so if you even have an average value articulator with a set of values I use Denar I’m biased because I was trained on Denar articulator. I use it, it works for me, but you can use you know different articulators, if you want. So I use Denar, slight Facebow and Denar articulator, again, I use semi adjustable but you can use average value to save money and also, if you starting your journey, you’re not going to use any setting of semi adjustable articulator and actually you’re risking, if any of the screw becomes loose, then the settings will change and you will notice and then all the mounting will be wrong. So just use, just buy average Value Articulator where all the values are set, which is 25 degree of inclination, seven degree of sides, sort of progressive shifts and zero degree of immediate side shift. So, that’s all set up so you don’t need to worry about that your calibration is much easier for those articulator as well. So, I use that. Now once I’ve done that now, we haven’t really talked about digital and we can talk about sometime later because I’m more analog person to be honest, but if you let’s say if you’re doing digital while in your and you’ve got a scanner, then you need to take obviously scans of upper and lower jaw, you still need to have some sort of a jaw relationship and scan the patient in that jaw relationship to mount model on the articulator, which is digital articulator really. So you still need to use a Lucia jig, or leaf gauge in order for you to get that CR position. And what I tend to do is I would have bite registration material squeezed on the back teeth, I would take one side of the bite registration material out, scan the bite, put that bite registration back, take the other side out and scan the bite. So then I have a stable occlusion when I’m scanning the bite and patients not moving around too much. [Jaz] So for those who are watching this on the like YouTube or the app which is coming soon, I’ll have a visual of exactly what this looks like. When you take a bite, digital bite in CR and you have all that lovely space. So I can share that with everyone, those listening, Dev made a good point about using bite reg left and right. I personally just use a leaf gauge at the front. And that stays at the front. And then I makes the patient stays in the position I want them to stay. And here’s the magic bit, at the desired vertical dimension I’m roughly aiming for to reduce the error in opening and then I’ll just scan left and right and yes, exactly. So this is the digital way to get the same information as analog. And I’m glad you mentioned that because some of our colleagues are digital now. So we need to please both groups. [Dev] Yeah, exactly. So now the model gets mounted. Now at this point many times what everyone does is they would send the impressions and the records to technician and say Look, mount the model, do the wax up. But in my case, I mean I personally met all my models myself, because I’m just I like it. So I would mount the models, I would then assess it because I want to really assess the occlusion I want to assess the plane. So when I’m planning the treatment, this is when more confirming my treatment plan which I already planning patients when patient was there because as I said last time, use patient’s mouth as an articulator, it’s the best articulator you can use because you’re going to use that, you know, treat the patient in the mouth. So make sure that you plan most of your treatment then and then and then what you’re doing is when you mounted the models, you reconfirming your planning because there are some views you cannot see in patient’s mouth, you know, so articulate helps to look at in the various angles. Now, there are five things I’m looking at when I’m planning any treatment not particularly just on the looking at the articulator, but just overall. So there are five things which I’m planning, the first one is, which we briefly touched upon, is assessing patient. Patient himself or herself, right? So my first criteria is, if I don’t get a good vibe, if you’re not getting on with each other, I will not start the case no matter how simple it is, I will not start the case. It’s different when you’re doing NHS dentistry and you don’t have a choice, you know, you have to treat patients before those main needs, you know if they have broken tooth and you need to fix it. That’s different [Jaz] Basic health needs. [Dev] Sorry, yes. Whereas we are doing we’re talking about full mouth reconstruction, we have a choice because this is private, it’s beyond NHS remet. Anyway. So, I choose who I treat and I choose very carefully now as I mature over the years, because I have been bitten before. So my criteria is first thing is, am I going to get along with this patient right? Because once you start doing full mouth reconstruction or even single arch, you kind of start with that patient for some time. So that’s one thing. [Jaz] One thing I want to sticks in people’s minds, Dev, Ian Buckle when he used to make the same point, he’s used to say very simply, date them before you marry them. And I love that because it is pretty much when you do a full mouth rehab. It is a marriage. You know when something happens in the future they’re gonna come back to you and whatnot. So date them before you marry them. Because sometimes that actually means… [Dev] Yeah, especially doing full mouth implants upper and lower. That’s it, they kind of end. [Jaz] Exactly. Sometimes it just means that you need to see them for a couple appointments just to go over hygiene and do that filling in the lower left six, which they need because it’s caries to suss out. Okay, can they? Are they a suitable patient, both in terms of their mouth and in terms of their personality profile that matches you going forward. So that’s a fantastic point, well made. Thank you. [Dev] Yeah. So basically, yes, I would assess patient. And the other thing I would assess is what they want, you know, the expectations, but I can match the expectation. We are very grateful to be honest, in UK, our patient match expectations are quite realistic, to be honest. So I never had a patient, well I would say never maybe once, maybe I had a patient where I could not match the expectation because it’s just unrealistic. So but otherwise, we are quite good. But you need to make sure that in your capacity, you have your capacity or skill level to match the expectation. Because once you start these cases, you can’t really go back. And we can argue day long about the you know, composite versus porcelain and composite is, “reversible treatment”, I don’t think composite treatment is reversible. Once you bond the two really nicely, or once you want the composite to really nicely, a patient doesn’t like it, you can’t really undo it, you can’t really take it out in patients on you know, there is no way [Jaz] You’ll never go back to the exact same position they were before. [Dev] Cannot. Yeah. So but it’s very easy to adjust. And if you’re doing full mouth reconstruction for the first time, I would highly recommend start doing adhesive sort of composite buildups, because it’s very forgiving especially if you’re bonding skills nice, then you know, you can, occlusion you can adjust here and there. So that’s what something I assess. The third thing I assess for the patient is non compliance. So some patients, they want to have nice teeth, but they don’t want to put an effort to have those nice teeth. So they don’t clean their teeth. They don’t want to do good hygiene. They don’t, they miss their appointments. I really don’t, I look at their history. And I tell them from up front that you know, you need to do all this record, I think because patient will say on that appointment that yeah, we’ll do everything. You know, I’ll stop smoking. I’ll you know, we’ll see hygienists every three months. But it may or may not happen. So you need to really suss it out what happens because, again, I’ve been bitten before. There, you know, there are patients who FDA before, their general dentists and I can see their history is quite patchy. And they need a full mouth reconstruction. And you know, it’s nightmare because they missed the appointment, they canceled appointment, there won’t comes first, which is I understand the problem is we are also working, so we can’t really, I have three hours appointment and the patient a day before cancels, I mean, I can’t fill that whole gap within 12 hours. So we need to understand whether this patients priority to fix their teeth or not. If patients priority is not that, then it is likely that they won’t take care of it. So that’s the… [Jaz] It might be not their priority right now. But, you know, a year down the line, I’m sure you’ve had patients given treatment plans before and they come back some years later, because again, and then they’re ready. So it doesn’t matter if you lose the case. Because if you lose the case, it’s a good thing. Because you know, you’ve decided this isn’t the right patient yet. Yes, being the key word and in the future, they might be your ideal patient. [Dev] I mean, I had a patient who, when I used to do normal checkups and everything, I proposed a full mouth reconstruction to him. And he literally laughed at my face and what how much, you know, I can do three holidays to Spain or whatever. So we discussed, we literally discussed four checkups, same thing and he laughs. In the fifth checkup, he said, Yeah, I want this done. Because things changed. You know, he broke couple of teeth during that two years time. And you know, he’s like, look, things are deteriorating, and I get it what you wanted, what you were saying to me two years ago, let’s get this done. Okay, so obviously he paid more because now it’s more work two years later on and the prices increase and make sure that you give that example to patients and other patients as well that you know, they may not realize. So that’s one thing. The second thing is I assess while I’m doing records is load test. Load test means is really checking the health of your TMJ whether you are assessing whether there is any intracapsular problems so keep it at around the TMD if there is any problems and for loas test, I used to make Lucia jig all the time, but I find leaf gauge very easy quick to use for load test. For mounting I’m still old school so I still use Lucia jig for mounting because it gives me a nice vertical stop and I lock them their bite on my Lucia jig so when I’m asking them to close their mouth, on the Lucia jig I know that they’re closing at the right point because bit leaf gauge, you cannot tell whether the patient’s going further back right by when you put your bite registration material or not. And I don’t like to push their jaw, I just like them to move their jaw forward come back comfortably. And that’s how you… [Jaz] With the load test. I just want mentioned if we go to the fifth one with the load test is for those people who don’t have a leaf gauge is A) get a leaf gauge. So it’s a very valuable solution, many scenarios. Exactly, it’s not expensive at all right? 20 pounds. And then for those who don’t have one, I mean, do they need to load test a patient right now, the other way they can do it is get a wooden spatula on one side, let’s say you want to load test the left joint, you put the wooden spatula between the right molars, and then you get the patient to clench on it, and then you assist with your hand by pushing the angle of mandible up. So you’re pushing the condyle into the fossa. And that’s another way to do the load testing for that one joint then obviously got to do the same thing for the other joint. So it’s important to have these baseline measurements including like when I’m doing more complex work, I need to know exactly in millimeters, the range of movement, I want to know the pathway. These are all things that you said you record in a very comprehensive check. So you need to have all this information. Because if something happens later on, you need to medically know exactly what situation your patient was in. So please do not take these measurements lightly. These are little details are important. [Jaz] Yeah, and one thing though, you can get false positive results with the load testing if your lateral pterygoid are a bit stressed. So what I tend to do is if I have patients it is bit painful around jaw joint area, I give cotton ball rolls, asked them to bite on both molars tight squeeze, release, squeeze, release, and then do the load test again. Sometimes the pain goes because it’s just that the lateral pterygoid are tense and then just relaxes [Jaz] So you just make sure that you check to get a true positive is quite rare thankfully, so to get a true positive load test, and that means that they got severe intracapsular issues. Thankfully, [Dev]Most of the time patient knows when you have true positive, patient would know that they have some issue going on with that TMJ. So make sure, so that if I do find true positive, or even some f alse positive, and I’m not really sure I would give them Michigan splint to start with to make sure that you know the occlusions, they can tolerate the raise OVD. A) their compliance is good. And there are lots of reasons why you should use Michigan splint before your full mouth reconstruction. But it doesn’t. When I was taught, I was taught that you need to do Michigan splint for 100% of the cases, full mouth reconstruction, 100% of the time, which I don’t feel necessary to be honest, in my opinion, if patients has got sort of load test is positive, you must give the Michigan splint and you make sure that you don’t start treatment until that pain goes, so you need to keep checking. If I’m doing load tests, everything’s fine. Patients not in pain, muscles are not tender. And I can really relax that jaw nicely and they go back into CR very nicely, then there’s no point in giving them Michigan split, okay? So I will then crack on. Especially if you’re doing composite reconstruction, you got plenty of time, even if you’re doing indirect reconstruction, you will have plenty of time to check because you’re going to do a mock up, you’re going to do your provisionals. And then you’re going to do final, so you will have time to sort of test it out as it were. So that’s that and then if there are some patients who are genuinely cannot, you cannot relax their jaw at all. In those cases, you can give them some deprogrammer, you know, and your course is really amazing. So you know, you can get some deprogrammer to use, I give them I make a bit larger version of duralay sort of lucia jig, which they can use, but you can get different types of deprogrammer. Give them to take it at home. Bring them later next time. So use it for a few days and then come back. [Jaz]What percentage of your patients would you say would have a splint therapy before doing a full mouth rehab? Just interesting to note. [Dev]Yeah. Very, very rare. I mean, not that many percent. So I would say, I don’t know, 5 to 10%, maybe? So not that many. [Jaz]And some clinicians are doing it in a much higher percentage. And that’s fine. You know, that’s part of their philosophy and it’s okay. But I think you’ve given us some good guidelines about when to consider it. [Dev]Yeah, I mean, I was taught like that, and I don’t see any issues with that. Having said that, it does increase the treatment time, first of all, but also by giving the Michigan splint, what you’re trying to do, you’re trying to relax the jaw, right? So if you feel that you have their jaws relaxed and you know you can go to CR and this is all about feelings. Remember I’ve been doing this for 10 years so initially all my cases used to get Michigan splint. So whether you when you start getting more experience, you know that this patient got really tense muscles, you don’t want to start the treatment, you want to get a Michigan splint first, make sure they’re nice and relax. And then having said that patient who are bruxist, past parafunctionist, they will always do that. You know, we know that Michigan splint 24/7 is not a good idea. So you know, for all the time. So you know, you need to take everything with a pinch of salt, and modify your treatment according to your experience. But in the beginning, when you’re starting, not sure, if you’re not sure, just give them Michigan Splint. That’s the best, safest way to start full mouth reconstruction. [Jaz]And again, if you’re not sure, then again, it’s another way to check the patient’s compliance to check the patient has really committed as well. That’s sometimes the reason I do it purely just to check their compliance. Very rarely, if they are severe Bruxist but I still get their muscles relaxed, then it’s fine. But sometimes it’s important for them to understand that what they’ve done to their own teeth, they destroy them, they’ll probably put the restorations under the same stress unless we can somehow switch off that trigger that they have for their bruxism, which is very difficult. Therefore, in some cases, you might give it for a secondary reason to also check their compliance. [Dev]Yes, because for those bruxism patient, I want them to wear Michigan splint after I finished the treatment. So if they think the CR convert this, then that’s the best point I would say, Look, I can’t treat you because you know, you’re going to break things. I mean, I tell all my patients who are treating cases that you will break might whatever I’m doing to your teeth, you know, 100% chance, at some point, you will break something. It may last 10 years, and you will break it or it may last you know two years. I mean, it’s very difficult to tell. Obviously, we’ll do our best to give you the best treatment, but you know, you might break things. So that’s that. Once I’ve done the load test, I would then check the type of wear. So how many teeth are worn down whether and that will allow me to decide where the patient needs single arch reconstruction. I just posted a case sort of late December. But I’ve just done single arch, upper arch, it’s erosive case, patient had, she had a sort of fizzy drinks issues, drink a lot of fizzy drinks and everything. So she has one, just her upper teeth quite massively, and the lower teeth were almost not too bad. So just single arch reconstruction and lower arch levitating up. So depends on the wear, you’re going to decide whether you’re going to do single arch, we’re going to do full mouth reconstruction, or you’re going to do just anterior reconstruction and dahl the patient into the posterior teeth in. Dahl means, you know, orthodontic movement of the teeth without putting braces on. Right? So you put in, you’re doing just anterior buildups, and you’re allowing anterior teeth to intrude and posture to extrude. Having said that, it’s not very well utilized in the sense that if the very strict criteria, which cases you can use dahl, I mean, if patients got posterior wear, it’s a complete No, no, I mean, you increasing this, you creating this nice space to restore posterior teeth, why not just restore there and then, why just dahl the patient and most of the time it’s easy to communicate with patient and dahl technique because it’s cheaper, right? So you know, it’s full mouth reconstruction is much more expensive, because posteriorly, you’re going to involve more onlays more you know, until you can just do composite, dahl, quick done. [Jaz]Because if you have like you said, if you’ve got a significant posterior wear, restore it. Planning for restoration, don’t leave it to dahl. It’s very much a interceptive treatment for localized anterior tooth wear. That’s the way I think about it. And for those who if you haven’t listened to Episode 16, and 18 with Dr. Tif Qureshi, he really goes into full detail of a couple hours about this, beyond the limit of what we’re talking because we were talking about the full mouth rehab now, but great point, not every case that you see, needs to be treated a certain way, you got to have different tools in the shed. So some cases may be amenable to a dahl. And that’s a point well made. [Dev]And also don’t try to fit you know everything into the tools you have. Just because some people just comfortable to dahl there just to dahl everything. They dahl all the cases which is not ideal, but anyway, so now if you have posterior wear and anterior teeth are completely intact, and I’ll show you the case, at some point where I have treated case like that, where you just want to restore posterior teeth. Now how can you do that? You can do orthodontic movement of the posterior teeth, braces, intrude the teeth create the space or restore the posterior teeth and have braces to close the anterior teeth down because when you restore the posterior teeth, you’re going to almost increase the, decrease the Overbite so you know you’re going to sometime can create open bite interior If the patients come through the very edge to edge almost occlusion, and those patient who are have quite heavy posterior wear, they don’t have very deep bite unless they go into CR and grinding their teeth, okay? But if it’s localized one or two teeth posteriorly, then orthodontic treatment helps a lot in managing them. So again, how many teeth are involved helps me planning what I’m going to do, also the type of wear. So if a patient comes with wear, how would you know whether you need to increase OVD or you need to do crown lengthening, and restore the patient in the same OVD, because there is envelop of compensation and patients have already worn up. So patient actually hasn’t lost any OVD. But just the two teeth have overerupted because the idea of compensation, and one of the quick way to measure that is asses patient’s smile. If patient’s smiling and all the teeth are on display, you can’t really increase too much OVD because then you’re going to give them horse teeth, okay? So then you need to think about also you need to think about Crown Lengthening, other things apart from increasing just increasing OVD, okay? So that’s a few things you need to keep in mind when assessing wear. [Jaz]Just a point on that Dev. So now I’m going to continue because I think you’re gonna come to it, go for it. [Dev]So the fourth thing I assess is Curve of Spee. So I want my occlusal planes flat-ish if I can, okay? I don’t want very steep curve of spee on the lower. So when I’m assessing my models that will help me in assessing Okay, how much I’m going to add on the lower arch and how much I’m going to add on the upper arch to get that plane flatter, okay? It’s not always possible without orthodontic treatment, because the teeth have may have moved so much. But keep that in mind. Because sometimes what happens is you have, again, every the compensation of the lower anterior, lower anterior’s come up, the posterior is quite lower down. And now if you’re building the lower anterior, you’re really increasing the steepness of the curve. So to make it flatter, you need to really have quite thick posterior onlays to match up with the level of the incisors. Now, that’s when you realize okay, this really case needs orthodontic intrusion, and then treatment rather than just building everything up or a crown lengthening or not build too much length out. So, [Jaz]So the models or your 3d scan will give you so much information to be able to assess the occlusal plane all that information [Dev]Yes,, exactly. So 3d scan will help you a lot, patient’s mouth, you know, you just look at patient’s mouth again this articulator so I really assess a lot when patients they’re in the chair, it helped me a lot with planning. And then the rest of it is just literally confirming what are planned. And it just gave me a little more time to think about and patients there. I don’t want to just have pause and lots of you know, silences where patients like wondering what’s going on. So I will do what I need to do, I need to assess what I need to assess and then thinking time will be after patients left. So that’s that, and then we assess any limiting factors. So you need to make sure that what are the limiting factors for me if I sometimes receive cases, I, right now, I mean, I don’t do much checkups, I see patients on referral basis. So I get consultations patients come to me. And sometimes they refer to me for single implant and dentist has done some crowns and some veneers and I think okay, now this patient kind of needs a full mouth reconstruction. The problem is they’ve just done a new crown or new veneer, can I fit my full mouth reconstruction within that, without changing it, because the crown veneers really nice, it’s really nicely done, don’t want to really disturb the tooth too much. And put patient to extra cost. So that’s something is not a limiting factor. But something you need to be you need to I need to make sure that you’re aware of it. Another limiting factor, which I believe is quite some time with patients who have all dentistry done is posting core crowns with very poor endodontic treatment. Now, when I raise OVD, we kind of committing to at least doing one single arch reconstruction. So if the post and core crown is falls within the arch, which I’m doing reconstruction for, then I need to change that crown and it’s much higher risk when you removing the post when you’re doing the crown. Because if the endodontically treatment’s not done very well to need to remove the post, do the proper endodontic treatment and then put a new post in, new crown in and the cost of seeing a specialist having all that done, and then it just increases increases, increases, and then you thinking, Okay, why not just take it out and do an implant. Because even though you do all that, the tooth is going to be very weak because it’s already got post in there, you’re doing a lot of things in the root. So that’s something, I always need to have a constant sort of discussion with patient during my treatment planning discussion. The other obviously.. [Jaz]You’re right, so I’m just trying to pick you on old dentistry. So I’m just probably a bit further with old dentistry, that is a real challenge. When it plans old dentistry really gets in the way, it’s much nice to treat those erosive cases where they’ve just haven’t got many restorations and you got, you can do what you want in a way. But when you got old dentistry, you have to be a little bit smarter. Now one question I have for you is, what about those cases of wear, I’m sure you’ve seen loads of these, because of the nature of the clientele you see, that they have so much wear on the anterior is that the anterior teeth were root filled at some point, and then they continue to wear and now they’ve got a GP exposed, you know, 3-3, What are the guidelines that you suggest in terms of doing a re-RCT for every one of those teeth before then restoring it defensively? Because again, it’s another factor, which can significantly increase the cost of a plan by several thousand of pounds, because you’re doing now so many re-RCTs and lots of time commitment. Any guidelines on that? [Dev]Yeah, well, for me, I mean, for me, it’s clear cut, if the GP’s exposed, that means there is a contamination. And if I’m doing something to that tooth, that tooth needs to be re-treated, I wouldn’t feel comfortable doing I mean, if I’m doing direct composite buildup, maybe I’ll take a chance, if I know the patient very well, and I think but I haven’t taken that chance yet. I’m just saying maybe I’ll take a chance. But I have not taken that chance yet. Because I just don’t feel comfortable. Because we know that one of the main reason why root canal treatment fail is because of the leakage of your corporate restoration. Now, if the GP is exposed, you see a lot of bacterias going in and you know, maybe yes, patient doesn’t have pain. But when you do something, you’re going to change that by sort of a fluora anyway. So patient might then start getting pain. So any indirect restoration complete No, no, I mean, I will not even, if the root, there is no periapical pathology, but the root canal treatment is short and is not great. I do not feel comfortable doing any indirect restoration on that tooth, I would always send patient to a specialist, or I’ll do a specialist because specialists endodontist incentives, they are busy, you know, at least the area where I’m working. And if a patient needs to have wait for months, then I will just do it myself. But I’m trying to shy away from root canals as much as possible. [Jaz]Wise man, but not that I think that’s a nice clicker answer. If you have GP that’s exposed by time that comes and seen you, it’s probably exposed for a long time, it’s probably contaminated. So although it might raise the cost of the case, overall, it’s based on sound principles that you should before you put the indirect on it. Treated textbook. So that’s the answer, clearly, [Dev]Yeah, I think it’s a textbook. But also, I’ve seen a lot of exam because I have associates approaching me all the time with the planning and also approaching with me when they have done something and hasn’t worked out. And I’ve seen a lot of cases where they feel trapped when they have done that kind of treatment without being re-root canal. And now patients turn and say, look, it wasn’t painful before. And they completely forget the discussion you had with them that you know, it may get painful, it’s completely out of there. They don’t remember that because you know, a lot of things goes on. And it’s very difficult to remember every single thing you tell the patient for the patient, for you it’s easy, but for patient that gathering all the information, so yeah, I don’t tend to take chances. So then the other clear cut limiting factor is existing implant, which are good. So if doing reconstruction and implant is in the right position, then it’s fine, you just change the crown, you’re done. But if implants are not in the right position, you want to do ortho, you want to move the teeth, then you are kind of limited by the position of the implant, if it’s in the molar area, maybe it’s easier, but if it’s an anterior area a few degrees can change the implant restoration from screw retained to cement retain. I personally don’t prefer cement retained restorations. But, you know, it just changes the method of how you’re going to restore the implant. So implant is one of the reason you need, it’s the limiting factor. The other limiting factor which is supraerupted teeth, which you will see a lot if you start restoring cases which is heavily wear, edentulous areas some of the areas where teeth starting supraerupt so much so that even if you’re increasing OVD you can’t get occlusal plane to flat and especially the posteriors, you start Getting sometimes this big slice because of those supraerupted teeth. So in that case, you need to have a discussion with the patient whether they’re happy to have intentional endodontics, chop the tooth down and then do an onlay on that or extraction implant or orthodontic moment, obviously. So that’s what we discussed before as well. So it’s these things just nuances you need to really be keep in mind, there are lots and lots and lots of them. I’ve just stopped touched upon [Jaz]Just a real world sequencing question there. But I mean, these important considerations and important discussion that you have with a patient, you’ve obviously seen the patient for a comprehensive evaluation, you’ve given them an idea, you’ve gained some sort of commitment for them, you’ve probably charged them some degree of money to do some planning. And now you’ve got your articulators. You’ve done your process, you’ve done your load testing. In your mind’s eye, you know, you’re limiting factors, you know about the implant curve, some compromises, but these sort of a next lot of discussions that you figured out based on doing your articulator analysis and you decided, actually, I need to discuss this further with the patient, because there are some decisions, the patient’s needs to make, should we extract this? should we do ortho? Are you inviting the back and then presenting an ideal plan and having those discussions again? And so how long does that take? [Dev]100%. So this is so first, when I do the treatment planning, I would have said about most of the limiting factors to them anyway, because this is quite obvious factors. So you know that so patient would have almost 80% idea what to expect, when they see me 85 to 90%, I would say. And the only reason the treatment plan might treat them in a manner when I’m planning is 90% 95%, 90 to 95% there when patients first appointment. And the only reason it changes a lot sometime is because I’ve forgotten to put something in like whitening, or you know, and I need some time and you know, you just came away with things. So that’s why I never tell patients that this is the final treatment plan, I will do mounting, I’ll assess everything, even when I’m doing mounting a man might put some wax here and there just to have an idea to whether I will be able to achieve what I want, and how much opening and everything. For all direct cases, I do all my wax up myself. Because it’s just easy, because then I’m building that in patient’s mouth. So I know the anatomy, I know exactly the shape how I’m going to get the shape, especially when you’re doing the interior. But now with, you know, injection molding technique or smile fast, you can you know, you can avoid knowing too much about the anatomy and all that but I’m still old style. So I will do wax up myself and do direct build up myself. So, after this appointment, patient comes back again and I will give them the full analysis, full treatment plan with still ifs and buts because you know, you never know when you remove all amalgams what you’re going to find underneath it, sometimes the cusps goes and you’re planning to do single simple MOD restoration and now it becomes a non lead because one cusp just flew off. So you need to let patient know, you also need to let patient over the root canal treatment for those deep old amalgam fillings. Having said that, using adhesive techniques and adhesive onlays I’ve done 1000s And I could probably count five or six patients which got pathetic after treatment. So you know, many dentists get scared of removing this big amalgams. It’s pretty safe because the nerve has already created that tertiary dentine, you know, protection around the thing. So, you know, you’re quite alright, unless there is active caries, and you’re now taking the caries out. So, because you’re doing adhesive restorations, even the sound amalgam comes out in my cases, so I remove old amalgam out and replace them with composite. So, I have checked with patients, once patients happy. And once I’ve got the plan, that’s when I would send either I do the wax up or out send models to technician to do the wax up. So that’s when the vaccine is going to happen. Now, of course, if… [Jaz]At this point, Dev have you presented any sort of imaging, like some people like will give them an image of their face, and like a digital mock up of what their smile could look like? There’s something to motivate them or something to show them to something for them to go away with and make it more real for them. [Dev]Most of my cases, I showed them previous cases before and after. So they kind of can imagine. I sometimes what I do is I take photos, and I’ll send it to technician because although I’m quick at doing analog, I’m quite rubbish and takes time to do in digital. So I’ll send to technician they’ll do digital kind of wax up on patient’s mouth. Do that sort of before and after and send it to me, and I’ll show them to patient, if patients quite aesthetically driven. But otherwise, or sometimes what I’ve done is I’ve taken quite large have expired composite, just literally direct, quick mock up in patients there and then well on the model, and then show them how it looks like you know how it’s going to look before and after. So if you want to do… [Jaz]The pro tip is to use expired composite on the models and not actual compositet. And the reason I mentioned this Dev is because you’ve got all these bank of cases that you’ve done, you’ve got all these cases that you can show to a patient, but to the dentist is perhaps new in full mouth rehabilitations, and taking that next step, they may not have cases that they can show. So at that point, you can do some sort of like a 3d imaging, send to technician, you could do a wax up, you could do an intraoral mock up or even better do on model just using some expired composite. Perfect. Yes. [Dev]100%. Expired composites really helpful. If you ask your boss, you know, I’m sure they will have some expired composite laying around, you put it on a model, and then quickly so you avoid the cost of paying for wax up before patient says yes to the treatment plan, right? Because you don’t want to have a full mouth wax up done sure your patient pays like I’m not interested. So I would present the treatment plan. Sometimes if I’m not sure, I will charge them for wax up, I would charge them for full mouth wax up, everything, and then present the treatment plan, they would have some sort of estimate before, but I’ll do the wax up and then present them the proper treatment plan later on. And that happens a lot of times, because I need to rely, I need to make sure that but mainly it’s because whether they want veneers on the interior, or they just want edge bonding on palatal. So you want full functional reconstruction or you want some aesthetic component to it as well. So if they want a veneer and if I put, if I do two type of wax up so technician can do not putting anything on the buckle wax up, and then another model, duplicate that and do another with the buccal last sort of and wax on the buccal and then we can do trial on both and show it to patient to show a difference and mock up is the next step, so next step number three or appointment kind of number three is a mock up, right? So now you decided what you were going to do, plus or minus veneers on the buccal. You asked technician to do a wax up so patients, technicians done the wax up. And then now you’re going to take that wax up, use Putty indices, bis-acryl or acrylic whatever reason you have and transfer that into patient’s mouth. I have a video of that demonstrating it. And then also video on YouTube to be honest, but I have a video if someone’s interested, I can provide you link. [Dev] You need to score the model so then there is less of the access coming through the putty. You just pick up the bur and just below the sulcus, so i’m just going to score it tiny bit. Need to extend too much maybe one or one and a half tooth either side is fine. So it needs to be thick enough to hold the rigidity. Then when patient comes in we’re just going to squeeze the material in there, temporary crown and bridge material in here and seat it in patient’s mouth and let it set. Take it out remove the excess and show you to patient how it will look like. Okay so that’s your mock-up. So this is just temporary to show you how it would look like when we finished. [Dev] It’s very, I mean it’s good for single anterior tooth you know when you’re doing wax up, so you must must do a mock up in patient’s mouth. So mock up is something you do in patient’s mlouth, wax up is on the model. Yeah, so that’s the difference. So the mock up, when I’m doing the mock up, I would make sure you wet the model, make sure it’s wet because when you put the putty on the model, sometimes it gets stuck if models really dry. So I wet the model, put the putty on there then cut the putty so then it’s not too much access when you’re making that putty indices or any PVS indices, make sure that’s thick, so you need around five millimeter good thickness so that when you pushing it, it doesn’t bend. Okay? And then I’ve done both ways I’ve used light body after the putty set and put light body in there, put it again on the model, squeeze it really hard to make sure get nice finer details and I’ve done it without and they both work if your impression’s accurate. So the main thing is your impression needs to be accurate and model needs to be accurate. I tend to put, on the model take a very sort of a medium small round bur and put a small notch around the crevices so that again that’s shown on my video but small crevices on the model, so when you put the putty compresses, it goes into the area and then when you put it in the patient’s mouth, it compresses around the sulcus area so that it’s a clean cut. And you know, you don’t get too much access and it’s easy to.. [Jaz] So it’s like a little groove, just it’s like a little groove that you make and some people even use an old ultrasonic scaler, an old one, little tip they can run across something just to create that demarcation. [Dev]Yes, just don’t use a new ultrasonic scaler, your boss won’t be happy. So just make sure, the round bur was quite easy, it was, the only thing is just it’s very easy to drill really hard and the stone is very soft. So you have to have very soft light hand to just do that. In the mouth, I would depends. I’m going to put the Vaseline on the teeth which I’m not going to put the wax on, the mock up on. So then it’s easy to flick things off, if they do go. I’ll put a ptfe on every interdental area, which is long ptfe, which comes through the puttu indices. So then when I see my putty, I can pull through that ptfe through the putty so that into proximately patient can still put the tepe brushes because remember, I’m going to leave patient with this wax up or at least the mock up with for at least a week, because I want them to assess, I want to assess their TMJ, I want to assess the muscles, I want to assess the speech sound or to assess for the breaking anything. So a lot of things I’m going to assess. Now if some teeth are added little bits, very little wax, then I will spot edge that before I would put this mock up in patient’s mouth to give a little bit more retention. Okay, no bond, just a spot edge in the middle of the buccal surface or whichever surface you put in the resin. So it just holds it a little bit better. But if you shrink fit, which means you putting this in patient’s mouth and leaving it until it completely sets and you take it out, even if one part of the area is a bit thinner, the other parts will hold that thinner area. So usually it is not a problem. Once that comes out, I would use either a bur or I tend to start with a blade, number 12 blade to remove the excess material. And then if I think I need to do bit more then I’ll use a bur, if you have a void which you will see in the video there is a void, then you can literally use the same shade composite and just fill the void, you don’t need to repeat the whole thing. If the incisal edge is hasn’t come across really well then you can just build incisal edges, I tend to then polish them really well because they tend to stain quite easily especially bas-acryl, if you using the nice resin, acrylic resin. You know the ones we use like PMMA based acrylic [Jaz] Unifast or [Dev] Yeah, exactly. They are very good, right? So but if you’re using bis-acryl that leaves this gooey, sort of a surface, on the buccal surface out to end a patient drinking tea or coffee straight away, then it will stain quite badly. So make sure you polish them really nicely. And then give the patient hygiene instructions, how to clean them make sure they know that they can floss between because they connected, how to clean them. At this point, I would have only done interior mock up, I’m not doing the full mouth, I’m doing anterior mock up with if I want to look at the arch the posterior then the buccal cusps of the posterior teeth are done. So then I can have the occlusal plane idea and I can know that but anterior wax up is the more important one, if you don’t full mouth, that’s fine, it’s just a little bit more tricky and more take time consuming to doing full mouth wax up in FASCO. So anterior wax up… [Jaz] Just to clarify then Dev here, you just when you’re loading up the putty with the bis-acryl like integrity or protemp for whatever, you’re only doing it on the anterior teeth so the patient will go away and the patient will look like as though they’ve had a dahl, because they’ve had upper 3-3, lower 3-3 or lower upper 4-4 whatever, or you’re actually doing the lower full arch? [Dev] Not 4-4, upper and lower 4-4, I would asked technician to just do 4-4 and duplicate the model so that your putty seats very well, because if they have done the full wax up when you take the putty indices from the full wax up, then the putty won’t seat very well. So you need to (overlapping conversation). Yeah, so but if you’ve done the full mouth, then that’s fine. You know everywhere there will be and that’s a good way to check. But for me to check the occlusion is much easier if it’s just a 4-4, to make sure my mounting’s correct. And that’s what I’m going to build first anyway, if and again, we are discussing about the steps of adhesive full mouth reconstruction mainly because that’s much more easy and practical. If you’re going into full indirect restoration, then it becomes a bit more complicated, a bit more complex, shall I say. But I’ll go through indirect steps in a minute as well. But for now, I’m doing 4-4 upper and lower to give myself some idea as to how my mounting was. So when I’m at this point, I’m checking patient’s occlusion. So patient bites, I want to check whether the occlusion patient’s mouth is the same which is on the articulator. If it’s not, then we have a problem. We have a problem, which means that somewhere in the process things have gone wrong, right? So if the occlusion in patient’s mouth doesn’t match up in the articulator, 90% 95% then there is a problem. I mean, you will be surprised how many times it matches up 100%, if you’re really methodical, if you do a really good job, it matches up really, really accurately even though using semi adjustable articulator or using older Facebow, which many people think that, you know, is useless, and it’s not proven that it’s useful, still using it. But it’s still, for me, it gives me sort of reproducibility. So I’ve checked the occlusion, make sure everything’s fine. What if occlusion’s not fine, right? So what are you going to do if the contact’s not great. So, first thing I would do is I will start adjusting them on my provisional or on my mock up, and see whether I can get them right by doing adjustment. If I’m going to do a lot of adjustment, and everything’s changed completely, then it’s going back to drawing board. But if I’ve done a little bit adjustment, but it’s more than sort of 5% kind of ish adjustment, then I’m going to, but patients happy after that, then I’m going to take impressions of that. And I’m going to duplicate the model, because I will then use that as my indices to use for my indices when I’m doing the buildups. Okay? So, two scenarios, two ways you can work out either you repeat everything start from the scratch, but what you don’t know which process things gone wrong. And there are things in place, you can check every single step, but you know, for me if I adjusted because I’m going to do composite it’s easier. And also even if you’re doing indirect, if you’re there about 5%, then you can still refine it in your provisional stage. So that’s, I’m checking all the F sounds and you know.. [Jaz] If patients got gone away. And then aesthetically, they’ll show their family and stuff and looking gray and they come back and you check the occlusion. Where do we now go from this situation where you got anteriors, pretty much waxed up, you haven’t yet waxed up the posteriors by the sounds of it, or have you done also a full mouth wax up? [Dev] No, I mean, I would assess the posterior whether I have enough spacing for spacing to make sure you know, if I’m not sure I would wax up the posterior to make sure I have enough space. But you can measure different ways whether you have enough space for posteriors or not, but no, I tend not to wax up posterior. I used to do everything full mouth. But this is now I’m following this for especially for adhesive reconstruction. So I’ll do that. And then. But if you’re not sure about patient aesthetics, and everything, by all means, ask technician do duplicate and do full mouth wax up, you know, so there’s no harm in doing that. It’s always better to have more information than less. So now the patients come back in one week time, I’m assessing same thing again, I’m assessing whether the occlusion’s changed, because it could be that my patient changed to CR, right? So the patient’s gone, more relaxed, and the jaw has gone for the back. And now patients off my ramps which I made. By the way I can again, this is 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 a natural palatal shape, which we’re not trying to achieve. The shape which I have, which I get is very artificial. It’s a nice perpendicular. So I want lower incisor to touch almost perpendicular to that platform. So that you get quite a good force, you’re not getting angled force on the interiors. So in particular shape again, I have a nice photo showing that if you can remind me and I’ll share that with you, or now at some point we can share, I can share that. So with regards to the secondary patience for that I’m checking occlusion again, checking in breakage of the temporaries I’m checking the TMJ, making sure the patient not having an TMJ pain, muscle pain or anything like that. And just checking making sure patients happy with what they want to do. Now once that’s done, I would then take everything off. Okay? The reason being that the gum becomes quite although they’re doing their best, I want my gingiva to be healthy perfect when I’m doing my bonding. Okay? So I’m taking all the mock up out when you’re doing that just make sure you tell patient you know I use sickle scaler to just flick them out, hand scaler you can if it’s quite thick, sometimes you can use a bur and then just flick that like crack them and then take them out. If they have a lot of undercuts, then what I tend to do sometimes is I would fill those undercut first with either putting some sort of I don’t know if you use, you can use Cavit or like on you know, sometimes you get really big copings on the rare cases on the incisal edges make huge copings and then if you put your mock up in there, it gets locked in there. And then it’s very difficult to take it out. So for those, I will preempt them. And I will put reuse a temporary filling material. So we call it TFM. So you put that on there and cure it, so that it’s quite soft. So it’s easy and then put them on. [Jaz] This is obviously a resin base like Telio? I imagine like [Dev] It’s the same thing. TFM is, you know that, Telio is [Jaz] I think maybe it’s Voco? [Dev] Yeah, that’s fine. So same thing. So I would you put that to block the undercuts before I put my mock up in. So make sure because then it makes your mock up quite easy to take it out. Otherwise this nightmare patient like [Jaz] To touch on means we’re going to be wrapping up the this episode, before we then re record for the final part to go into the nitty gritty details. But what just one thing to check is at the time of adding your bis-acryl, did you do any preparation to teeth? A) to make sure that your bis-acryl will be a bit thicker? Because it’s very thin in some areas is going to be a big issue. I know you’ve got some thickness from other areas and B) to remove any thin sharp bits, which you know you’re going to be losing in the future anyway, maybe with a sof-lex disc. Have you put any consideration to air just doing some adjustments before you send them home with this bis-acryl test drive for a week? [Dev] I try not to. The reason being that this is still a test drive. Okay? Patient can still go out from the answer. Look, I don’t want this. And I want that opportunity for me to say look, I haven’t touched your teeth. And you know, if you don’t want any treatment that’s done, no harm done kind of thing. If I’m now changing something that patient you put a drill into my teeth, you know things I prefer not to but yes, if there is a very sharp edge, I would tell patient. And by this time, my rapport would be really good anyway patient like yeah, do whatever. So you can just nicely made them smoother edges. But generally the edges are sharp, because you have coping. And what I tend to do is I fill that up with or some sort of temporary material rather than drilling them. Okay, and no, I don’t drill the buccal surface of the Comp because remember, I want freshly cut surface for my bonding. So I’m going to do that anyway, when I’m going to do bonding, so I don’t want to drill the, remove that a prismatic enamel now get contaminated, and then have to remove again some of the enamel for my bonding. So my aim would be to try and keep this, I’ll tell the patient that little chip and break anyway. So patients aware of it, just may warn patient that is it may chip or break. [Jaz] Brilliant. Well, I think what we’ll do then is take a little break, a little fresh and break and then we’ll come back for part three, which we’ll release next week. And in part three, we can now go from Okay, now they’ve had their mock up, you’ve test driven it, you’re happy to occlusion, aesthetics, and then how to now actually make it into the final form, ie full mouth form through adhesive rehabilitation. So stay tuned for that, everyone. Thanks so much for listening. And we’re gonna catch you in very shortly next week. Jaz’s outro: Well, there we have it, guys, thanks so much for listening all the way to the end. Always really appreciate you guys coming all the way to this bit. And part three, that part three of three of this adhesive full mouth rehab, as you get more and more gritty, the sequencing or you know how to place which composite, the different stents to use, the different techniques to use, that’s all going to be covered in the next part of this series, which probably be two or three weeks away. I’ve got so much coming your way, including a Top Gear style review of all the different IPR systems like how do you do IPR with a bur versus a strip versus a disc versus an oscillating handpiece and showing you videos of how to, you know, 4k videos 30 gigabytes worth of videos of how to do this, all coming on the podcast very soon. So stick around and subscribe to the emails if you haven’t already. And I’ll catch you same time, same place. Take care guys.

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